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Sanitation andHygiene Promotion

Programming GuidanceISBN 92 4 159303 2

This document was jointly produced by the following organisations:

London School of Hygiene & Tropical Medicine (LSHTM)Keppel Street, London WC1E 7HT, United KingdomTel: +44 20 7636 8636 Fax: +44 20 7436 5389Website: www.lshtm.ac.uk

Pan American Health Organization (PAHO)Pan American Sanitary Bureau,Regional Office of the World Health Organization525 Twenty-third Street, N.W.Washington, D.C. 20037, United States of AmericaTel: +1 202 974 3000 Fax: +1 202 974 3663Website: www.paho.org

United Nations Children Fund (UNICEF)Water, Environment and Sanitation Programme Division3 UN Plaza, New York, NY 10017, United States of AmericaTel: +1 212 824 6307; +1 212 326 7371 Fax: +1 212 824 6480Website: www.unicef.org

U.S.Agency for International Development (USAID)Bureau for Global Health, Infectious Diseases DivisionEnvironmental Health Team, USAID/GH/HIDN/IDRonald Reagan Building,Washington, DC 20523-1000, United States of AmericaTel: +1 202 712 0000 Fax: +1 202 216 3524Websites: www.usaid.gov www.ehproject.org

Water, Engineering and Development Centre (WEDC)Loughborough University, Leicestershire LE11 3TU, United KingdomTel: +44 1509 222885 Fax: +44 1509 211079E-mail: [email protected] Website: www.wedc.ac.uk

Water and Sanitation Program (WSP)1818 H Street, N.W.,Washington, D.C. 20433, United States of AmericaTel: +1 202 473 9785 Fax: +1 202 522 3313, 522 3228E-mail: [email protected] Website: www.wsp.org

Water Supply and Sanitation Collaborative Council (WSSCC)International Environment House, 9 Chemin des Anémones,1219 Châtelaine, Geneva, SwitzerlandTel: +41 22 917 8657 Fax: +41 22 917 8084E-mail: [email protected] Website: www.wsscc.org

World Health Organisation (WHO)Avenue Appia 20, 1211 Geneva 27, SwitzerlandTel: +41 22 791 2111 Fax: +41 22 791 3111Email: [email protected] Website: www.who.int

WHO

DedicationThis volume is dedicated to the memory of Dr. John H.Austin of USAID (1929-2004)

in recognition of his contributions to the water supply, sanitation and hygiene sector in

a career spanning over six decades working in all corners of the globe.


Programming Guidance

Sanitation and Hygiene Promotion – Programming Guidance

WHO Library Cataloguing-in-Publication Data

Sanitation and hygiene promotion: programming guidance.

1. Sanitation 2. Hygiene 3. Water supply 4. Health promotion 5. Program development 6.Guidelines

I. Water Supply and Sanitation Collaborative Council.

ISBN 92 4 159303 2 (NLM classification: WA 670)

© Water Supply and Sanitation Collaborative Council and World Health Organization, 2005

All rights reserved.

This publication can be obtained from:Water Supply and Sanitation Collaborative Council, International Environment House, 9 Chemin des Anémones, 1219 Châtelaine, Geneva, Switzerland (tel: + 41 22 917 8657, fax: + 41 22 917 8084, email: [email protected])

WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: [email protected]).

Requests for permission to reproduce or translate this publication – whether for sale or for noncom-mercial distribution – should be addressed to the Water Supply and Sanitation Collaborative Council.

The designations employed and the presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part of WSSCC or WHO concerning the legal status ofany country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers orboundaries. Dotted lines on maps represent approximate border lines for which there may not yet befull agreement.

All reasonable precautions have been taken by WSSCC and WHO to verify the information containedin this publication. However, the published material is being distributed without warranty of any kind,either express or implied. The responsibility for the interpretation and use of the material lies with thereader. In no event shall the WSSCC or WHO be liable for damages arising from its use.

Designed by MediaCompany Berlin Printed in Geneva

ContributionsThe development of this document was led by a team consisting of John Austin (USAID), Lizette Burgers (UNICEF),Sandy Cairncross (LSHTM), Andrew Cotton (WEDC / WELL), Val Curtis (LSHTM), Barbara Evans (consultant), Ger-ardo Galvis (PAHO/CEPIS), Pete Kolsky (WSP), Eddy Perez (EHP), Fred Rosensweig (EHP) and Darren Saywell(WSSCC). It was produced under the overall direction of Gourisankar Ghosh of WSSCC and John Borrazzo of USAID.

Detailed comments and inputs were provided by Len Abrams (World Bank), Adam Biran (LSHTM), Clarissa Brockle-hurst (consultant), Jennifer Davis (MIT), Jennifer Francis (GWA), Eckhard Kleinau (EHP), Eugene Larbi (TREND), ShonaMcKenzie (consultant), Brian Reed (WEDC / WELL), Kevin Samson (WEDC / WELL), Ines Restrepo (CINARA), Car-oline van den Berg (World Bank), Christine van Wijk-Sijbesma (IRC, on behalf of Gender Water Alliance), Minne Ven-ter Hildebrand (Umgeni Water) and Merri Weinger (USAID). A draft was circulated and discussed at the SADC Water,Sanitation and Hygiene Meeting (Gaborone August 7 - 11, 2003).

The document was prepared by Barbara Evans. Substantial text contributions were made by Fred Rosensweig (Chap-ter 3), Eckhard Kleinau (Chapter 7) and Pete Kolsky (Chapter 10). Design and production was managed by Sören Bauer,WSSCC.

The 1997 UNICEF Handbook which forms the basis for some sections of this document was prepared by a consult-ant team consisting of Jake Pfohl (principle author), Isabel Blackett and Clifford Wang. Additional inputs and commentswere provided by Steve Esrey, TV Luong, and Gourisankar Ghosh (UNICEF), John Austin and John Borrazzo (USAID),Eddy Perez, Diane Bendahmane, Betsy Reddaway and Darlene Summers (EHP / USAID), Mayling Simpson-Herbert(WHO). Review was provided by Massee Bateman and Fred Rosensweig (EHP / USAID), Sandy Cairncross (LSHTM)and members of the UNICEF Sanitation Working Group.

FeedbackSanitation and Hygiene Promotion are amongst the most challenging development sectors in which to work. This ispartly because effective sanitation requires the development of public policy in an arena which is intensely private andwhere results are only achieved when the household makes appropriate choices. Because of the complexity of the sec-tor, and in light of the relatively small body of public policy experience, it is inevitable that the current document willrepresent a work in progress. Hopefully with the new interest in the sector, there will be new ideas and experiencesto reflect on in the coming few years. Where readers feel that the current document can be usefully updated, changedor amended in any way to reflect such experience they are encouraged to contact:

Water Supply and Sanitation Collaborative Council (WSSCC)International Environment House, 9 Chemin des Anémones, 1219 Châtelaine, Geneva, SwitzerlandTel: + 41 22 917 8657Fax: + 41 22 917 8084Email: [email protected] Website: www.who.int

ISanitation and Hygiene Promotion – Programming Guidance

II

Table of ContentsA Note to the Reader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SECTION ONE SANITATION AND HYGIENE PROMOTION – GENERAL PRINCIPLES . . . . . . . . . . . . . . . . .6

Chapter 1 The Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61.1 More than 2 billion people lack access to hygienic means of personal sanitation . . . . . . . . . . .61.2 Increased access to Sanitation and Better Hygienic Practices

Have Significant Positive Impacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71.3 Improved Access to Hardware and Changes in Behaviour

at the Household are Critical Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101.4 Lessons for effective sanitation and hygiene promotion programming:

Supporting investments and behaviour changes within the household . . . . . . . . . . . . . . . . . . .121.5 The Role of Government – some principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

SECTION TWO THE PROCESS OF CHANGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Chapter 2 Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182.1 Changing the way services are delivered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182.2 Contextual Factors – selecting the right approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212.3 Before You Start - Building political will . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232.4 When You Start – Generating a Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242.5 Ideas for Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242.6 Applying the Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252.7 Identifying and implementing solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252.8 Practical Examples from the Field: How did they organize the programming process? . . . . .27

SECTION THREE CREATING THE ENABLING ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Chapter 3 Sanitation and Hygiene Promotion Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .303.1 The Policy Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .303.2 Signaling Public Policy Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .313.3 Locating Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323.4 Building on what exists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323.5 Applying the Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323.6 Programming Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .333.7 Practical Examples from the Field: What policy changes should we make? . . . . . . . . . . . . . . .33

Chapter 4 Allocating Resources Strategically . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .354.1 Focusing on objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .354.2 The need for transparent rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .374.3 Applying the Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .384.4 Programming Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

Chapter 5 Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395.1 What needs to be financed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395.2 Where will the funds come from? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395.3 Assigning Programme Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395.4 Household self-financing – sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .415.5 Subsidies for sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .415.6 Supporting self-financing through micro-finance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .425.7 Generating revenue for sanitation and hygiene promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . .435.8 Financial instruments to promote reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .435.9 Applying the Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .445.10 Programming Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .445.11 Practical Examples from the Field: How will we pay for the programme? . . . . . . . . . . . . . .44


III

Chapter 6 Roles and Responsibilities – Restructuring Organisations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .486.1 Who is going to deliver your Programme? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .486.2 What will define successful organisations in your Programme? . . . . . . . . . . . . . . . . . . . . . . . . .486.3 Allocation of Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .496.4 Capacity Building Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .496.5 Managing the Change Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .506.6 Applying the Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .506.7 Programming Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .506.8 Practical Examples from the Field: Who’s going to deliver our programme? . . . . . . . . . . . . . .52

Chapter 7 Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .567.1 Thinking about Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .567.2 What is Monitoring and Evaluation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .567.3 What to Monitor and Evaluate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .577.4 How to do the Monitoring and Evaluation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .597.5 Applying the Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .607.6 Programming Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .607.7 Practical Examples from the Field: How will we know

whether our programme is working? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

SECTION FOUR PROGRAMMING FOR BETTER IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

Chapter 8 Working with Communities and Households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .638.1 The different roles for communities and households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .638.2 Building capacity at the community level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .648.3 Communicating Effectively . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .648.4 Selecting Community Level Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .658.5 The Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .658.6 Scaling Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .668.7 Programming Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .678.8 Practical Examples from the Field: What will the community do? . . . . . . . . . . . . . . . . . . . . . .68

Chapter 9 Hygiene Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .709.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .709.2 Making Sure Hygiene Promotion Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .709.3 Applying the Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .719.4 Programming Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .729.5 Practical Examples from the Field: How will we promote hygienic behaviours? . . . . . . . . . . .72

Chapter 10 Selecting and Marketing Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7410.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7410.2 Making Sure that Technology Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7410.3 Selecting Technologies – the sanitation ladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7710.4 Other Factors – community management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7810.5 Building Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7810.6 Sanitation Marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7910.7 Key issues and barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8110.8 Applying the Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8210.9 Programming Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8210.10 Practical Examples from the Field: What Sort of Sanitation do we Want? . . . . . . . . . . . . .83


Sanitation and Hygiene Promotion – Programming GuidanceIV

List of Figures Figure i: The Hygiene Improvement Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Figure ii: Navigation Guide – The Programming Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Figure 1: The F-diagram of disease transmission and control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Figure 2: Additional transmission pathways due to poorly-managed sanitation . . . . . . . . . . . . . . . . . . . 10Figure 3: The Programming Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Figure 4: Reform and Investment: Country Typology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Figure 5: Household demand in the context of service delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

List of Tables Table i : Who should read this Document (Navigation Table) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Table 1: Impacts of Improved water supply, sanitation and hygiene on morbidity

and mortality for six common diseases: evidence from 144 studies . . . . . . . . . . . . . . . . . . . . . 8Table 2: Growth Rate of per capita Income 1995-1994 by income (GDP)

and infant mortality rate, 1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Table 3: Applying the Principles to the Change Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Table 4: Applying the Principles to Policy Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Table 5: Applying the Principles to Resource Allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Table 6: Illustrative Financing Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Table 7: Subsidy Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Table 8: Applying the Principles to Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Table 9: Applying the Principles to Organisational Restructuring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Table 10: Uses of Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Table 11: Indicative Programme Performance Monitoring Plan

for Sanitation and Hygiene Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Table 12: Some Tools for Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Table 13: Applying the Principles to Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Table 14: Applying the Principles to Hygiene Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Table 15: Range of Technology Choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Table 16: Illustrative sanitation marketing approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Table 17: Applying the Principles to the section and marketing of sanitation technologies . . . . . . . . . 82

Sanitation and Hygiene Promotion – Programming Guidance V

List of Reference Boxes Reference Box 1: The scale of the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Reference Box 2: Impacts of Improved Sanitation and Hygiene Promotion . . . . . . . . . . . . . . . . . . . . . . 9Reference Box 3: “Hygiene” and “Sanitation” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Reference Box 4: Lessons learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-14Reference Box 5: Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Reference Box 6: The Process of Programmatic Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Reference Box 7: The Programming Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Reference Box 8: Sanitation policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Reference Box 9: Needs and demands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Reference Box 10: Financial instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Reference Box 11: Organizational roles and responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51-52Reference Box 12: Monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Reference Box 13: Communications approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Reference Box 14: Hygiene promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Reference Box 15: Sanitation technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

List of Case Study BoxesCase Study Box 1: Do We Need a Programme? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Case Study Box 2: What Policy Changes should we make? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Case Study Box 3: How will we pay for the programme? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Case Study Box 4: Who’s Going to Deliver our Program? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Case Study Box 5: How will we know whether our programme is working? . . . . . . . . . . . . . . . . . . . . . 62Case Study Box 6: How shall we work with communities and households? . . . . . . . . . . . . . . . . . . . . . . 69Case Study Box 7: How will we promote hygienic behaviours? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Case Study Box 8: What Sort of Sanitation do we Want? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Advocacy: is a continuous and adaptive process ofgathering, organizing and formulating information into ar-guments to be communicated through various interper-sonal and media channels, with a view to raising re-sources or gaining political and social leadership accept-ance and commitment for a development programme,thereby preparing a society for acceptance of the pro-gramme i.

Civil Society: individuals and organisations who arenot part of the government apparatus including but notlimited to community organisations and informal groups,non-governmental organisations, voluntary agencies,small scale independent providers, private sector, mediaorganisations and professional bodies.

Ecological Sanitation: sanitation whose design buildson the concept of protecting ecosystems, and whichtreats excreta as a valuable resource to be recycled.

Empowerment: is a process of facilitating and enablingpeople to acquire skills, knowledge and confidence tomake responsible choices and implement them; it helpscreate settings that facilitate autonomous functioning.

Enabling Environment: Policies, financial instruments,formal organisations, community organisations and part-nerships which together support and promote neededchanges in hygiene practices and access to technology.

Environmental Sanitation: a range of interventionsdesigned to improve the management of excreta, sullage,drainage and solid waste.

Excreta: faeces and urine.

Sanitation and Hygiene Promotion – Programming GuidanceVI

Gender Equity: the process of being fair to women andmen. To ensure fairness measures must be often availableto compensate for historical and social disadvantages thatprevent women and men from otherwise operating on alevel playing field. Equity leads to equality ii.

Groundwater: water found below ground level in thesub-soil.

Groundwater Table: the level at which the subsoil issaturated.

Hygiene Promotion: a planned approach to pre-venting diarrhoeal diseases through the widespreadadoption of safe hygiene practices. It begins with and isbuilt on what local people know, do and want iii.

Off-site sanitation: system of sanitation where exc-reta are removed from the plot occupied by the dwellingand its immediate surroundings.

On-site sanitation: system of sanitation where themeans of collection, storage and treatment (where thisexists) are contained within the plot occupied by thedwelling and its immediate surroundings.

Pit Latrine: latrine with a pit for collection and de-composition of excreta and from which liquid infiltratesinto the surrounding soil.

Pour-flush Latrine: latrine that depends for its oper-ation of small quantities of water, poured from a con-tainer by hand, to flush away faeces from the point ofdefecation.

Glossary

The following glossary provides the reader with guidance about what ismeant by various terms used in this document. The list is not intended tobe exhaustive, nor the definitions definitive, rather this list is designed tohelp the reader to understand what is intended in the current text. Wherethe definition is taken from a published reference, this is noted.

Sanitation and Hygiene Promotion – Programming Guidance VII

Private Benefits: benefits (of hygiene improvements)which accrue to the household or individual (for exam-ple savings in the household budget for health-relatedexpenses).

Private Sector: individuals, companies or organisationswho provide goods and services relating to hygiene im-provements on a commercial basis for profit.

Programming: the establishment of a set of rules andconventions under which all sanitation and hygiene pro-motion projects and investments can be made, such thatthey all work towards and agreed long-term vision for im-proved health and dignity for the entire population.

Public Benefits: benefits (of hygiene improvements)which accrue to society as a whole (for example, im-provements to the health of the population at large re-sulting from a significant proportion of individuals adopt-ing hygienic behaviours such as hand washing).

Public Policy: decisions enshrined in laws, regulationsand policy documents which express the will of govern-ment towards public concerns such as sanitation and hy-giene promotion.

Sanitation: interventions (usually construction of facil-ities such as latrines) that improve the management ofexcreta.

Septic Tank: a tank or container, normally with oneinlet and one outlet, that retains sewage and reduces itsstrength by settlement and anaerobic digestion.

Sewer: a pipe or other conduit that carries wastewaterfrom more than one property.

Sewerage: a system of interconnected sewers.

Small-scale Independent Provider: individual,company or voluntary/non-profit organisation providinggoods or services relating to hygiene improvement op-erating independently of the system of public provision.

Social Mobilisation: is a process bringing together allfeasible social partners and allies to identify needs andraise awareness of, and demand for, a particular devel-opment objective.

Sullage: dirty water that has been used for washing,cooking, washing clothes, pots, pans etc)

Ventilated Improved Pit Latrine: pit latrine with ascreened vent pipe and darkened interior to the super-structure which is designed to keep flies out and minimisesmell.

i UNICEF, WHO, USAID, BASICS (2000) Communication Handbook for Polio Eradication and Routine EPI: UNICEF, New York

ii Lidonde, R., D. de Jong, N. Barot, B. Shamsun Nahar, N. Maharaj, H. Derbyshire (2000) Advocacy Manual for Gender and Water Ambassadors Genderand Water Alliance, Delft

iii UNICEF (1999) A Manual on Hygiene Promotion UNICEF, New York

Endnotes

VIII Sanitation and Hygiene Promotion – Programming GuidanceVIII

List of Abbreviations

APL Adaptable Program Loan BASICS II Basic Support for Institutionalizing Child Survival CHC Community Health Clubs DWAF Department for Water Affairs and Forestry EHP Environmental Health Project ESA External Support Agency GWA Gender Water Alliance HIF Hygiene Improvement Framework HIPC Highly Indebted Poor Countries IDWSS International Decade for Water Supply and Sanitation IRC International Water and Sanitation Centre ITN International Training Network lpcd Litres per capita per day LSHTM London School of Hygiene and Tropical Medicine MDG Millennium Development Goal MPA Methodology for Participatory Assessment MTEF Medium Term Expenditure Framework NGO Non-governmental Organisation PEAP Poverty Eradication Action Plan PHAST Participatory Hygiene and Sanitation Transformation PLA Participatory Learning and Action PRA Participatory Rural Appraisal PRSC Poverty Reduction Support Credit PRSP Poverty Reduction Strategy Paper RSM Rural Sanitary Mart SADC Southern African Development Community SECAL Sector Adjustment Loan SIM Sector Investment and Maintenance Loan SWAp Sector Wide Approach TOM Technician for Operation and Maintenance TPPF Twin-Pit Pour Flush (Latrine) UNDP United Nations Development Program UNICEF United Nations Childrens Fund USAID United States Agency for International Development VIP Ventilated Improved Pit (Latrine) WASH Water, Sanitation and Hygiene for All; global advocacy campaign of WSSCCWEDC Water, Engineering and Development Centre, University of Loughborough WELL Water and Environmental Health at London and Loughborough WHO World Health Organisation WSP Water and Sanitation Program WSSCC Water Supply and Sanitation Collaborative Council

1

A Note to the Reader

At the World Summit on Sustainable Development atJohannesburg in September 2002 the World Communi-ty committed itself to “halve by 2015 the proportion ofpeople without access to safe sanitation”. Since 1990 anestimated 747 million people have gained access to san-itation facilities (equivalent to 205,000 people every day).Despite this huge achievement, a further 1,089 millionrural and 1,085 million urban dwellers will need to gainaccess in the coming 15 years if the 2015 target is to berealized.

Many governments are now asking what they can do tosystematically respond to the challenges laid down inJohannesburg.

The Water Supply and Sanitation Collaborative Council(WSSCC), in partnership with the United States Agencyfor International Development (USAID), the United Na-tions Children’s Fund (UNICEF), the EnvironmentalHealth Project (EHP), the World Bank and the Waterand Sanitation Program (WSP) have agreed to collabo-rate on the production of a new updated documentwhich can provide the sort of practical guidance which isbeing requested. Much of the material presented here isbased strongly on an earlier UNICEF Handbook i but thetext has been revised, updated and shortened, with newmaterial added based on both recent experience andfeedback from users of the earlier handbook.

International Commitments to Sanitation

What is this document about?

This document is about Sanitation and Hygiene Promotion

It is about setting in place a process whereby people(women, children and men) effect and sustain ahygienic and healthy environment for them-selves. They do this by erecting barriers to preventtransmission of disease agents (broadly by means of san-itation) and by reducing the main risky hygiene practicesand conditions which they face (usually the main focus ofhygiene promotion) ii.

Safe disposal of excreta and hygienic behaviours are es-sential for the dignity, status and wellbeing of every per-son, be they rich or poor, irrespective of whether theylive in rural areas, small towns or urban centres.

The primary direct impact of sanitation and hygiene pro-motion is on health, and of all health impacts, the mostsignificant is probably the prevention of diarrhoeal dis-ease. Primary barriers to diarrhoeal and other water-related disease transmission include both physical infra-structure (amongst which household sanitation is impor-tant), and hygienic practices (washing of hands with soapor a local substitute after contamination with excreta).Experience has shown that sustained improvements inaccess to sanitation and sustained changes in hygienic be-haviours require an appropriate enabling environment(of policy, organisations, finance, management and ac-countability). The Hygiene Improvement Framework is aconceptual model developed by USAID to help pro-grammers visualize the relationship between these threeelements (see Figure i) iii.

Sanitation and Hygiene Promotion – Programming Guidance 1

Sanitation and Hygiene Promotion – Programming Guidance2

Figure i: The Hygiene Improvement Framework

Hygiene Diarrheal Disease Prevention

The Hygiene Improvement Framework (HIF) stateshygiene improvement (and hence health benefits to so-ciety) arise when three things are in place: ● hygiene promotion; ● improved access to hardware for water supply,

sanitation and hygiene; and ● an enabling environment.

This document focuses on a selection of the interven-tions identified by the HIF (improved sanitation at thehousehold level, access to soap, hygiene promotion andthe enabling environment), while recognizing that others(such as improved water supply, solid waste manage-ment, better drainage, school sanitation and so on) arealso important if the health benefits of sanitation andhygiene promotion are to be realized iv.

Access toHardware

Water supply systemsImproved sanitation facilitiesHousehold technologies andmaterials● Soap● Safe water containers● Effective water treatment

HygienePromotion

CommunicationSocial mobilizationCommunity participationSocial marketingAdvocacy

Enabling Environment

Policy improvementInstitutional strengtheningCommunity organizationFinancing and cost recoveryCrosssector & PP partner-ships

This document talks about developing a programme formore effective investment in sanitation and hygiene pro-motion. It is not about developing projects and it doesnot give blue-print solutions for project-level interven-tions. Rather it lays out a process for long term changewhich may encompass institutional transformation of thepolicy and organizational arrangements for provision ofgoods and services. It argues that the objective of policymakers should be to:

establish a consistent set of rules under which all sani-tation and hygiene promotion projects and investmentscan be made, such that they all work towards an agreedlong-term vision for improved health and dignity for theentire population.

This document recognises that sanitation andhygiene promotion may happen within broad-er poverty alleviation strategiesThe document recognizes that in many countries and re-gions, sanitation and hygiene promotion may well beplanned and managed within a broader social develop-ment agenda, by local governments, national ministries orby specialized agencies. However, it argues that specificattention needs to be paid to the promotion of hygien-ic behaviours and to improving access to sanitation hard-ware as a key element of poverty reduction efforts. Thisdocument is intended as a resource for anybody work-ing with this aim in mind.

This document is about Programming

3


The document also acknowledges that regional, provin-cial or local programmes may be appropriate, while insome countries the logical level for programming is na-tional. Many urban areas may be autonomous and pro-gramming may take place at the city-level (such an ap-proach is often politically expedient v). This documentwill use the term programme to imply a programme de-veloped at whichever level is appropriate.

This document recognises that it has a broad audience Recognising that in different institutional contexts, sani-tation and hygiene promotion programmes will be or-ganized in different ways, this document aims to reach abroad general audience. It is designed to help

Those people with some responsibility in sanitation andhygiene promotion (whether they are directly engagedor working in wider social development or economic pro-grammes), and with resources (of time, money or ex-pertise), who are committed to achieving the outcomethat households and communities in rural areas, smalltowns and cities gain equitable access to sanitation andhygiene promotion services that are sustainable, at ascale which contributes to achievement of the Millenni-um Development Goals

The authors recognise that stand-alone sanitation and hy-giene promotion programs are rare and unlikely to be ef-fective. They also recognise that many people who takeresponsibility for improving access to sanitation and pro-moting hygienic practices may not be specialists in thefield. Therefore this document has been written with thenon-specialist in mind.

This document is biased because the authorsbelieve that certain approaches to sanitationand hygiene promotion are more effectivethan othersOur biases are laid out in Section One but in summarywe believe that:● sanitation and hygiene promotion are a vital ele-

ment in poverty alleviation;● sanitation hardware alone is ineffective as a tool to

alleviate poverty; what is needed is changes in be-haviour coupled with improved access to sanitation;

● the needed changes (investments and behaviours)largely happen at the household level; the role ofgovernment is to facilitate good decision-making atthis level;

● in the absence of well functioning public provision,people have been providing their own solutions andan understanding of this should form the basis of

new programmes of support. For many householdsand service providers sanitation is a business whichneeds to be supported;

● every country or locality needs to build a new ap-proach which has policies, money, organisations andtrained people who can create demand for sanita-tion and support rational decision making at thehousehold level; and

● a programming process needs to develop bothshort-run interventions to maintain progress and in-crease access, and long-run interventions which set inplace a radically new institutional framework to sup-port sustained service delivery over time.

How to use this documentSanitation and hygiene promotion programming is aprocess carried out by a wide range of people and or-ganisations. At the outset most of the people and or-ganisations concerned will probably not regard sanitationas their priority activity (despite their commitment, mostpeople and organisations have a range of other respon-sibilities to undertake). It is unlikely therefore that manypeople will have the motivation or time to read the en-tire document presented here. To assist readers a summary or generic programmingprocess is shown schematically in Figure ii. Broadly thedocument is organized in sections which reflect the keysteps in the programming process. Different actors maybe involved in each of these key stages. Figure ii, alongwith Table i, indicate which sections may be of most in-terest to each reader.

Additional InformationThe text contains information on where to find additionalspecific information. This is flagged in the ReferenceBoxes. Reference material is also presented in the notes.

Users of the document are encouraged to use whatev-er elements are appropriate to their particular situation.Sections of the document can be freely copied and re-produced, and the authors encourage this as part of awider programming and capacity building effort.


Decide to PrioritiseSanitation and Hygiene

Promotion

Establish Principles(1)

Design a Process of Change (2)

Change the enabling environment –

●● Develop Policy (3)

●● Allocate Resources (4)

●● Design Financing (5)

●● Adjust Roles andResponsiblities (6)

●● Monitor and Evaluate (7)

Improve Implementation

Pilot projects

●● Work with communitiesand households (8)

●● Implement hygiene promotion (9)

●● Select and market sani-tation technologies (10)

Large-scaleinvestment

Formation ofcoalitions

Capacity Building

Linkages to other sectors)

Figure ii: Navigation Guide – The Programming Process


Note: Numbers in brackets indicate the chapter containing additional discussion of the topic

i UNICEF and USAID (1997) Towards Better Programming: A SanitationHandbook, Water, Environment and Sanitation Technical Guidelines Se-ries No.3, EHP Applied Study No. 5. UNICEF New York. The hand-book benefited from inputs from the World Health Organisation(WHO), the United Nations Development Program (UNDP) and theWorld Bank and was subject to a wide consultation. Many of the orig-inal ideas for the handbook were developed by the environmental san-itation working group of the Water Supply and Sanitation Collabora-tive Council (WSSCC). The Handbook was aimed at UNICEF field of-ficers and was widely disseminated through the UNICEF network.

ii The concept of sanitation as a process is drawn from the 1997 Hand-book. The description of hygiene promotion is developed from Apple-ton, Brian and Dr Christine van Wijk (2003) Hygiene Promotion: The-matic Overview Paper IRC International Water and Sanitation Centre,

iii Environmental Health Project (2003) The Hygiene ImprovementFramework: a Comprehensive Approach for Preventing Childhood Di-arrhoea.

iv Throughout the text the reader is directed to sources of informationon wider water supply and sanitation issues where these are important.The focus of this document is on the safe management of human exc-reta, primarily at the household, not because other interventions arenot needed, but because the nature of the institutional interventionsfor management of household excreta are sufficiently different fromthose required for the management of other public services to meritseparate treatment and different institutional interventions.

v Where regions or urban areas have sufficient autonomy they may beable to implement programmes which are more advanced than thoseimplemented at central government level. Indeed this is sometimes themost effective way to make progress.

1: Sanitation andHygiene Promotionin a wider context

1 The Basics

Section Chapters Content Illustrative Users

Table i: Who should read this Document (Navigation Table)

Puts sanitation and hygienepromotion in context, andshows how effective hygieneimprovements result in socially,economically and environmen-tally sustainable development.

Broadly states what is knownabout how to effectively imple-ment sanitation and hygienepromotion.

All readers

Non-specialists wishing to get upto speed on key thinking in sanita-tion and hygiene promotion

Specialists wishing to make them-selves acquainted with the viewsand biases of the authors of thisdocument

2: The Process of Change

2 Getting Started Lays out a process for pro-gramme development, includinga discussion of the key contex-tual factors which will deter-mine how programming can bebest carried out

Programme catalysts, (ie senioroperational staff in national levelgovernment departments or atmunicipal level, representatives ofnational NGOs, ESAs etc)

3: Creating the Enabling Environment

3 Sanitation and hygienepromotion policies

4 Allocating resourcesstrategically

5 Financing

6 Roles and responsibilities– restructuring

organisations

7 Monitoring and Evaluation

Provides detailed guidance onprogramming. In each case,specific guidance is provided asto how the principles outlinedin Section One can be imple-mented practically throughpolicy level decisions.

Programme catalysts

High level policy makers

Senior staff of NGOs and ESAs

4: ImprovingImplementation

8 Working with commu-nities and households

9 Hygiene promotion

10 Selecting and market-ing technologies

Discusses briefly some of thepractical implementation detailswhich will be determined at pro-gramme level, but implementedlocally through projects. This information, includingspecific details on hygiene pro-motion, selection and marketingof technologies and communitymanagement, is specifically linkedto programming decisions.

Programme catalysts

Staff working on the details ofprogramming

National and local NGO, ESA andgovernment staff working atproject level who wish to makecontributions to the programmingprocess.

Endnotes




At the World Summit on Sustainable Development atJohannesburg in September 2002 the World Communi-ty committed itself to “halve by 2015 the proportion ofpeople without access to safe sanitation”. Since 1990 anestimated 747 million people have gained access to san-itation facilities (equivalent to 205,000 people every day).Despite this huge achievement, a further 1,089 millionrural and 1,085 million urban dwellers will need to gainaccess in the coming 15 years if the 2015 target is to berealized. Today, sixty percent of people living in devel-oping countries, amounting to some 2.4 billion people,have no access to hygienic means of personal sanitation i.

SECTION ONE:SANITATION AND HYGIENE PROMOTION –GENERAL PRINCIPLES

This section provides some information that may be useful in designing advocacy pro-grammes at national level. It also introduces some of the basics of sanitation and hygienepromotion and lays out the authors’ biases in terms of new approaches to making pro-grammes more effective. Non-specialists are particularly encouraged to read this section.

The section sets out to explain why sanitation and hygiene promotion are important.Selected results are provided to show how improved sanitation and hygiene impact posi-tively on health, education and economic development. These data could be used byadvocates for sanitation and hygiene promotion, to attract more investment and neededinstitutional attention to these subjects.

After this the document looks at what is known about how to make investments in sanita-tion and hygiene promotion effective. This includes the basic theories about disease trans-mission, the reasons why management of excreta and hygienic practices in the home are im-portant, and some key principles which are likely to make sanitation and hygiene promotionprogrammes more effective. The authors argue that in many parts of the world, sanitation isa business, and that key investment and behavioural decisions are made at the householdlevel. The role of government is primarily to support rational decision making at the house-hold level.

Reference Box 1: The scale of the problem

For: information on sanitation coverage statisticsand health indicatorsSee: UNICEF/WHO Joint Monitoring Programme Global Water Supply and Sanitation AssessmentReport WHO (1999)Get this reference on the web at:http://www.wssinfo.orgSee also: The WASH Campaign and Vision 21: A Shared Vision for Hygiene, Sanitation and WaterSupply and A Framework for Action Water Supplyand Sanitation Collaborative Council (2000) Get this reference on the web at:http://www.wsscc.org

1.1 More than 2 billion people lack access to hygienic means of personal sanitation

Chapter 1 The Basics


SECTION ONE: SANITATION AND HYGIENE PROMOTION – GENERAL PRINCIPLES

Chapter 1: The Basics

The water supply and sanitation sector has long recog-nized the importance of investing more effectively tobring services to poor people around the world. A doc-ument known as “Vision 21” lays out some specific col-lective learning from the sector and emphasizes thatprogress is possible provided governments and civil so-ciety can work together and recognize both the socialand economic aspects of water supply and sanitation ser-vices ii. What is needed now is for these lessons to beimplemented within wider poverty reduction pro-grammes throughout the world.

The Water Supply and Sanitation Collaborative Councilhas provided the rallying point and has spearheaded acampaign to get sanitation and hygiene promotion ontothe world’s political map. The Campaign, known as“WASH” is a global initiative which has had a huge im-pact on the level of awareness of the international com-munity to issues of hygiene and household health.

In every country, advocates for sanitation and hygienepromotion now need to find locally-generated informa-tion to make the case for more and better investments.Often, there is a need to show policy-makers what san-itation and hygiene promotion really can achieve. In manyrural areas, a good way of doing this for example, is todevelop “latrine acquisition curves” – by asking house-holds when they first had a latrine and started using it.From this data it is possible to plot a curve showing thecumulative % of households in any given community whouse a latrine over time. Similar investigations can provideinformation about use of a wider range of sanitation in-terventions, the use of soap, beliefs about hygiene and soon. Such exercises generate important information abouthow and why people adopt (or fail to adopt) sanitary be-haviours (in this case using a latrine). Even more impor-tantly they get officials into the habit of visiting house-holds and asking questions about hygiene. This is vitallyimportant because most people are reluctant to talkabout sanitation and hygiene practices, and often remainunaware of what is really happening on the ground. Before reaching this stage, sanitation “champions” mayneed to use more generalized data about the positive im-pacts of sanitation and hygiene behaviours, in order tostimulate interest in the subject. Some of the startlingfacts about sanitation and hygiene promotion are pre-sented below. Additional sources of information are in inReference Box 2.

Sanitation, Hygiene Promotion and health:

● WHO data on the burden of disease shows that “ap-proximately 3.1% of deaths (1.7 million) and 3.7% ofdisability-adjusted-life-years (DALYs) (54.2 million)worldwide are attributable to unsafe water, sanitationand hygiene.” In Africa and developing countries inSouth East Asia 4 –8% of all disease burden is attrib-utable to these factors. Over 99.8% of all the deathsattributable to these factors occur in developing coun-tries and 90% are deaths of children iii.

● A 1993 WHO/SEARO meeting of health specialistsgave safe excreta disposal, especially by diseased peo-ple and children, and more water for personal hygiene,especially handwashing, and protecting water quality, inthat order as the most influential factors on reducingmorbidity and mortality of diarrhoeal disease.

● A 1991 review of 144 studies linking sanitation andwater supply with health, clearly states that the “role[of water quality] in diarrhoeal disease control [is] lessimportant than that of sanitation and hygiene”iv. Thestudy identified six classes of disease where the posi-tive health impacts of water supply, sanitation and hy-giene have been demonstrated (Table 1).

● A 1986 study emphasizes the importance of sanitationspecifically, as compared to stand-alone water supplyinterventions. Seventy-seven percent of the studieswhich looked at sanitation alone, and seventy-five per-cent of those which considered sanitation and watersupply, demonstrated positive health benefits, com-pared with 48 percent of those which consideredwater supply alonev.

● A recent report states that “adding hygiene promotionis particularly efficient and effective in reducing mor-bidity and mortality from child diarrhoea” and goes onto cite a 1996 study which gave a cost of USD21 perdisability-adjusted life year saved, against costs of USD24 for oral rehydration therapy and USD15 –35 forexpanded immunizationvi.

1.2 Increased access to Sanitation and Better Hygienic Practices Have Significant Positive Impacts

8

Sanitation, Hygiene Promotion and Education

● Children in the age range of 5 –14 are particularlyprone to infections of round worm and whip worm vii

and there is evidence that this, along with guinea wormand other water-related diseases, including diarrhoea,result in significant absences from school viii

● School exclusions have a gendered aspect; girls whoare unable to access clean, safe and separate toiletsand handwashing facilities, may disproportionatelydrop out of school at puberty, or even earlier.

● Nokes et. al. (1992) found that helminth reductionprogrammes in schools can have a dramatic impact onhealth and learning among school children.

● The 1993 World Development Report estimated thatmaternal education was highly significant in reducing in-fant mortality and cites data for thirteen African coun-tries between 1975 and 1985 which show that a 10percent increase in female literacy rates reduced childmortality by 10 percent.

Sanitation, Hygiene Promotion and Economic development

● WHO analysis shows a strong link between lower ini-tial infant mortality rates and higher economic growth.Table 2 shows growth rates in a selection of severaldozen developing countries over the period1965–1994. The table shows that for any given initialincome interval, economic growth is higher in coun-tries with lower initial infant mortality rates.

● WHO estimates that a 10 year increase in average lifeexpectancy at birth translates into a rise of 0.3 – 0.4%in economic growth per year.

● Appleton and van Wijk (2003) state that “Peru’s 1991cholera epidemic is estimated to have cost the na-tional economy as much as US$1billion in health costs,tourism and production losses. [In India] outbreaks ofplague in 1994 meant a loss of two billion dollars dueto import restrictions. On top of that came the lossfrom thousands of cancelled holidays and public healthcosts.”

● The WHO Commission on Macroeconomics andHealth cites research showing a strong correlation be-tween high infant mortality and subsequent state col-lapse.

Table 1: Impacts of Improved water supply, sanitation and hygiene on morbidity and mortalityfor six common diseases: evidence from 144 studies (after Esrey et.al 1991)

Expected reduction in morbidity and mortality from improved water supply and sanitation (%)

All studies Methodologically more rigorous studies

N Median % Range % N Median % Range %

Ascariasis 11 28 0–83 4 29 15– 83

Diarrhoeal disease 49 22 0–100 19 26 0–68

Morbidity 3 65 43–79 – – –Mortality

Dracunculiasis 7 76 37–98 2 78 75–81

Hookworm infection 9 4 0–100 1 4 –

Schistosomiasis 4 73 59–87 3 77 59–87

Trachoma 13 50 0–91 7 27 0 –79

Child Mortality 9 60 0–82 6 55 20–82


9Sanitation and Hygiene Promotion Programming Guidance

Table 2: Growth Rate of per capita Income 1965–1994 by income (GDP) and infant mortality rate, 1965 ix

Initial GDP, 1965 (PPP-adjusted 1990 US$)

Infant Mortality Rate

<50 50 –<100 100 –<150 >100

750 – <1,500 – 3.4 1.1 -0.7

<750 – 3.7 1.0 0.1

750 – <1,500 – 3.4 1.1 -0.7

1,500 – <3,000 5.9 1.8 1.1 2.5

3000– <6000 2.8 1.7 0.3 –

>6,000 1.9 -0.5 – –

For detailed Information on the Impacts of Sanitation on Health, Education and the Economy see:

Cairncross, S., O’Neill, D. McCoy, A. Sethi, D. (2003) Health, Environment and the Burden of Disease: A GuidanceNote Department for International Development (DFID), UKHoward, G. and Bartram, J. (2003) Domestic Water Quantity, Service Level and Health World Health OrganisationWHO (2002) World Health ReportEsrey, S.A., J.B. Potash, L. Roberts and C. Schiff (1991) Effects of improved water supply and sanitation on ascaria-sis, diarrhoea, dracunculiasis, hookwork infection, schistosomiasis and trachoma in Bulletin of the World Health Or-ganisation, 69(5): 609–621Esrey, S.A. and J.-P. Habicht (1986) Epidemiological evidence for helath benefits from improved water and sanitationin developing countries in Epidemiological Reviews, 8:117–128Murray C and Lopez AD (1996) Global Health Statistics. WHO, Harvard School of Public Health, and the WorldBankWHO (1997) Strengthening interventions to reduce helminth infections: an entry point for the development of health-promoting schools Dickson R, Awasthi S, Williamson P, Demellweek C, Garner P. (2000) Effects of treatment for intestinal helminthinfection on growth and cognitive performance in children: systematic review of randomised trials British Medical Jour-nal 2000 Jun 24; 320(7251): 1697–701WHO (2001) Macroeconomics and Health: Investing in Health for Economic Development Report of the Commis-sion on Macroeconomics and Health

Get these references in good technical libraries or on the web at www.who.int/water_sanitation_health/en/

Reference Box 2: Impacts of Improved Sanitation and Hygiene Promotion



10

Most of the diseases which result in diarrhea are spreadby pathogens (disease-causing organisms) found inhuman excreta (faeces and urine.) The faecal-oral mech-anism, in which some of the faeces of an infected indi-vidual are transmitted to the mouth of a new hostthrough one of a variety of routes, is by far the mostsignificant transmission mechanism: it accounts for mostdiarrhoea and a large proportion of intestinal worm in-fections. This mechanism works through a variety ofroutes, as shown in Figure 1 – the “F” diagramx.

1.3 Improved Access to Hardware and Changes in Behaviourat the Household are Critical Interventions

The most effective ways of reducing disease transmissionis to erect “primary” barriers which prevent pathogensfrom entering the environment. This can be done by:

● washing hands with soap after defecation or aftercleaning children’s bottoms after their defecation; and

● constructing sanitation facilities which can prevent thespread of disease by flies and the contamination ofdrinking water, fields and floorsxi.

Figure 1: The F-diagram of disease transmission and control(after Wagner & Lanoix)

Figure 2: Additional transmission pathways due to poorly-managed sanitation (after Prüss et al.)

Primary interventions which have the greatest impact onhealth often relate to the management of faeces at thehousehold level. This is because (a) a large percentage ofhygiene related activity takes place in or close to thehome and (b) first steps in improving hygienic practicesare often easiest to implement at the household level.However, to achieve full health benefits and in the inter-ests of human dignity, other sources of contaminationand disease also need to be managed including:

● Sullage (dirty water that has been used for washingpeople, cloths, pots, pans etc);

● Drainage (natural water that falls as rain or snow); and ● Solid Waste (also called garbage, refuse or rubbish)xiv.

Where sanitation facilities are badly planned and con-structed, poorly maintained, used wrongly or not used atall, their construction can set up further potential diseasetransmission routes, and lead to contamination of the en-vironment (see Figure 2)xii. Selection of the right tech-nologies, good design, appropriate use and proper man-agement are required to protect against these addition-al risksxiii.


PrimaryBarriers

SecondaryBarriers

Faeces

Fingers

Fluids

Flies

Fields/Floors

Food NewHost

Disease transmission route

Barriers to transmission

Damaged or poorly-functioning

water-borne sewerage

Fingers

Food

NewHost

DrinkingWater

SurfaceWater

GroundWater

Poorly managednon-recycling

latrines

Poorly manageddry sanitation

involving re-use

11

For a comprehensive introduction to hygiene improvement, and links to additional referencesSee: Appleton, Brian and Dr Christine van Wijk (2003) Hygiene Promotion: Thematic Overview Paper IRC Inter-national Water and Sanitation CentreGet this reference on the web at: http://www.irc.nl See also: Environmental Health Project (2003) The Hygiene Improvement Framework: a Comprehensive Approach for Preventing Childhood DiarrhoeaGet this reference on the web at: http://www.ehp.org For a discussion of the cost-effectiveness of targeting various risky practices in hygiene promo-tionSee: Curtis, Valarie, Sandy Cairncross and Raymond Yonli (2000) Domestic hygiene and diarrhea: pinpointing theproblem Tropical Medicine and International Health, volume 5 no 1 pp 22–32 January 2000.

For an introduction to the basics of sanitation in developing country contextsSee: Cairncross, S. and R. Feachem (1993) Environmental health engineering in the tropics: an introductory text.(2nd edition) John Wiley & Sons: Chichester.Get these references from: good technical libraries or bookshopsFor further information on school sanitationSee: UNICEF School SanitationWebsite on the web at: http://www.unicef.org

For further information on sanitation in emergenciesSee: Wisner, B., and J. Adams (Ed) Environmental Health in Emergencies and Disasters: A Practical Guide WHO,GenevaThomson. M.C., Disease Prevention through Vector Control, Guidelines for Relief Organisations Oxfam PracticalHealth Guide No. 10, Oxfam, UKFerron, S., J. Morgan and M. O’Reilly (2000) Hygiene Promotion: A practical Manual for Relief and Development In-termediate Technology Publications on behalf of CARE InternationalHarvey, P., S. Baghri and R. Reed (2002) Emergency Sanitation WEDC, Loughborough University, UK

Get these references on the web at: www.who.int/water_sanitation_health/hygiene/emergencies/emergencies2002/en or in good bookshops stocking IT publications

Reference Box 3: “Hygiene” and “Sanitation”

All these sources of contamination must be managed inall the locations where they are generated. Thus a full-scale programme to improve hygiene wouldneed to address the management of excreta, sullage,drainage and solid waste at:

● Households (both formal and informal);● Schools;● Semi-public places (such as hospitals);● Public places (such as markets, bus stations etc); and● Refugee communities.

Sanitation and hygiene promotion would also have to begeared up in many cases to handle “emergency” situa-tions. Such emergencies could relate to the outbreak ofepidemic disease (such as cholera) or to a physical eventsuch as a hurricane or earthquake.

Although environmental sanitation in its broadest senseis important, this document will focus on programmingfor the better management of faeces at the householdlevel. Reference to other areas of intervention will bemade where this provides useful guidance for the reader.





Public investments in sanitation and hygiene promotionare at a very low level but what is probably more im-portant is that much of the money is being spent inef-fectively (see Reference Box 4).

Despite low levels of investment, households continue toprovide themselves with means of sanitary disposal ofexcreta. The available data suggest that, particularlywhere public agencies are failing, people have been find-ing their own solutions and in many countries small-scaleentrepreneurs have stepped into the market to provideservices. While many of these solutions are not perfect,they show that households have the potential to investresponsibly and make changes in personal hygienic prac-tices (see Reference Box 4).

Lesson One: the role of government may often needto shift away from direct service provision towards: cre-ating supportive arrangements for households to makedecisions; promoting demand for sanitatoin; promotingbehaviour change; and stimulating systems of local sup-ply and management which provide better facilities formanagement of wastes at the household level xv.

In most European countries, investments in early sanita-tion systems were heavily supported by private interestsor governments, anxious to maintain the health of theworkforce, particularly in industrial urban centres. This ledto a “supply-driven” culture amongst public health offi-

1.4 Lessons for effective sanitation and hygiene promotionprogramming: Supporting investments and behaviourchanges within the household

cials and technicians which persists to this day. In addi-tion, in countries which have long enjoyed the benefitsof near total coverage of household facilities, attentionhas moved on to focus on the management of the ex-ternal environment. This is why the emphasis in publichealth engineering education in many countries is onwastewater collection, treatment and disposal. This em-phasis has tended to skew investments in sanitation in de-veloping countries towards these more expensive ele-ments of the sanitation system, to the detriment of thedevelopment of appropriate approaches to the manage-ment of wastes at household and local level (see Refer-ence Box 4).

Lesson Two: Where coverage is low, governmentsmay need to switch priorities back towards increasingaccess to services and changing behaviours at thehousehold level, and reduce expenditure on costly retic-ulated systems and wastewater treatment facilities.

The real challenge for many countries and localities maybe to work out how household investments and changesin behaviour can best be supported. Such householdchanges need to become more effective, and importantlybegin to occur at scale so that coverage does finally startto increase in line with needs. Programmers need to startto see sanitation as a business, which can effectively berun outside government and move beyond latrine build-ing programmes.

13

Levels of Investment

● WHO/UNICEF estimates that the overall level of effective investment in sanita-tion may have to increase by as much as 28 % in urban areas and by 400 % in ruralareas in order to achieve the 2015 target. This suggests annual investment rates al-most double those which were achieved in the nineties. The Global Water Part-nership estimates that the needed investments are even higher, when municipalwastewater and industrial effluent are also included, along with the costs of oper-ating and maintaining existing infrastructure (an increase from US$22 billion toUS$ 117 billion annually)xvi.

● In 2000 WHO/UNICEF estimated that in Africa only 12 % of the money investedin water supply and sanitation went specifically to fund sanitation. In Asia the figurewas higher at 15 %, while Latin America and the Caribbean spent 38 % on sanita-tion. This higher figure probably reflects more expensive levels of service commonlyprovided in countries in the Latin American region and the lower levels of self-provision (see below).

Quality of Investment

● Figures compiled from OECD / DAC data by the USAID Development InformationService show 52% (US$52 billion) of donor aid in the overall water sector wentto support “large system” water supply and sanitation over the period 1995–2000as compared to 6 % to “small systems” water supply and sanitation. It is reasonableto assume that in general “large” water supply and sanitation schemes do not in-clude community or household management, suggesting a persisting bias towardstop-down supply-driven schemes. There is some evidence that this is beginning tochange. A 2000 review of World Bank funding for sanitation observed that expen-diture on software (non-construction activities including community development,hygiene promotion etc) “increased markedly in the nineties” jumping from 6 % to14 % of total costs for projects prepared after 1994xvii.

● A 1995 review of global evaluations of sanitation programmes xviii found that in-vestment in sanitation has been inadequate and often misdirected, due in part to alack of perceivable demand and also in part to the fact that most development in-stitutions are not geared to respond to a demand-led approach. To quote thestudy: “Most decision-makers are not clear about an overall strategy for sanitation pro-gramming, have not reached a consensus on the definition of sanitation, and differ on theoptimal role for governments, NGOs, communities, the private sector, and donors in pro-gramme implementation.”

● The review specifically found that: programmes lacked strategies for addressing hy-giene and sanitation behaviour change and were often narrowly focused on latrineconstruction; there was often an emphasis on specific technologies; there was littledata on the economics and financing of sanitation; and coordination between sani-tation and water supply was challenging because demand for water generally out-paced demand for sanitation. However, good links had sometimes been establishedwith the health and education sectors.

● Interestingly the review found that programmes implemented by NGOs or the pri-vate sector with communities, sometimes in collaboration with government, weremore likely to succeed than programmes implemented by government alone.

Reference Box 4: Lessons learned

>





Self-Provision

● A striking aspect of many of the better known of the sanitation success stories is theabsence of large scale public funding. The Orangi Pilot Project in Karachi Pakistan,mobilized communities to invest in sewers, while in Midnapore West Bengal India,households were supported to invest in on-plot latrinesxix. The common feature ofthese two well-known cases was that, while external funding was used to supporttechnical innovation, participatory research, hygiene education and social marketing,direct funding of hardware was not included; households were responsible for the localinvestment themselves.

● Recent research in India indicates that of the household sanitation which does existonly a tiny proportion has been financed by governments. In the six years from 1985/86to 1991/92 the government of India constructed 2.26 million latrines in rural areas,raising coverage from 0.5 % to 2.7 % overall. In 1988 /89 the 44th round of the NationalSample Survey found that just under 11% of the rural population had a latrine, suggest-ing that as many as 8 % of rural households across the country had invested their ownmoney and used small private providers to construct latrinesxx. Research in Africaconfirms that the role of the small scale private sector in sanitation provision is signifi-cantxxi. Importantly, many households already invest in sanitation facilities themselves,outside of government or donor funded programmes.

For a summary of lessons learned in hygiene, sanitation and water supply sincethe early 1980s

See: Cairncross, A.M. Sanitation and Water Supply: Practical Lessons from the Decade. WorldBank Water and Sanitation Discussion Paper Number 9. World Bank: Washington, D.C.

Bendahmane, D (Ed.) Lessons Learned In Water, Sanitation and Health: Thirteen years ofExperience in Developing Countries USAID, Water and Sanitation for Health Project(WASH) (1993)

La Fond, A. (1995) A Review of Sanitation Program Evaluations in Developing CountriesEnvironmental Health Project and UNICEF, EHP Activity Report no. 5, Arlington VA.

Water Supply and Sanitation Collaborative Council (2000) Vision 21: A Shared Vision forHygiene, Sanitation and Water Supply and A Framework for Action Water Supply andSanitation Collaborative Council, Geneva

WELL (1998) Guidance Manual on Water and Sanitation Programmes WEDC LoughboroughUniversity, UK

Luong, T.V. (1996) Reflections on the Sanitation and Hygiene programme in BangladeshUNICEF, Water and Sanitation for Health Project (WASH) Technical Report No. 86,Arlington VA.

Get these references from: good technical libraries, and on the web at www.ehp.org, www.whelpdesk.org, www.wsscc.org, www.unicef.organd www.lboro.ac.uk/wedc

For information on the nature and scale of small-scale independent serviceproviders in sanitation and hygiene promotion

See: Collignon, B. and M. Vezina (2000) Independent Water and Sanitation Providers inAfrican Cities: Full Report of a Ten-Country Study WSP

Solo, T.M. (2003) Independent Water Entrepreneurs in Latin America: The Other Private Sectorin Water Services WSP

Get these references from: http://www.wsp.org

Reference Box 4: Lessons learned

>

15

Much of the evidence presented above suggests that in-vestments and decisions made at the household level arecritical to achieve improved sanitary conditions. Howev-er, improved access to sanitation, and better hygienicpractices have benefits that reach beyond the immediatehousehold to the entire population. A reduction in in-fection and disease among some part of the populationwill reduce the risk of infection in others. The construc-tion of a sanitation system may also have negative healthexternalities especially where inappropriate designs areused or maintenance is poor. Poorly maintained silt trapsand uncovered sewers, for example, can act as breedinggrounds for disease vectors such as mosquitoes.

These external health implications are the reason why in-vestments in sanitation and hygiene promotion are oftenseen as a “public” responsibility. These and other “pub-lic good” aspects of sanitation, such as safety and envi-ronmental protection, remain the responsibility of socie-ty as a whole. Governments need to establish incentivesthat enable individual household choices to achieve publicpolicy objectives and to uphold and regulate principles andpolicies for the public good. They may also continue tofinance investments in shared infrastructure (such astrunk sewers and wastewater treatment facilities) andsupport interventions which raise household demand forsanitation, promote improved hygienic practices, and fa-cilitate service providers to deliver appropriate services.

Principle One: The role of government is to balancepublic and private benefits of sanitation to ensure in-creased access at the household level while safeguard-ing society’s wider interests.

Having established that there is a “public” benefit toachieving high levels of coverage of sanitation and hy-gienic practices, it is surprising to find that access to san-itation is patchy and that this is a persistent problem evenin areas where overall coverage is improving. Data forLatin America (a region where many countries havealready achieved impressive overall coverage) for exam-ple show a consistent bias against rural and poor popu-lationsxxii. Where segments of the population consis-tently fail to access better sanitation facilities and im-proved hygienic practices, health benefits to thepopulation as a whole are likely to be limited.There is however, an even stronger case to be made, inthe interests of justice, that such inequities be addressed

1.5 The Role of Government – some principles

by sanitation and hygiene promotion programmes. Theburden of poor hygiene falls more heavily upon poorpopulations who tend to have a higher dependency ondaily-wage labour, and few financial reserves to manageperiods of ill health or the costs of treatment for sick fam-ily members. Inherent biases in sanitation coverageagainst women- and children-headed households furtherdeepen their poverty and may lock them into cycles ofill health and dependency. Addressing the needs and as-pirations of these segments of the population may be themost challenging aspect of programming for govern-ments, but is probably also the most important.

Principle Two: Many groups are excluded from thebenfits of traditional ‘sanitation’ programmes. The roleof government is to balance the interests of differentgroups in society and redirect resources to those whoare systematically excluded

It is often tempting to start a new programme fromscratch identifying “ideal” solutions (either technical or in-stitutional). In reality existing practices, habits and cus-toms are probably an important part of the solution. Dis-regarding them risks failure; they are unlikely to be easi-ly changed or abandoned, and in failing to respect themprogrammers may already be alienating potential part-ners and communities xxiii. The first rule must always beto look hard at what currently exists and plan to build andimprove from there. Once there is understanding of cur-rent practices, it will be easier to map out a path to im-prove the situation.

Principle Three: It is no good selling (or even giving)people something that they don’t want. The role of gov-ernment is to identify and support what already exists.

Recognising that people are already investing in sanitationand changing their behaviours also means recognizingthat many actors are already involved. In many cases(particularly in urban areas) sanitation services are al-ready provided by a mix of small scale entrepreneurs,government departments, NGOs, community groupsand individuals while many of the same actors, along withsoap manufacturers, schools and health workers may al-ready be engaged in trying to change behaviours. All ofthese actors may have something to contribute to thedesign of a new programme for sanitation and hygienepromotion.





Partnerships are hard to forge and even harder to main-tain and strong leadership will be needed. Governmentcan play a key role in drawing in multiple actors to solveproblems and design a new programme.

Principle Four: Many actors may have knowledge andexperience which can inform a sanitation and hygienepromotion programme. The role of government is toidentify and forge partnerships with any organisation orindividual who can be part of the solution.

All of the above suggests that major changes are need-ed in the way in which hygiene improvement services areformally supported. The role of many actors is likely tochange, and significant reorganization may be needed.

Importantly, in the longer term, changes may result in sig-nificant reductions in the numbers of staff employed ingovernment agencies; a shift in the skills required; arecognition of a greater role for new actors (perhaps thesmall scale private sector, civil society, local government);and a change in the way decisions are taken and actionis effected. Crucially there will need to be a serious in-crease in the accountability of all service providers to-wards the household.

Principle Five: New approaches may result in a shiftof power and resources. It is the role of government topromote and support this shift including finding re-sources to build capacity and support institutionalchange.

For a thorough discussion of the relationship between water supply and sanitation programmingand equity

See: van Wijk-Sijbesma, C. (1998) Gender in Water Resources Management, Water Supply and Sanitation: Rolesand Realities Revisited. (especially chapters 5, 6 and 7). Technical Paper Series No. 33-E, IRC, DelftGet this reference on the web at: www.irc.nl/products/publications/title.php?file=tp33e For ideas on how partnerships work in the water and sanitation sectorSee: Caplan, K., S. Heap, A. Nicol, J. Plummer, S. Simpson, J. Weiser (2001) Flexibility by Design: Lessonsfrom Multi-sector Partnerships in Water and Sanitation Projects BPD Water and Sanitation Cluster, London. Get this reference from: Building partnerships for Development at www.bpd.org.uk

See also: Janelle Plummer (2002) Focusing Partnerships – A Sourcebook for Municipal Capacity Building in Public-Private Partnerships Earthscan Publications Ltd, LondonSaadé C.,M. Bateman, D.B. Bendahmane The Story of a Successful Public-Private Partnership in Central America:Handwashing for Diarrheal Disease Prevention USAID, BASICS, EHP, UNICEF, The World Bank GroupGet these references from: good technical libraries

Reference Box 5: Principles

17

i UNICEF/WHO Joint Monitoring Programme (2000) Global WaterSupply and Sanitation Assessment 2000 Report

ii Water Supply and Sanitation Collaborative Council (2000) Vision 21:A Shared Vision for Hygiene, Sanitation and Water Supply and A Frame-work for Action Water Supply and Sanitation Collaborative Council,Geneva

iii WHO (2002) World Health Report

iv Esrey, S. A., J. B. Potash, L. Roberts and C. Schiff (1991) Effects of im-proved water supply and sanitation on ascariasis, diarrhoea, dracunculia-sis, hookwork infection, schistosomiasis and trachoma in Bulletin of theWorld Health Organisation, 69(5): 609–621

v Esrey, S.A. and J.-P. Habicht (1986) Epidemiological evidence for helathbenefits from improved water and sanitation in developing countries in Epi-demiological Reviews, 8: 117–128

vi Murray C and Lopez AD (1996) Global Health Statistics. WHO,Harvard School of Public Health, and the World Bank

vii WHO (1997) Strengthening interventions to reduce helminth infections:an entry point for the development of health-promoting schools

viii Nokes C, Grantham-McGregor S. M., Sawyer A.W., Cooper E. S.,Bundy D. A.(1992) Parasitic helminth infection and cognitive function inschool children Proc R Soc Lond B Biol Sci. 1992 Feb 22; 247(1319):pp 77– 81

ix WHO (2001) Macroeconomics and Health: Investing in Health for Eco-nomic Development Report of the Commission on Macroeconomicsand Health

x Wagner, E.G. and J. N. Lanoix, (1958). Excreta disposal for rural areasand small communities. WHO:Geneva.

xi Earth floors contaminated with children’s wastes are favourable forthe development of intestinal worm eggs.

xii Prüss, A., Kay, D., Fewtrell, L., and Bartram, J. (2002) Estimating theBurden of Disease from Water, Sanitation and Hygiene at a Global LevelEnvironmental Health Perspectives Vol 110, No 5 pp 537–42

xiii the reader is directed to Chapter 13 for a fuller discussion of tech-nology choice.

xiv Modified from Pickford J. (1995) Low Cost Sanitation: A Survey of Prac-tical Experience Intermediate technology Publications, London.

xv This is true even in congested urban areas where “networked” solu-tions such as sewers may be used. People at the household level willstill need to invest in household facilities (toilets, taps, connections tosewers) and change behaviours, the challenge here is to respond tothis household action, and provide the wider “network” actions need-ed to support them.

xvi UNICEF/WHO (2000) ibid. GWP estimates were assembled fromdata presented in Global Water Partnership (2000) Towards Water Se-curity: A Framework for Action, and Briscoe, J. (1999) The Financing ofHydropower, Irrigation and Water Supply Infrastructure in DevelopingCountries, cited in Winpenny, J. Financing Water for All: Report of theWorld Panel on Financing Water Infrastructure World Water Council,3rd World Water Forum, Global Water Partnership

xvii Word Bank (2000) The State of Wastewater and Sanitation at the WorldBank in Investing in Sanitation: World Bank Water Supply and Sani-tation Forum, Staff Day April 5, 2000.

xviii La Fond, A. (1995) A Review of Sanitation Program Evaluations in Devel-oping Countries Environmental Health Project and UNICEF, EHP Ac-tivity Report no. 5, Arlington VA.

xix Hasan, A. (1997) Working with Government: The Story of OPPs collabo-ration with state agencies for replicating its Low Cost Sanitation ProgrammeCity Press, Karachi; UNICEF (1994) Sanitation, the Medinipur Story, In-tensive Sanitation Project, UNICEF-Calcutta, India; Ramasubban, K. S.,and B. B. Samanta (1994) Integrated Sanitation Project, Medinipur,UNICEF, India

xx Kolsky, P., E Bauman, R Bhatia, J. Chilton, C. van Wijk (2000) Learn-ing from Experience: Evalutaiton of UNICEF’s Water and EnvironmentalSanitation Programme in India 1966 –1998 Swedish International De-velopment Cooperation Agency, Stockholm

xxi Collignon, B. and M. Vezina (2000) Independent Water and SanitationProviders in African Cities: Full Report of a Ten-Country Study WSP

xxii For the Latin America region as a whole, it is estimated that 30,000people every day are gaining access to some form of improved sani-tation (of these 20,000 are connecting to sewerage). Despite this im-pressive record, 103 million people still lack access to any form of san-itation, and of these a disproportionate number (66 million) live inrural areas. (Gerardo Galvis, PAHO, presentation to WaterWeek2003, World Bank, Washington DC).

xxiii Examples of ill-designed sanitary facilities falling into disrepair abound.See for example Pickford, J. (1995) ibid. pp 23 – 34

Notes for Chapter One:





SECTION TWO:THE PROCESS OF CHANGE

Chapter Two talks about how to make a start in changing the way sanitation and hygienepromotion happen. It presents a generic approach to programming for change, and discusseshow you can decide what approach to adopt, given the circumstances of the country or region where you work. It also provides some practical pointers for those wishing to launcha programming process, and provides examples of approaches taken in other countries andregions.

This chapter has been written for people who are willing and able to take a lead in the pro-gramming process.

The ChallengeIn Chapter 1 we saw that new approaches to sanitationand hygiene promotion may require fundamental shiftsin policies, financing, organisational arrangements and im-plementation approaches. We also saw that the bene-fits of making sanitation and hygiene promotion work atscale can be huge and will play a significant role in pover-ty alleviation. As sector professionals we need to findways to effect this change.

Developing sanitation and hygiene promotion pro-grammes may require changes at a number of levels. Inany given country there may be a need for:

● an explicit decision at the highest level, to prioritisehygiene improvement;

● a process to manage fundamental institutionalchange;

● changes to the enabling environment including de-sign and implementation of new policies, changes inresource allocation, design and use of new financialinstruments, changes in roles and responsibilities,and new monitoring and evaluation systems; and

● specific efforts to improve implementation througheither pilot projects or restructuring of large scale in-vestment programmes.

2.1 Changing the way services are delivered

While this task may seem daunting most countries orlocal jurisdictions will probably be able to identify quick-win opportunities to show progress while working onmore systematic changes.

The ProcessFigure 3 shows a schematic representation of the stepsneeded to effect such changes. While this diagram sug-gests a linear process, in reality the process may be cycli-cal, with changes in some areas feeding in to subsequentchanges in other areas. It may be easier to consider Fig-ure 3 as representing all the elements of programming.

●● Prioritise Sanitation and Hygiene Promotion

The first step may be a decision that things need tochange. This may happen at national level, or in decen-tralized situations, at local government level. This decisionmay be taken in response to lobbying from within thehealth sector or from water supply and sanitation spe-cialists, or it may arise out of a process of assessing over-all strategies to alleviate the effects of poverty and sup-port growth. Once it is agreed that sanitation and hygienepromotion are important, it will be useful to agree on theground rules and principles. Defining what is meant by

Chapter 2 Getting Started

19

“sanitation” and “hygiene promotion” and being explicitabout the links between sanitation hardware and hygienebehaviour change may be an important step. (See Sec-tion 1 for a discussion of why sanitation and hygiene pro-motion improvement should be prioritized and a discus-sion of what may make sanitation and hygiene promo-tion programmes work).

Decide to PrioritiseSanitation and Hygiene

Promotion

Establish Principles(1)

Design a Process of Change (2)

Change the enabling environment –

●● Develop Policy (3)

●● Allocate Resources (4)

●● Design Financing (5)

●● Adjust Roles andResponsiblities (6)

●● Monitor and Evaluate (7)

Improve Implementation

Pilot projects

●● Work with communitiesand households (8)

●● Implement hygiene promotion (9)

●● Select and market sani-tation technologies (10)

Large-scaleinvestment

Formation ofcoalitions

Capacity Building

Linkages to other sectors)

Figure 3: The Programming Process

Note: numbers in brackets indicate the chapter containing additional discussion of the topic


SECTION TWO: THE PROCESS OF CHANGE

Chapter 2: Getting Started


●● Design a Process of Change Good programming flows from a solid understanding ofthe current situation, a realistic assessment of what ispossible, and through drawing in expertise from many ac-tors. Information needs to be assembled and analysed,strategies must be developed, capacity will need to grow,and all this must happen in a linked and mutually rein-forcing way. For this to happen some sort of structuredapproach to the process will certainly be helpful. (Sec-tion 2 – this section – contains some ideas for processand information management).

●● Change the enabling environmentIf new approaches are to become embedded and effec-tive at scale, structural changes may be needed. Makingsuch changes (to policy, financial instruments, organiza-tional roles and responsibilities, and monitoring systems)may take a long time and will be politically and techni-cally difficult. Importantly, it will almost certainly resultfrom an iterative process, where new ideas are devel-oped tested and evaluated as part of a process of long-term change. (Section 3 contains a more detailed dis-cussion of the enabling environment).

●● Improve ImplementationThere is usually a pressing need to make rapid progress,even though getting the enabling environment right maybe a long-run objective. At the same time, the pro-gramming instruments that are put in place at the insti-tutional level (the elements of the enabling environment)need to be tested through ongoing investment projects.Where the new approaches are radically different fromwhat has gone before, this may best be effected throughwell designed and carefully evaluated pilot interventions(although care is needed to ensure that these occur atsufficient scale and in a replicable context so that findingscan reflect accurately back into systematic investmentsand institutional decisions). In other cases, new ap-proaches can be rolled out at scale, always with the pro-viso, that the programming process may result in subse-quent alterations and changes to the overall approach.The key issue here is to link programming of the enablingenvironment, with a realistic evaluation of the elementsof investment projects (both pilot and at scale). Thus, asinvestments mature, a new round of information andanalysis may be required to move the sector further for-ward, or a re-evaluation of the underlying programmingprinciples which would then result in more long-termchanges to the enabling environment. (Section 4 in-cludes a discussion of the programming implications ofshort-run investment implementation).

For a comprehensive discussion of hygiene promotion, sanitation and water supply programmes

See: WELL (1998) Guidance Manual on Water supply and Sanitation Programmes Department for InternationalDevelopment, UKUNICEF (1999) Towards Better Programming: a Manual on Hygiene Promotion, Water, Environment and Sanita-tion Technical Guidelines Series No. 6 , New YorkYacoob, M. and F. Rosensweig (1992) Institutionalising Community Management: Processes for Scaling UpWASH Technical Report No. 76, USAID, Washington DC

Get these references from www.lboro.ac.uk\wedc , www.unicef.org and www.ehp.org

Reference Box 6: The Process of Programmatic Change

21

2.2 Contextual Factors – selecting the right approach

Different countries / regions / municipalities will find dif-ferent programming approaches more or less appropri-ate depending on the context. Those leading the processmay need to assess the situation prior to launching aprogramming process.

●● Decentralisation / Government structuresThe level of decentralization and the structure of na-tional/ regional and municipal or local government willdetermine how programming should be organised. Incountries where both responsibilities and resources aredecentralized local government will play a central role inthe process and local coalitions will be the most impor-tant vehicle for change. A few key policy decisions maystill need to be taken at national level (for example set-ting of fiscal and trade policies that influence the ability oflocal manufacturers to produce appropriate goods andservices, environmental legislation, legislation for privatesector participation in hygiene improvement, safety stan-dards, approaches to technical education, organizationalchange in national agencies etc). Where programminghappens at the local level it may be advisable to design aprocess than enables local actors to influence regional ornational policy.

Where government is centralized decision making maybe easier, but turning programming decisions into effec-tive local action may be more challenging. One approachmight be to work in limited geographical area initially, todevelop new ideas and build local capacity before scal-ing up to a national level programme.

Where multiple actors are involved (as they often willbe), the challenge is to draw in the appropriate actorsfrom a range of disciplines/ ministries without creating in-stitutional stasis. Here a lead or champion agency mayneed to take responsibility to oversee the process.Where possible the choice of agency should not pre-clude radical new approaches (using the national utilityto lead the process may limit the ability to debate break-ing up that organisation into smaller units for example). The key idea is to keep the process as simple as possiblewhile at the same time ensuring the real participation ofthe key actors at the lowest (most local) level possible.

●● Institutional ConfidenceThe degree to which households and individuals haveconfidence in the institutions which support the delivery

of goods and services is important. This “confidence”often relates to the maturity of the institutions con-cerned. In some situations for example, water and san-itation utilities may have a good track record of deliver-ing appropriate services at reasonable cost. In this situ-ation, there may be strong confidence from households(even those awaiting connections to the sanitation sys-tem) that the utility can take responsible decisions ontheir behalf. Similarly the delivery of health and hygienemessages by that utility may be quite effective. Thebiggest risk in this situation is to pockets of the popula-tion are persistently unable to access services. Program-mers may need to focus very explicitly on these exclud-ed groups and draw in a range of non-conventional part-ners who may be better able to serve them than thetraditional utilities.

In other situations the track record of public agenciesmay be very poor, with low coverage, poor sustainabili-ty, high costs and high perceived levels of corruption.The legal and regulatory regime may be very weak. Inthis situation, households may not have confidence in aprogramming process which does not provide them witha specific mechanism to make their voice heard Rec-ommendations coming from a process seen to be dom-inated by these organisations may be discounted bythose not involved in the process. In such cases, in theinterests both of justice and of finding workable solutions,programming needs to provide specific mechanisms forinclusion.

● Technical and cultural issues / consumer ex-pectations

Related to the maturity and confidence of the institutions,is the technical situation. This has two dimensions; thephysical conditions which determine what technologiesmight work; and the expectations of consumers.

Technology choice may be constrained by a number offactors including: availability of water and congestion –which determines the availability and location of space fortreatment facilities. (A more detailed discussion of physi-cal conditions and technology choice is in Chapter 13.)

Consumer expectations also affect technology choice.In countries which already have high levels of coveragewith flush toilets and (for urban areas) sewers, house-holds may aspire to advanced systems and be willing to





cover some at least of the costs. In other situationswhere there is limited experience with sanitation, incre-mental improvements starting with simple systems, maybe more appropriate and a greater emphasis on hygienepromotion may be needed. Different regions of thesame country may adopt different technologies (perhapssmall bore sewers in congested slums, Ventilated Im-proved Pit Latrines in rural areas etc).

The probable technological choices to be made will in-fluence decisions about how to organize the program-ming process, because it will determine what types of or-ganisations need to be most heavily involved. In regionswhere there is high demand and the resources to pay fornetworked solutions the role of sanitation “utilities” maybe central, whereas where on-site systems are likely topredominate, the small scale private sector, NGOs andhealth extensionists may play a more central role.

●● ResourcesThe availability and structure of finances is important be-cause it determines who should be involved in decisionmaking. In countries/localities without adequate financialresources of their own, potential funding partners needto be involved as early as possible to ensure that they toohave ownership of the ideas and approaches in the pro-gramme.

Where human resources are weak, and additional peo-ple or new skills are required, professional bodies, train-ing and educational organisations and other sector agen-cies who may provide skilled staff will be central to theprogramming process.

●● Environment and VulnerabilityIn countries or regions prone to natural disasters such ashurricanes and earthquakes, the ability to respond quick-ly with appropriate hygiene and sanitation interventionsmay be one of the most significant contributions tohealth; this may determine some of the organisational de-cisions to be taken. Pulling in key players such as disas-ter response agencies, international NGOs and ESAsmay be critical.

Vulnerability of this sort can also have a strong influenceon the type of technical approaches used (large seweredsanitation systems may be more vulnerable for examplein earthquake prone areas, than smaller decentralized oron-plot systems). These in turn may also dictate the mostappropriate organizational approaches to hygiene im-provement.

Society’s attitude to the wider environment will also in-fluence programming. In countries and regions wherehousehold coverage of sanitation is relatively high, focusmay fall on the need to protect vulnerable ecosystemsfrom poor quality sanitation interventions. Attentionmust then be paid to preventing:

● over-regulation leading to spiraling costs and stifled investment

● environmental regulation which is unrealistic or caneasily be ignored.

In countries and regions where the protection of the widerenvironment is a priority, environmental agencies need tobe drawn into the programming process, to build their ca-pacity to regulate in an effective and constructive manner.In regions where coverage is very low, it may be more ap-propriate to focus initially in solving access problems first,and only draw in wider environmental agencies later.

●● Rural areas, small towns and urban com-munities

The degree of urbanisation, and the nature of commu-nities (in terms of their physical economic and social char-acteristics, geographical distribution and linkages) will in-fluence both the focus and the outcome of the pro-gramming process.

Approaches to sanitation vary widely according to thedensity and size of communities, while approaches to hy-giene promotion will vary according to how cohesivecommunities are and whether a “traditional” or a more“urban” culture dominates. The structure of local gov-ernment will play a key role in determining how pro-gramming can best be organized for each type of com-munity. The approach to programming must be in-formed by the range of circumstances under whichpeople live and the reach of the proposed programme.

●● Status of the SectorSome countries already have excellent policies but lackthe right institutional context to turn them into reality.Others have excellent projects but fail to scale them upbecause of the existence of inappropriate policies andthe wrong institutional context.

For countries with poor policies and low levels of in-vestment (“A” in Figure 4) change may start with the de-velopment of some critical pilots to demonstrate newapproaches, and an advocacy effort for the sector to at-tract additional investment from domestic or external

23



Figure 4: Reform and Investment: Country Typology

sources. In countries where policy development is quitewell advanced, (B) pilots may not be needed but thefocus would fall on designing financial instruments, iden-tifying new sources of needed investment and buildingthe capacity to roll out implementation at scale. Wherethere is a programme of investment but the enabling en-

vironment is weak (“C”) the focus would naturally fall onlong term institutional change. In each case the objectivewould be to move towards a situation where an appro-priate enabling environment supports a programme ofwell-structured investments, delivered at scale.

A: Poor policies, low level of in-vestment

Isolated projects applying inconsistent rulesand approaches. Limited successes may beachieved but these will remain local.

B: Good policies, low level of in-vestment

Reforms are not implemented. Isolatedprojects may demonstrate local success butare not scaled up.

C: Strong projects in weak institu-tional environment

Multiple approaches are used with no systematic learning. Sustainability may belimited.

D: Programme Implementation

“Good” sector institutions drive a pro-gramme of well structured investments.The result is effective and sustained imple-mentation at scale.


Implementation

2.3 Before You Start – Building political willProgramme development can continue for some time inthe absence of high level political support but sooner orlater it will probably come up against an impossible pol-icy barrier unless there are high level allies to support it.It may be useful to anticipate this early in the process andtry to overcome it by:

● IIddeennttiiffyyiinngg HHiigghh--LLeevveell AAlllliieess:: People in official posi-tions can often cut through red tape, overcome con-straints, and provide a strong impetus to sanitationprogrammes. It is important to build relationships atthe highest level and promote critical thinking andawareness of the issues so that when assistance isneeded, it can be quickly provided;

● HHoollddiinngg EEffffeeccttiivvee NNaattiioonnaall--LLeevveell MMeeeettiinnggss ttoo LLeeggiitt--iimmiizzee PPrrooggrraammmmiinngg WWoorrkk aanndd ddeevveelloopp ppoolliiccyy::Special meetings on key topics can attract higher levelstaff and give greater priority to sanitation. Sometimesthe presence of a high profile national commentator,or “international experts” may be useful at such ameeting to increase its profile;

● LLiinnkkiinngg SSaanniittaattiioonn PPrrooggrraammmmiinngg ttoo IInntteerrnnaattiioonnaallMMoovveemmeennttss:: Politicians may feel more comfortablesupporting radical change in sanitation and hygienepromotion if they feel that it is part of an internation-ally mandated movement. The Millennium Develop-ment Goals for example provide a useful “peg” to



show that efforts in sanitation are highly valued by theinternational community. Linking national program-mes to regional bodies may also provide needed pro-file for national champions; and

● LLiinnkkiinngg SSaanniittaattiioonn ttoo EExxiissttiinngg PPuubblliicc HHeeaalltthh PPrriioorriittiieessaanndd CCuullttuurraall NNoorrmmss:: Identifying health problems thatare already recognized as national crises, and showing

their relationship to sanitation can generate a lot ofpublic and policy level support. Similarly, emphasizingthe strong links between hygienic behaviours and cul-tural traditions or religious beliefs can increase thelevel of support from traditional and religious leaders,and will probably result in better solutions which aremore acceptable at the local level.

2.4 When You Start – Generating a Vision

Vision is important, it provides a pointer for what the sec-tor is collectively trying to achieve. At the very least itprovides a “reality check” for programmers working onthe details of policy, programmes or projects. If what isproposed does not contribute to the agreed vision it isprobably not right. Visioning is all about taking a bold stand and aiming foran ambitious target. To define a broad vision it may beuseful to start by describing where the sector should bein the coming period:

● Where does the sector want to be in the next five, tenand fifteen years.

Then consider the current situation broadly to help iden-tify the constraints to achieving this vision:

● Why is this vision not achievable today? What are theconstraints to people accessing sanitation and hygienepromotion services? Who is excluded and who benefitsfrom current financial, institutional and social arrange-ments?

This should then point to some key areas where addi-tional information is needed:

● What are the main features of sanitation and hygienepromotion currently? Broadly who is responsible for what,who is entitled to what? how is service being delivered?Who is being excluded? How is the sector financed? Ismore money needed? How are people coping? Is therepolitical will to improve the situation?

2.5 Ideas for Process

FacilitationA skilled facilitator can assist the policy developmentprocess by building rapport and trust, listening to peo-ple’s priorities and concerns and identifying the motiva-tions of each actor. The facilitator can then assist in bring-ing institutions together and assisting in the organisationof dialogue. In some cases the facilitator may also helpindividuals and organisations to express their positionsmore effectively, and may also be able to bolster capac-ity. A facilitator (individual or organisation) should bewidely respected and considered as far as possible a“neutral player” in the process. It may be best to avoidusing the existing lead agency or a major donor to playthis role as this may limit the effectiveness of the processwhen it comes to discussing significant institutionalchanges.

Creating fora for information exchange anddecision makingFor partners to participate effectively in decision making,information exchange and capacity building need to bepart of the programming process. Probably the most ef-fective way of achieving this is to design a series of eventsthat allow participants to share information and debatepossible developments in an interactive environment.Creating this environment may be challenging at first, andit may be necessary to start with smaller groups workingtogether to build confidence before bringing largergroups together. (For example it may be advantageousfor community group leaders to work together to de-velop a common position before they have to interactwith government staff).




Forming national-level working groupsThe recommendations of an informal coalition may beinsufficient to effect major institutional change and it istherefore worth considering establishing a formal work-ing group which can act as the vehicle through which sec-tor recommendations are translated into policy change.These groups need to be inclusive and find ways to drawin experience from the local level while interacting at thepolicy level.

Building special interest groupsBuilding coalitions of specific groups, such as NGOs,community-based organisations (CBOs), private sectoragencies, or individuals with specific technical skills, is animportant option as part of this programming process.Apex or umbrella groups can emerge from such coali-tions to strengthen the work of member agencies andbuild capacity over time. As such, small working coalitionscan start up during the programming process itself, ded-icated to specific tasks such as studies, field tests, infor-mation sharing, participatory investigations, etc. This thenhelps both to set the stage for these groups’ broader in-volvement in implementation stages and to build partnercommitment along the way.

Conducting Consultations among NGOs,Government, and the Private SectorWhere NGOs or small scale entrepreneurs are interact-ing with government for the first time in a planning arena,

it will be important to develop mutual trust and over-come resistance at high levels. The experience of Gov-ernment, NGOs and the private sector must be sharedso that each comes to be seen as a national resource andpart of the solution rather than part of the problem. Itmay be necessary to facilitate a large number of smallermeetings between groups so that discussions can be heldin a non-threatening environment and leaders can de-velop better understanding before being asked to re-spond and comment in large public fora.

Making a start even if progress seems difficultCreating a coherent national/ regional or municipal pro-gram for sanitation and hygiene promotion may seem tobe a daunting task. However, where it seems that realprogress cannot be made it is important to rememberthat even small changes can have a big influence in thelong run. If major change is not possible today, it may bepossible to pull together small successes and create somemomentum and pressure for change. Where institutionsare so heavily entrenched that it seems they will neverchange, success at the local level can help maintain opti-mism and will also continue to make a very real differ-ence in the lives of those households which are directlyaffected.

Reference Box 7 contains pointers towards more ideasfor process.

2.6 Applying the PrinciplesThose leading the process retain responsibility to ensurethat it delivers on public policy priorities, including en-suring that wider societal interests are protected and that

the poor and disadvantaged are adequately representedin the process. Table 3 sums up how governments andtheir partners can do this.

2.7 Identifying and implementing solutions

The rest of this document discusses in more detail whata Sanitation and Hygiene promotion Program might ac-tually contain. It is important to note that there are noblue-print solutions to be offered, and the developmentof new ideas and solutions will continue to be an itera-

tive process, with new ideas being continually tested andreviewed. The identification and implementation of so-lutions in effect becomes the starting point for a renewedprogramming process.


Table 3: Applying the Principles to the Change Process

Maximising publicand private benefits

Consult widely and beinclusive but recog-nize that governmentmay retain responsi-bility for deliveringpublic policy out-comes (such as safe-guarding health andsafety). Those representingcommunities andhouseholds mustshow discipline inrepresenting theirviews.

Achieving Equity

Ensure the voice ofthe "unserved" isheard in the process-Include individuals andorganisations not cur-rently part of the"formal" system ofservice delivery

Building on whatexists and is indemand

Participants must beaware of the existingsituation and repre-sent it accurately inthe programmingprocess

Making use of prac-tical partnerships

Be patient when de-veloping the program-ming partnership -recognize it will behard to forge andmaintain

Building capacityas part of theprocess

Create mechanismsfor transferring ideasfrom the field to theprogramming processand vice versa. If programmingchanges are too diffi-cult start with smallerscale interventions

For ideas about programming for sanitation at city levelSee: GHK Research and Training (2000) Strategic Planning for Municipal Sanitation: A Guide GHK Researchand Training, WEDC, WSP South AsiaRosensweig, F., and Eduardo Perez with Jeanine Corvetto and Scott Tobias (2002) Improving Sanitation in SmallTowns in Latin America and the Caribbean – Practical Methodology for Designing a Sustainable Sanitation PlanEnvironmental Health Project Contract HRN-1-00-99-0011-00, Washington D.C.Cotton, A. and K. Tayler (2000) Services for the Urban Poor: Guidance for Policy Makers, Planners and Engi-neers WEDC, Loughborough, UK.Get these references from www.lboro.ac.uk\wede and www.ehp.org

For examples of what can go wrongSee: WSP-South Asia (2002) Strategic Sanitation Planning: Lessons from Bharatpur, Rajasthan, India WSP South AsiaField NoteGet this reference from: www.wsp.org

For ideas about how national or regional programming can be organisedSee: Derbyshire, H. J. Francis, R. A. Villaluna, P. Moriarty, C. van Wijk-Sijbesma (2003) Policy Development Man-ual for Gender and Water Alliance Members and Partners Gender and Water Alliance, DelftGet this reference: on the web at www.genderandwateralliance.org/english/training.asp

See also: Edwards, D.B. (1988) Managing Institutional Development Projects: Water and SanitationSector WASH Technical Report No.37 USAID, Washington DCDFID (2003) Promoting Institutional and Organisational Development Department for InternationalDevelopment, London, UK

Reference Box 7: The Programming Process

27




2.8 Practical Examples from the Field:How did they organize the programming process?

In 1994 the government of the Republic of South Africawas very clear that it did indeed need a programme torapidly improve delivery of water supply and sanitation.The precise circumstances of South Africa at that timewere undoubtedly unique, but this does not take awayfrom the achievement of the new administration, in de-livering a coherent programme which included policy de-velopment, new financial arrangements, organisationaltransformation, decentralization to local government bod-ies and implementation of an intensive capital works pro-gramme. The programming process was led by the De-partment of Water Affairs and Forestry, which itself standsto be completely reorganized in the long-run. In tandemwith the long-term programming process, DWAF has alsobeen able to deliver on a significant and intensive capitalworks programme through a variety of organizationalpartners and a range of institutional arrangements. Togive some idea of the scale of this programme the allo-cation in 2002 was over US$ 230 million, although a ma-jority of these funds were spent on water supply.

Another country which has been able to put together acomprehensive national programme for water supplyand sanitation is Uganda. In 1998 the government ofUganda began to reform the water supply and sanitationsector in response to its own Poverty Eradication ActionPlan (PEAP). Policies enshrined in the PEAP are basedon three key approaches; decentralization, privatizationand poverty alleviation. The interesting thing aboutUganda’s programming process is that it is so firmly root-ed in an overall poverty-alleviation strategy. This enablesplanners and sector specialists alike to find innovativeways of working across sectors which have traditionallybeen separated. The proposed reforms are based on asuite of studies which looked at rural, urban water sup-ply and sanitation, water for production and water re-sources management. These studies were importanttools both for analysis and for building consensus. Theother key element is the move towards a sector-wide ap-proach (SWAp) which replaces existing project-basedapproaches with a sector-wide programme involving co-ordinated funding of water and sanitation provisionthrough government budgets.

The Ugandan model of participatory programming forpoverty alleviation is now being replicated in a numberof countries currently participating in the Debt Relief

process (as part of the initiative for Heavily IndebtedPoor Countries (HIPC)). In most cases this results in thedevelopment of a Poverty Reduction Strategy Paper(PRSP) which lays out the policy, institutional, financialand implementation details of poverty alleviation pro-grammes at the national and local level. This type of na-tional level programming is attractive but can be chal-lenging. Recent research by the Water and SanitationProgramme in countries in Africa who have participatedin the HIPC process, found that very few had succeededin linking people’s strong identification of water supplyand sanitation as priority needs at the local level, withcorresponding institutional and financial commitments inthe PRSP. This suggests that sector specialists have failedto step in to help national government (usually led byPlanning and Finance ministries) articulate pragmatic ap-proaches to improving water supply and sanitation cov-erage.

While South Africa and Uganda took a systematic standto develop new programmes for (in these cases) watersupply and sanitation service delivery, other countriesand regions have experienced programming ‘from thebottom up’ as it were. In 1997 the state of Kerala in Indiasaw five of the fourteen district panchayats (local gov-ernment administrations) launch panchayat-managedprogrammes for total sanitation. In 1998 this translatedinto a state-wide program called “clean Kerala”. In thesame year the People’s Planning Campaign saw 1793sanitation projects, with a total value of INR 303 million(US$ 459,000), identified by 990 local panchayats in localmeetings. The impetus for this massive shift in empha-sis on the part of the state government, came, in part,from the experience of an externally–funded communi-ty-managed sanitation programme. The Indo-Dutchproject had tried out a range of strategies and identifiedan effective local management model which built on thestrengths of the local panchayats. Visible successes of theprogram (which helped 85,000 households construct la-trines between 1991 and 1996) resulted in the uptake ofthe approach across the state. Importantly latrine con-struction was only one (small) part of the approachwhich also built capacity and provided intense supportfor hygiene behaviour change.

Success at the level of the project does not, however,guarantee that projects can be scaled up to program-


matic levels. In Jamaica, USAID supported a local NGO,the Construction Resource and Development Centre toimplement a sanitation program in two peri-urban com-munities in Montego Bay. Despite implementing an ef-fective, comprehensive community-based project andsuccessfully supporting more than 600 households in theconstruction and use of sanitary solutions for excreta dis-posal, so far, the approach has not been replicated orbrought to scale in Montego Bay. The positive experi-ence of the project, which was able to offer land title tothose households willing to invest in sanitation, has notled to a change in housing policy in Montego Bay. This isperhaps partly due to the fact that the project took placeoutside the ordinary remit of the local administrationwhich “never became a stakeholder in this process”.

Organisational approaches which build capacity to lobbyfor and effect programming change have also been used.In 1982, as part of the International Decade for WaterSupply and Sanitation, UNDP sponsored a series of na-tional consultations of NGOs in the South Asian region.In Bangladesh, the national consultation was one of thefirst vehicles for NGO-government dialogue on waterand sanitation. As a result, the NGO community decid-ed to launch the NGO Forum on Water and Sanitation,which over several years developed as a service agencyand apex body. It now has over 600 partners, mostlyNGOs and community-based organisations, with someprivate organisations. Collectively the NGO Forummembers have more than 38,000 people engaged in hy-giene improvement work. Initially the forum providedtraining, materials, and technical assistance and helpedlink NGOs to donors, including UNICEF and the gov-ernment. The NGO Forum continues to play an impor-tant role in strengthening the quality and quantity of ef-fort in community water and sanitation.

Another spin-off from the International Decade for WaterSupply and Sanitation was the formation of the Interna-tional Training Network which brought together nationaltraining centres, each of which had received both financialand technical support from a variety of agencies. The ITNcentres did not grow into a network as extensive as theone originally envisaged by their supporters, but a numberof the ITNs have become major resource centres and keyparticipants in the global effort to promote hygiene im-provements. They remain important and active advocatesfor appropriate approaches to sanitation and water sup-ply, and are active in linking developing country decisionmakers with new ideas and capacity.

Programmes which grow from the development of ap-propriate technical approaches have also had success ina number of cases. The National Sanitation Programmein Mozambique took off when detailed analysis of con-straints led to a realization that peri-urban householdswere willing to build and use latrines but needed assis-tance to be able to afford, and safely construct, the slab.In Zimbabwe, the development of a locally-appropriatelatrine model (the so-called “Blair” latrine, or VentilatedImproved Pit Latrine) enabled the government of Zim-babwe to roll out a national programme which has hadimpressive results. This type of technology-led pro-gramming can be risky however; a 2002 evaluation inIndia found that a similar approach which led to the gov-ernment of India standardizing the Twin-Pit Pour Flush la-trine constrained the sanitation programme in India formany years, because the model was too expensive andtoo complex for many poor households to make effec-tive use of it.

Nonetheless India has seen a number of ambitious na-tional efforts to roll out programmes for water supply andsanitation in rural areas. The most recent national pushgrew from a major pilot project in the state of UttarPradesh. The Uttar Pradesh Rural Water and Environ-mental Sanitation Project (known as “Swajal”) used inno-vative institutional arrangements, developed from experi-ence with an earlier pilot project in Nepal known as “Jak-pas” to reach more than 1000 villages. While Swajal hadmany unique features, was housed in a specialized projectmanagement unit, and benefited from financial and tech-nical support from the World Bank, the government ofIndia was nonetheless able to convert lessons from Swa-jal, for use in the national programme. This happened be-cause government was able to develop an understandingof the elements of the project which had been effective,and it resulted in a shift in national policies, financing ap-proaches and institutional arrangements. Supporting thiseffort were a number of semi-formal capacity-building andnetworking initiatives including a rural water supply andsanitation forum, known as “Jal Manthan” and a sector-wide newsletter entitled “Jalvaani” both of which createdspace for information sharing and debate.

No country would wish to have to replicate the politicalupheaval of the new South Africa, simply to put in placebold development programmes, but South Africa andUganda both provide a powerful reminder that solid andvisionary political leadership can overcome what mayseem like an insurmountable challenge. Where this lead-

29



ership is lacking it may also sometimes be possible towork “from the bottom up” and use local success todrive programmatic change as happened in Kerala. How-ever, whichever path is taken, it is essential to understandthe intensely political nature of all development, and en-

sure that the process is led by, or at the very least hasthe tacit support of, legitimate local stakeholders who canrealistically play a part in driving forward programmes andtheir implementation.


Case Study Box 1: Do We Need a Programme?

The section on South Africa’s Reforms was based on:Muller, M. (2002) The National Water and Sanitation Programme in South Africa: Turning the ‘Right to Water’ intoReality Field Note 7 in the Blue-Gold Series, Water and Sanitation Program – Africa Region, NairobiElledge, M.F., Rosensweig, F. and Warner, D.B. with J. Austin and E.A. Perez (2002) Guidelines for the Assess-ment of National Sanitation Policies Environmental Health Project, Arlington VA p.4

Information on Uganda’s Reform Programme came from:Robinson, A. (2002) Water and Sanitation Sector Reform in Uganda: Government Led Transformation Field Note 3in the Blue-Gold Series, Water and Sanitation Program – Africa Region, NairobiElledge, M.F., Rosensweig, F. and Warner, D.B. with J. Austin and E.A. Perez (2002) Guidelines for the Assess-ment of National Sanitation Policies Environmental Health Project, Arlington VA p.5

The description of the origins of the Clean Kerala Campaign is in: Van Wijk-Sijbesma, C. (2003) Scaling Up Community-managed water supply and sanitation projects in India presentation to the IDPAD Water Seminar, IHE, Delft, The Netherlands, May 12-13, 2003.

An assessment of the Montego Bay Project is described in:Environmental Health Project (2003) the Hygiene Improvement Framework: a Comprehensive Approach to Pre-venting Childhood Diarrhoea USAID Washington DC

Information about the International Training Network is on the web at:www.ihe.nl/vmp/articles/projects/PRO-ICB-ITN-PH.htmlwww.wsp.org/english/partnerships/itn.html

The National Sanitation Programme in Mozambique is described in: Colin, J. (2002) The National Sanitation Programme in Mozambique: Pioneering Peri-Urban Sanitation Field Note 9in the Blue-Gold Series, Water and Sanitation Program – Africa Region, Nairobi and in Saywell, D. (1999) Sanitation Programmes Revisited WELL Study Task No: 161 WELL – Water and Envi-ronmental Sanitation – London and Loughborough, London.

Information about the use of VIP latrines in Zimbabwe is taken from: Robinson, A. (2002) VIP Latrines in Zimbabwe: From Local Innovation to Global Sanitation Solution Field Note 4 inthe Blue-Gold Series, Water and Sanitation Program – Africa Region, Nairobi

The Swajal Pilot Project is described in various publications: A useful starting point is WSP-SA (2001) Community Contracting in Rural Water Supply and Sanitation: The Swa-jal Project, India Water and Sanitation Program. Further information on the government of India’s rural water supply and sanitation programme is availablewith the Rajiv Gandhi National Drinking Water Mission on the web at www.rural.nic.in/rgndw.htm. Backnumbers of Jal Manthan and Jalvaani can be found on the web at www.wsp.org

30

SECTION THREE:CREATING THE ENABLING ENVIRONMENT

Changing the enabling environment so that investments in sanitation and hygiene promotion are consis-tently more effective, is a challenging task. In many countries or regions, the sort of high-level changeswhich are required (in policies, financial instruments, organizational arrangements and so on) may requirechanges to legal and regulatory instruments. Even if this is not required, for such changes to be translatedinto reality they have to be widely owned and accepted. For this reason such systematic changes may haveto develop slowly. Programmers may have to find pragmatic ways of making progress on the ground in themeantime.

This section discusses the sorts of changes which might be needed in the long run to secure consistent andeffective sanitation and hygiene promotion programmes. Chapter 3 talks about changes in policies whichmay be needed to facilitate a new role for government and the inclusion of new actors in sanitation in hy-giene promotion. Chapter 4 discusses how to make decisions about allocating resources between re-gions and between activities. Chapter 5 discusses what is known, and what you need to know, to designand roll out new financial instruments which can promote effective sanitation and hygiene promotion.Chapter 6 talks about appropriate arrangements for delivering services in terms of roles and responsi-bilities for different types of activity. Chapter 7 discusses the requirements for monitoring and evaluat-ing sanitation and hygiene promotion at the programmatic level.

This section should be read selectively by people who are involved in making long-term changes to the waysanitation and hygiene promotion are carried out. Many readers will of course be considering the subjectwithin the context of wider poverty alleviation strategies, so the ideas and recommendations included hereshould be read in the context of other changes you may be making to the delivery of social services.

Policies are defined as the set of procedures, rules, andallocation mechanisms that provide the basis for pro-grammes and services. They set priorities and provide theframework within which resources are allocated for theirimplementation. Policies are implemented through fourtypes of instruments:● laws that provide the overall framework; ● regulations in such areas as design standards, tariffs,

discharge standards, practices of service providers,building codes, planning regulations and contracts;

● economic incentives such as subsidies and finesfor poor practices; and

● assignment of rights and responsibilities for in-stitutions to develop and implement programs.

More details on the development of economic incentivesand assignment of rights and responsibilities can be foundin CChhaapptteerrss 55,, 66 aanndd 77..

In order to work out whether changes are needed to thepolicy framework, programmers need to provide an-swers to the following core questions:● Are existing policies adequate?● Will they result in the implementation of the vision for

sanitation and hygiene promotion?● How are these policies translated into programmes?● How effective are these programmes in improving

services?

3.1 The Policy Context

Chapter 3 Sanitation and Hygiene Policies


31

SECTION THREE: CREATING THE ENABLING ENVIRONMENT

Chapter 3: Sanitation and Hygiene Promotion Policies

The policy framework provides the instruments (guid-ance, positive incentives and penalties) which turn pub-lic priorities into reality. Policy may deal with:

● Targeting of Resources (see CChhaapptteerrss 66 aanndd 99):Policies can be used to signal where resources are tobe spent (which aspects of sanitation and hygiene pro-motion are to be funded, to what levels) and whichcommunities should be targeted.

● Equity: Policy statements, laws and budgetary alloca-tions can be used to steer resources to specific socialgroups or geographic areas. They can also support anequitable programming process by enabling the partic-ipation of marginalized groups or organisations (it couldfor example, require that public consultations on hy-giene issues are always attended by an umbrella bodywhich represents the interests of indigenous people).

● Levels of service (see CChhaapptteerr 1100)): Appropriate in-terventions may range from hygiene promotion alone,through the provision of simple sanitation systems, toimproved levels of service including indoor flush toi-lets. School sanitation and hygiene promotion will bea key element in most programmes. Policy can signal(a) what levels of service are acceptable (ie are thereminimum health, safety and environmental standardswhich need to be maintained?); and (b) what activi-ties will be promoted (through the provision of sub-sidy perhaps, or support to specific providers). Levelsof service decisions are usually reflected in technicalnorms and standards used by engineers, in buildingcodes, planning regulations and in allocations of fund-ing (see above). Historically, technical standards havetended to prohibit anything but the “highest” levels ofservice which stifles innovation and prices mosthouseholds out. This may need urgent review.Adopting standards which focus on outcomes ratherthan those that specify inputs (ie defining safe separa-tion of faeces from human contact, rather than dis-cussing bricks and mortar) may help to promote in-novation and enable flexibility if the situation changes(due to emergencies, influx of refugees, change inschool populations etc) See Section 4.7 for examplesof where this has happened in practice.

● Health considerations: The policy frameworkneeds to provide for the full range of interventions(access to technology, promotion of hygienic behav-

3.2 Signaling Public Policy Objectives

iours and the enabling environment) which will enablehouseholds to improve their health status. Policystatements and even laws may be particularly usefulin providing incentives for hygiene promotion to takea more prominent role over “traditional” latrine con-struction or ahead of curative health care.

● Environmental considerations: Sanitation is in-creasingly seen as a key issue in environmental pro-tection. Improper disposal of human wastes can pol-lute water bodies, groundwater, and land surfaces andaffect the quality of life for those living in the area. Inaddition, the economic impact of environmentaldegradation on tourism, fisheries, and other industriessensitive to pollution is a growing problem. Policiesmay be needed to address environmental protection,but these should be placed in the context of priori-ties (care is needed to ensure that environmental reg-ulations do not inadvertently preclude incrementalprogress in household sanitation for example).

● Financial considerations (see CChhaapptteerr 66): Policiesmay be needed to provide guidance on who will payfor what. This is particularly important where there isa shift away from a traditional ‘subsidised latrine’ ap-proach – but will also be necessary where a particularrevenue stream is to be allocated to financing aspectsof the programme. Whether or not such allocationsneed to be enshrined in law depends on the context.

● Institutional roles and responsibilities (seeCChhaapptteerr 77): Policies, or at the least, a high level poli-cy discussion may be needed to ensure that roles andresponsibilities are clearly defined (a) between publicagencies; and (b) between public and private/civil so-ciety agencies. A policy forum may also be able toprovide effective interagency coordination. Impor-tantly policy change may be needed to enable smallscale independent providers, non-governmental or-ganisations and other civil society groups to effective-ly play a role in promoting and implementing house-hold level and community sanitation and hygienepromotion activities. Some of these organisationsmay need legal recognition in policy. The develop-ment of institutional policy must also consider how or-ganisations charged with given responsibilities will im-plement them, and how their capacity may need tobe strengthened. Again, explicit attention must bepaid to how organisations are to be funded.



Very few countries currently have explicit stand-alone“sanitation and hygiene promotion policies”. Recent re-search by USAID and EHP found only three examples(Nepal, Republic of South Africa and Uganda) wheresuch a policy could be said to exist. Such a unified poli-cy may not be required in every case. Well known ex-amples of successful programmes often pull in expertisefrom the health, education, water supply and sanitation,and social development fields, and make use of staff froma range of organisations. Policy dialogue could thus takeplace in a number of ways through:● the development of a single unifying policy framework

around which all organisations can develop their ap-propriate approaches and inputs (as for example inSouth Africa);

● the inclusion of sanitation within a wider poverty-re-duction and economic development framework (asfor example in Uganda, and at the local level in the cityof Johannesburg); or

● through inclusion of aspects of sanitation and hygienepromotion in policy relating to all relevant sectors (in-cluding health, education, housing, urban and rural de-velopment etc).

While it is not possible to define for every situation howpolicy should be framed, a useful principle might be tominimize policy at every level, to ensure that, whereverpossible, responsibility is delegated downwards (to localgovernments, communities and ultimately households).In some cases, however, the existence of policy at a“higher” level may be a useful incentive to improve per-formance (examples might include national regulation forprotection of the environment, and regulatory oversightof private sector providers provided at a level higher thanwhere the day-to-day contractual relationship with thepublic sector is managed).

3.3 Locating Policy

3.4 Building on what exists The legality of the policy framework is a key determinantof its legitimacy. Policies must therefore be rooted in theconventions of local laws, legislative acts, decrees, regu-lations, and official guidelines. For this reason informationabout existing legal conventions is essential to the devel-opment of effective policies (see RReeffeerreennccee BBooxx 88). Policy development also needs to be based on a goodunderstanding of: the basic situation (population, cover-age, investments; health status); institutional contexts (in-cluding the performance of service providers); how peo-ple are currently accessing services; what works (even onthe small scale locally); and what has potential to bescaled up.Importantly, there is no point in developing policies thatare beyond the capacity of the current institutional setup. This returns us to the theme of a cyclical process –

Policy development as a process can provide opportuni-ties to analyse and debate what works at the implemen-tation level. When approaches are recognised as part ofthe long-run solution to the sanitation and hygiene pro-

For: approaches to assessing current policySee: Elledge, Myles F., Fred Rosensweig and Den-nis B. Warner with John Austin and Eduardo A.Perez (2002) Guidelines for the Assessment of Na-tional Sanitation Policies Environmental Health Pro-ject Contract HRN-1-00-99-0011-00, WashingtonD.C.Get this reference from: EnvironmentalHealth Project at www.ehp.org

Reference Box 8: Sanitation policies

3.5 Applying the Principlesmotion challenge they can be converted into policy.Those leading the policy development process can en-sure that the principles of good programming are appliedboth in the process and in the outcome (see TTaabbllee 44)

policy is needed to improve current performance in theshort run, and to create incentives to strengthen the over-all institutional context in the longer run.

Table 4: Applying the Principles to Policy Development


Use policy to signal

● Targeting ofresources·

● Levels of service·● Health aspects·● Environmental

priorities·● Financial

approaches● Institutional roles

and responsibilities

Achieving Equity

Use policy instru-ments to steer re-sources to areaswhich have been neglected

Provide protectionfor marginalizedgroups of individualswithin organisationsor for marginalizedorganisations

Building on whatexists and is in demand

Root policy on goodunderstanding of theexisting legal frame-work, institutionalcontext and existingpractices

Align policy with ap-propriate financial andinstitutional instru-ments


Make efforts to linkpolicy upwards (togain political support)and downwards (togain acceptance andimplement on theground)


Consider policieswhich will build ca-pacity, and use policydevelopment as partof the capacity build-ing effort

33


Chapter 3: Sanitation and Hygiene Promotion Policies

Policy reform takes time. Strong political support willaccelerate the timeframe, but policy change is a long-run objective of programming. Where possible, pro-grammers should maintain support for efforts to makepractical progress on the ground in parallel with thepolicy development process. This can be achievedthrough:

3.6 Programming Instruments

● creating space and ‘waivers’ of existing regulations toenable localized innovation and testing of new ideas;

● policy-related evaluations of pilots and investmentprojects;

● establishing technical working groups to review tech-nical norms and standards, building codes, profession-al training etc; and

● capacity building for regulators.

The government of Bangladesh has long been commit-ted to improving the sanitation situation in the country.However recent research by WaterAID, showed thatwhile subsidies (the core plank of government sanitationpolicy) gave people the “opportunity” to construct la-trines they did nothing to generate the “capacity” to doso. In contrast the Bangladeshi NGO Village Educationand Resource Centre (VERC) has shown that commu-nities acting together can take steps to significantly im-prove their sanitation situation i . Villages where VERC hasworked have developed a whole range of new ap-proaches to solving sanitation problems, including thedevelopment of more than 20 new models for low-costlatrines. These achievements took place with almost nopolicy direction at all, almost as if the absence of any pol-icy constraint, coupled with the commitment of VERC tofind solutions to the problem, unlocked communities’

3.7 Practical Examples from the Field:What policy changes should we make?

ability to solve a problem for themselves. Analysis of thisstory might lead one to think that no policy is sometimesbetter than some policy. Another interpretation is thatthe most useful policy changes would relate to a redi-rection of some public funds from subsidies, to supportto participatory planning, and an evaluation of whethertechnical norms and standards could be reorganized togenerate incentives for technicians to add their expert-ise to local efforts to develop new latrine models.

The critical nature of technical norms and standards indetermining sanitation outcomes is very clear. In India thewidespread adoption of the Twin-Pit Pour Flush Latrine(with its associated high cost and high level of subsidy)may have been the single biggest constraint on scaling upaccess to rural sanitation in the past 15 years. By contrast,in La Paz-El Alto, Bolivia, the efforts of the private oper-



ator of the water and sanitation network, with supportfrom the Swedish International Development Coopera-tion Agency (SIDA) and the Water and Sanitation Pro-gram (WSP) resulted in the development of the condo-minial approach to sewered sanitation in the poorestneighbourhoods of the city (The approach was pio-neered in Brazil, and this project was an important stepin its replication as it was expanded into Bolivia for thefirst time). This experience enabled sanitation to be pro-vided to indigenous groups who had hitherto been ex-cluded from service provision, and resulted in adoptionof the low-cost technology as a standard for the utilityfor all income groups. The specific provision of fundsfrom SIDA to support WSP in technical training and ad-vocacy of the approach, resulted in a change in the na-tional norms and standards, which have enabled condo-minial sanitation to be rolled out in other municipalities.

Outside technical norms and standards, housing andplanning policy probably ranks highly in terms of influ-

encing sanitation outcomes. Where access to sanita-tion is bound up with land title (or lack of it) somepoor populations are consistently excluded. On theother hand where land title is positively linked tohousehold investment incentives to improve sanitationmay result. In Burkina Faso, eligible communities cangain land title if they construct latrines inside theirhouses while in Montego Bay, Jamaica, USAID had con-siderable success in generating demand for householdsanitation in poor neighbourhoods by providing the in-centive of land title.

At the highest level though, a thorough review and over-haul of sanitation and hygiene promotion policy has beenrare. Interestingly, in a review of 22 African countries,WSP found that only two (South Africa and Democrat-ic Republic of Congo) included hygienic practices in theirdefinition of access to “improved sanitation”, an indica-tor in its own right that policies are not yet dealing withhygiene improvement as a whole in many cases.

Notes for Chapter 3:

i One of the core tools of the approach is the use of participatory exerciseswhich explicitly look at how and where people defecate. A public transectwalk which sees the whole community walking through the village identify-ing where each household defecates, the so-called “walk of shame”, has be-come the “most important motivating tool, and in almost every case resultsin the setting up of the first community meeting to discuss solutions”.

Case Study Box 2: What Policy Changes should we make?

The analysis of the impacts of India’s use of the TPPF latrine is based on Kolsky, P., E Bauman, R Bhatia,J. Chilton, C. van Wijk (2000) Learning from Experience: Evaluation of UNICEF”s Water and Environmental San-itation Programme in India 1966-1998 Swedish International Development Cooperation Agency, StockholmSouth Africa’s systematic reforms are described in Muller, M. (2002) The National Water and Sanitation Pro-gramme in South Africa: Turning the ‘Right to Water’ into Reality Field Note 7 in the Blue-Gold Series, Waterand Sanitation Program – Africa Region, Nairobi and Elledge, M.F., Rosensweig, F. and Warner, D.B. with J.Austin and E.A. Perez (2002) Guidelines for the Assessment of National Sanitation Policies Environmental Health Project,Arlington VA p.4Information on Uganda’s Reform Programme can be found in Robinson, A. (2002) Water and Sanitation Sec-tor Reform in Uganda: Government Led Transformation Field Note 3 in the Blue-Gold Series, Water and SanitationProgram – Africa Region, Nairobi and Elledge, M.F., Rosensweig, F. and Warner, D.B. with J. Austin and E.A.Perez (2002) Guidelines for the Assessment of National Sanitation Policies Environmental Health Project, Ar-lington VA p.5The El Alto experience is described in Foster, V. (n.d.) Condominial Water and Sewerage Systems – Costs of Im-plementation of the Model Water and Sanitation Program, Vice Ministry of Basic Services (Government of Bo-livia), Swedish International Development Cooperation AgencyThe review of definitions of access can be found in Water and Sanitation Program – Africa (2003) Water Sup-ply and Sanitation in Africa: How to Measure Progress toward the Millennium Development Goals? Paper present-ed to SADC Meeting on Water Supply, Sanitation and Hygiene, Gaborone, Botswana August 4-7 2003

35


Chapter 4: Allocating Resources Strategically


Introduction In a world of limited resources it is necessary to developan approach to sanitation and hygiene promotion whichyields the maximum possible health benefit. The visionand objectives of the programme need to be matchedwith financial and human resources. This invariably meanssetting boundaries and steering resources to specificareas or activities. The following decisions need to betaken:

1. What resources will be made available forsanitation and hygiene promotion?

Allocations of funds and people to sanitation and hygienepromotion are usually made within a wider process ofbudgeting (for social programmes in general, or from awater supply and sanitation sector budget for example).To secure the needed resources for sanitation and hy-giene promotion you will need to:

● work out roughly how much money and how manypeople are needed to meet the objectives of the pro-gramme; and

● be prepared to make, and repeatedly prove, the casefor sanitation and hygiene promotion as a significantcontribution to the achievement of overall poverty re-duction goals.

To strengthen your case it may be useful to be able toexplain how resources will be spent when allocated, andalso to show what sort of coverage you could achievewith different levels of budgetary allocation.

2. What is the balance of activities to befunded?

Where funds are used to leverage household in-vestment (ie where public funds are to support house-hold investments rather than substitute for them) ratesof coverage may increase significantly. A smaller propor-tion of public resources will now be spent on construc-tion of hardware and subsidies for household latrines. In-stead public funds may increasingly be used to marketsanitation, promote hygienic behaviours and supportsmall-scale independent providers. The disadvantage ofthis approach, from a political perspective is that the di-rect link between funds and coverage will become lessclear. To ensure that politicians (who control funding de-

cisions) remain comfortable with the approach, house-hold investments in sanitation must be closely monitored,and selected investments in trunk infrastructure and fa-cilities in schools and public places should continue to bemade. This will enable politicians to demonstrate thattheir funding decisions are yielding tangible results.

Resource allocations should also keep pace with institu-tional capacity. Getting more sanitation facilities inschools is critical for example, but in some cases policiesand experience in the Department of Education mayconstrain progress and mean that investments madetoday may be wasted as facilities fall into disrepair. Insuch a case some resources must be allocated to thelong-term goal of changing the Department’s approachto school sanitation while resource allocations for con-struction of facilities are progressively increased overtime. Similarly, if funds are to be diverted towards hy-giene promotion, and if the best vehicle for this is the De-partment of Health, allocations should only be made inline with the human resources available in the depart-ment to go out and deliver hygiene promotion activities.A step-by-step approach may be needed so that in-creased financial resources can be matched with grow-ing human capacity.

3. Will the program target specific regionsand if so which?

Where resources are stretched, it may be appropriate towork, at least in the short term, in selected regions or lo-cations. Greater health benefits may accrue from a moregeographically focused programme.

Piloting: Focused programmes may be justified if newapproaches need to be tested and demonstrated aheadof wholesale institutional change. This “pilot” approachmay help to “shift gears” and increase the speed ofprogress in the sector but may well conflict with equityconcerns in the short term. Identifying areas where thechances of success are high is hard. Allowing the infor-mal sector and civil society to lead the process may workin some contexts along with the use of formal indicatorssuch as:

● existence of community organisations/ past experi-ence of collective interventions etc;

4.1 Focusing on objectives

Chapter 4 Allocating Resources Strategically


● presence of well-trained outreach workers who canextend their interventions effectively to include hy-giene promotion and sanitation marketing;

● pre-existence of sanitation practices and technologieswhich can be effectively scaled up;

● existence of small scale independent providers; and● potential for simple small-scale interventions to

achieve benefits (such as selecting areas where on-plot latrines are a potential solution rather than ad-dressing areas which require networked solutions).

Equity and Targeting: It is already known that de-mand for sanitation hardware is low – that is one reasonwhy coverage is so poor. But it is also clear that wheredemand exists provision may follow rapidly through theefforts of households themselves and the small scale pri-vate sector.

For these reasons, while available public subsidy for san-itation could probably be steered towards those areas ofhighest demand, a much more pressing issue in mostcountries is probably to work towards stimulation of de-mand in areas of greatest need. This means that both hy-giene promotion, sanitation marketing and support forthe enabling environment, should be targeted towardsthose areas.

The real problem then comes in assessing which areas fallinto this category. A number of approaches can be usedincluding targeting communities/ households with:

● poorest health status as indicated by incidence of epi-demic disease such as cholera;

● poorest overall health status as indicated by formal as-sessments using internationally agreed indicators;

● lowest access as assessed through formal empiricalresearch into numbers and use of latrines, incidenceof hygienic behaviours etc;

● highest incidence of poverty (as defined by agreed na-tional norms and assessed nationally or regionally); or

● highest incidence of other proxy indicators of pover-ty and/or poor access, such as low ownership of cap-ital assets, poor school attendance, or incidence ofwomen- and children-headed households.

Equity may also demand that support is specifically tar-geted towards those households/communities more af-fected by a specific health/poverty related situation –such as Acquired Immune Deficiency Syndrome (AIDS).More ideas about assessing needs and demands can befound in Reference Box 9.

4. Will the program target specific types ofcommunities and if so which? Depending on the institutional and demographic shapeof the country, it may sometimes be appropriate to pro-gramme specifically for rural, small town or urban situa-tions. Better programming may result from different ap-proaches being used for each type of community. On theother hand, it may be that better coverage could beachieved at lower costs if elements at least of the pro-gram (some aspects of hygiene promotion and sanitationmarketing for example) were developed for use nation-ally or across an entire region.

Targeting can also be used to reach communities whoare persistently excluded. Good information about cov-erage in rural, small town and urban areas may indicatea need to focus on one of these for example.

5. Will the program target specific segmentsof society and if so which? Some countries and regions may take a specific policy de-cision that public funds should be steered exclusively, orsubstantially, towards a specific segment of society. It isnot uncommon for countries to have a policy of target-ing the poorest, indigenous groups or specifically of thosewithout access to a minimum level of service. It is some-times difficult and costly to identify target communities,in which case proxy indicators (such as targeting sub re-gions where the incidence of poverty is high) may haveto be used. Sometimes the rich and powerful are ableto subvert such targeting, so if this approach is to betaken, explicit notice must be taken of how targeting isto be monitored and what incentives might be neededto secure funds for the stated objectives.

37


Chapter 4: Allocating Resources Strategically

4.2 The need for transparent rules

One of the most important mechanisms for establishingand maintaining trust between partners is to ensure that,where money is being allocated, there is a clear andtransparent process and a set of known rules. Whatev-er programming decisions are taken all partners shouldbe confident that (a) decisions about the rules for re-source allocation had a sound basis (even if the individ-uals disagree with the final decision); (b) resources arebeing allocated on the basis of these rules; and (c) boththe initial decision and the ongoing allocation of re-sources are carried out within an institutional arrange-

ment which precludes collusion and encourages the op-timum use of resources in the public interest. In many cases political reality may dictate the allocationof resources. This may mean that resources have to beshared equally between competing regions, or that moreresources must be steered towards areas of greaterpoverty. In such cases, where the case for resources al-location is not specifically technical, it is important to beas up-front as possible; most organisations and individu-als will accept that political processes are an importantpart of the institutional landscape.


For a discussion of demand in the context of water supply and sanitation projectsSee: Katz, T. and Sara, J. (1997) Making Rural Water Supply Sustainable: recommendations from a Global StudyUNDP-World Bank Water and Sanitation ProgramGet this reference at: [email protected]

For a discussion of the challenges of assessing and responding to needs and demands See: Cairncross, S. and Kinnear, J. (1992) Elasticity of Demand for Water in Khartoum, Sudan, Social Science andMedicine, 34 (2): pp183-189Dayal, R., C. van Wijk and N. Mukherjee (2000) Methodology for Participatory Assessments: Linking Sustainability withDemand, Gender and Poverty WSP on the web at www.wsp.org Coates, S., Sansom, K.R., Kayaga, S., Chary, S., Narendaer, A., and Njiru, C. (2003) Serving all Urban Consumers –a Marketing Approach to Water Services in Low and Middle-income countries. Volume 3 PREPP, WEDC, Loughbor-ough University, UK. on the web at www.lboro.ac.uk\wedcWhittington, D. (1998) Administering Contingent Valuation Surveys in Developing Countries World Development26(1): pp21-30Whittington, D. (2002) Improving the Performance of Contoingent Valuation Studies in Ddeveloping Countries Envi-ronmental and Resource Economics 22 (1-2): pp323-367Willing to Pay but Unwilling to Charge: Do Willingness to Pay Studies Make a Difference? WSP Water and SanitationProgram – South Asia Field Note (1999) on the web at www.wsp.orgWedgewood, A. and K. Samson (2003) Willingness-to-pay Surveys – A Streamlined Approach: Guidance notes forsmall town water services WEDC, Loughborough, UK. on the web at www.lboro.ac.uk\wedc

Reference Box 9: Needs and demands


4.3 Applying the Principles


TTaabbllee 55 sums up the principles as they apply to resource allocation.

Table 5: Applying the Principles to Resource Allocation


Use public funds toleverage, rather thansubstitute householdinvestment

Leverage expendi-tures across a rangeof social sectors

Achieving Equity

Consider targeting re-sources towards ex-cluded populationsand specific activitiesthat support the ex-cluded within commu-nities


Invest in informationgathering

Test ideas first wheninformation base isweak

Steer resources toareas where there isinstitutional capacityto spend


Ensure clear andtransparent processesfor allocation of fundsEstablish water-tightprocesses for trackingexpenditures

Communicate financ-ing decisions unam-biguously


Use resource alloca-tion to signal new ap-proaches and buildconfidence in them

Once decisions are made on what balance of resourceswill be steered towards activities, regions, communitiesand segments of society, what sort of instruments can theprogramme use to ensure that the programme aims areachieved? Clearly, this depends to some extent on theway in which programmes are to be financed and howorganisations are to be structured but some possible in-struments would include:

● Setting up targeted regional programmes or projects– setting aside funds specifically to be spent by localjurisdictions or by national agencies for designated re-gions;

● setting rules for externally funded interventions whichencourage funding to specific regions or in support ofagreed programming priorities;

● establishing demand-responsive funds which regions/urban centres or agencies could apply to use, wherethe rules of the fund reflect specifically the program-ming allocation priorities;

● creating (financial) incentives for staff of agencies towork in specific regions or communities; and

● setting aside funds to provide financial or other sup-port to non-governmental organisations and the smallscale private sector where these organisations seek tobuild their capacity in agreed programming priorityareas

39


Chapter 5: Financing

5.2 Where will the funds come from?

Sanitation and hygiene promotion come with a range ofcosts which can be covered from various sources. Theprogramme has to identify sources of funding for:

● Enabling Environment including the costs of pro-gramming, monitoring and evaluation, regulation,technical oversight, organizational change, training, co-ordination with other sectors, and public advocacy(to generate understanding of and support for thesector).

● Promoting Hygiene Behaviours based on asolid understanding of what current conditions are,and how they need to change to bring in the antici-pated health benefits. Thus financing is required for

assessing the current situation, development of mate-rials, training programmes, staff costs, transport andoffice overheads along with the ongoing costs of op-erating in communities and supporting a dynamicchange process at local level.

● Improving Access to Hardware including sani-tation marketing (costs include staff, transport, of-fice overheads, preparation of materials, cost of mediaplacement, training, construction of demonstration fa-cilities and other pilot interventions), capital costs(of household and shared facilities including materialsand labour) i, and operation and maintenancecosts (which will vary widely depending on the tech-nology chosen) ii.

The financing arrangements for the programme need to:

● be self sustaining (ie have internal integrity so thatfunds are always available for the key elements of theprogramme, and funding matches the responsibilitiesand capacities of different institutional partners);

● provide funds for all the agreed elements of the pro-gramme; and

● be consistent with the agreed principles.

In fact, the financing structure needs to be more than con-sistent with the agreed principles – the financing arrange-ments are likely to be one of the most powerful pro-gramming instruments for driving the application of those

principles which is why getting financing arrangementsright is such an important step in programming.

Costs may be covered from a range of sources including:

● central government;● regional / local / urban government; ● large scale private sector;● shared community resources; ● small scale private sector; and ● the household.

Note however, that any private sector investment will ul-timately be repaid from one of the other sources (gov-ernment, community or household).


5.1 What needs to be financed

Chapter 5 Financing

Sanitation and hygiene promotion have public and pri-vate costs and benefits. As a useful principle, public funds(government funds, external donor funds and so on)should generally be used to maximise public benefits; pri-vate funds should be used for essentially private elementsof the system (soap, individual latrines etc).

While the focus of financial planners may fall on financ-ing household investments in hardware, it is vitally im-

portant that adequate funding is available for all the otherelements of the programme and that household invest-ment is not out of scale with other supporting activities.For example, if investments are urgently needed in sani-tation for schools, public latrines in market places, and hy-giene promotion programmes, these are areas which, al-most by definition, need financial support from publicsources or explicit policy support to generate privatefunding (for privately- constructed and managed public

5.3 Assigning Programme Costs


TTaabbllee 66 illustrates four financing models, not to suggest that these are the only approaches but rather to show how arange of solutions may be employed in different cases.

Table 6: Illustrative Financing Models

Role


Hygiene Promotion

Sanitation Marketing

Capital costs

Operation andmaintenance

Urban, higher levels of subsidy to utility andhousehold

National government

Urban government

Urban government

Utility, repaid byurban government

Utility with grants fortrunk services,Household for house-hold services

Urban, no house-hold subsidy

Urban government

Urban government

Utility, repaid byhousehold

Utility, repaid byhousehold

Utility with grant forwaste water treat-ment, Household forall other

Rural, householdsubsidy

National government

Local / regional gov-ernment


Household and localgovernment

Household

Rural, no house-hold subsidy

National government



Household

Household

It is important to note here, that even the “no subsidy”model comes with significant public costs in the shape ofadministration, regulation, monitoring and evaluation andso on. The public benefits of sanitation and hygiene

promotion (and the corresponding public cost if no ac-tion is taken) mean that, whatever financial regime isadopted, government retains significant responsibilitiesand attendant costs.

latrines for example). Only once the financial structureof the whole programme has been established, will it bepossible to judge whether financial support to householdinvestments are appropriate or can be provided fromavailable sources.

In particular it is worth considering how grant and con-cessionary funding (available domestically or through ex-ternal support mechanisms) can be most effectively har-nessed to support the programme within the context ofwider poverty-reduction goals. The ultimate scale andnature of the programme should be decided on this basisand not in isolation.

Broadly costs might be allocated as follows:

● Enabling EnvironmentThese costs would normally be covered from nationalgovernment budgets, except in cases where federatedstates or autonomous urban areas take full responsibili-ty for programmes and have the financial means (throughlocal taxation) to support these costs.

● Promoting Hygiene BehavioursBecause hygiene promotion has a strong “public good”element, it would normally be part of the supporting roleof the programme and be covered from governmentsources at the appropriate level. This is a good area fortargeting soft or grant-funding from external sourcessince these costs are unlikely to be recovered from users.

● Improving Access to Hardware● Sanitation marketing costs may be covered from

government sources or from the private sector iii. ● The financing of capital costs of sanitation hard-

ware has traditionally been the significant elementin many sanitation programmes. What is arguedhere is that this is counterproductive and in mostcases sanitation hardware should be the responsi-bility of households. However this places a re-sponsibility on programmers to support and pro-mote goods and services which are appropriate.A further discussion of subsidies is included inSection 6.5 iv.

● In most cases households would be expected tocover operation and maintenance costsv.

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5.4 Household self-financing – sanitation

5.5 Subsidies for sanitation

Where demand is sufficiently high, households may bewilling to meet the full capital and operational costs ofsanitation. Formal willingness-to-pay surveys can provideinformation about this, but they are expensive and diffi-cult to administer. As a first step, informal discussion, andparticipatory evaluations can be used to confirm whetherself-financing is viable. Some proxy-indicators of appro-priate levels of willingness-to-pay include:

● ownership of consumer durables of equivalent value;● high percentage of private house ownership;● extremely poor sanitary conditions, linked to high lev-

els of dissatisfaction; and

Relying on household investments for hardware inter-ventions can be problematic where:

● demand is low (due to conflicting demands on house-hold resources, high levels of poverty or low levels ofawareness);

● household action will have limited effect due to con-gested conditions (often in urban areas this problemis exacerbated because the only viable technical op-tion is piped sewerage of some sort); or

● there is a high percentage of rented accommodation– householders may be unwilling to invest in a housewhich is not their own, owners may be unwilling toinvest where tenants are readily available to rent poorquality housing.

In such cases subsidies may be advocated to jump-startlatent demand or in the interests of equity – to encour-age increased access for targeted segments of society.Many “sanitation” programmes have provided capitalcost subsidies which were either available universally (thisis always the case for piped sewerage for example), avail-able through means- testing which linked subsidies to“poverty”, or linked to specific levels of service. Theseprogrammes have consistently exhibited a set of prob-lems including:

● lack of financial sustainability; a policy which states thatcertain, usually poor, people are entitled to free or re-duced cost services, is meaningless if there are inade-quate public funds to support it;

● general awareness of health problems and the linkswith poor sanitation.

Where households are expected to finance sanitationthe message must be clearly articulated and unambigu-ously applied. Many households may be reluctant tomake the needed investments if they believe that (a) for-mer subsidy programmes are still operating; (b) subsidiesare likely to be reinstated; (c) alternative agencies mayprovide subsidies; or (d) subsidies can be made availableif pressure is brought to bear through local politicians.

● the relationship between poverty and access is morecomplex than programmers imagine - there may bemany reasons why people do not access services -cost may not be the most important. In this situationsubsidies may not increase access;

● subsidised facilities built during a pilot phase may ac-tually suppress demand as other households wait andsee if a subsidy will also come their way;

● subsidies often create expectations that cannot befulfilled in surrounding areas and among other incomegroups;

● the use of subsidies for construction of “standard” fa-cilities distorts the market and suppresses innovationsthat might bring down costs;

● substandard construction of “subsidized” latrines maysuppress demand;

● subsidies aimed at helping the poorest sometimes as-sociate a certain technology with poverty and theneed for assistance further distorting demand;

● means-testing for subsidies is expensive and ex-tremely difficult; and

● requesting a down payment or contribution to assessdemand before a subsidy is released may exclude thepoorest households.

If subsidies are to be used, programmers need to thinkcarefully and select a subsidy mechanism which is likelyto (a) achieve the intended policy outcome; (b) reach theintended target group; (c) be financially sustainable; and(d) be implemented in a clear and transparent manner.



The following general principles should always be ap-plied:

● in the public interest use subsidies to maximise healthbenefits and increase access specifically to groups whoare persistently excluded;

● subsidise the lowest possible level of service to max-imise spread and avoid distortions to the market.Leave room for households to make incremental im-provements over time;

● base subsidies on solid and rigorous informationabout what types of service people want and are will-ing-to-pay for, what is the affordability for the targetgroup, and what can be scaled up in the long term.

The range of sanitation subsidy instruments are summa-rized in TTaabbllee 77 and discussed further in the notes sec-tion6.

Table 7: Subsidy Mechanisms

Mechanism

Subsidies for latrine construction

Social subsidies

Consumption subsidies throughthe tariff (Urban networks)

Access subsidies through the tariff(urban networks)

Strengths

Direct link between input and output-Targets those households without ac-cess

Lower per-latrine costs. May supportlatent local suppliers

Uses existing tariff collection and pay-ment system

Addresses access problem directly andmay be better targeted

Weaknesses

Expensive and complex Overdesign and high costsInadequate funds to complete latrinesStifles innovation and the local marketProne to corruptionLimited reach

Targeting may be poorRequires national social policy frame-work

Poor targeting (does not reach the un-connected)May not overcome access barriersDoes not support in-house costs

Usually links water and sanitation - maynot reach some households who re-quire sanitation alone.

5.6 Supporting self-financing through micro-financeThe alternative to subsidies is the provision of appropri-ate financing services – commonly credit, but also ex-tending to savings, insurance and so on. Many micro-fi-nance programmes have failed in the past. This is oftenbecause financial services were provided by organisationswhich lacked the appropriate financial skills and failed tooffer an appropriate mix of services, or failed to establishtheir own financial integrity. In addition, provision of fi-nancial services can be very difficult in situations where:

● inflation has been or still is very high;● interest rates are high;● it is uncommon to borrow money for capital goods;● legal/ regulatory controls limit the activities of small

scale specialist credit agencies or prohibit lending for“non-productive assets”; or

● many ad hoc financial obligations make plannedhousehold expenditures very difficult for low-incomehouseholds.

If micro-finance is likely to be an important element ofthe programme then it is important to consider the fol-lowing possible programming interventions:

● policy / legal / regulatory changes to encourage smallscale financial service providers;

● capacity building for financial service providers to as-sist with a move into infrastructure service provision

43



5.7 Generating revenue for sanitation and hygiene promotion

5.8 Financial instruments to promote reform

● capacity building for non-governmental organisationsworking in infrastructure to assist with a move intomicro-finance;

● provision of seed funds, partial or full guarantees orother financial instruments to encourage on-lendingto small scale borrowers;

Moving away from the household as the focus of financ-ing, it may still be possible to use cross-subsidy or othermechanisms to generate some revenue which can beused to support hygiene promotion and sanitation in-vestments. Examples of possible tools include:

● levying a surcharge on water bills to finance new con-nections to sanitation networks, or hygiene promo-tion activities;

Financial instruments can also be used to promote re-forms which are needed to improve the enabling envi-ronment. This can be done, for example, by making fundsavailable in a way that creates incentives for local juris-dictions to change policies and innovate. Examples ofthese types of instruments include:● conditional grants (either tied to specific sectors and

activities, or granted on a discretionary basis) fromhigher to lower-tiers of government or departments;

● conditional grants linked to demonstrated improve-ments in performance;

● social investment funds/ special projects, independ-ently managed and able to provide grants to commu-nities in response to demand;

● community development funds, focused on creatingsocial capital in the poorest communities with opera-tional costs covered through fund income;

● institutional-reform-linked challenge fundsvii, to meetthe transactions costs of institutional reform;

● sector-wide frameworks within which poverty reduc-tion is linked to overall sector finance strategies – in-cluding: the sector-wide approach (SWAp) and Medi-um Term Expenditure Framework (MTEF) which arelinked to debt relief; investment lending (from devel-opment Banks) for sector investment and maintenance(SIM) and adaptable program lending (APL); and ad-justment lending through sector adjustment loans(SECAL) or poverty-reduction support credit (PRSC).

● cross subsidizing from richer households paying forsewered connections, to provide funds for on-site andlower costs public services; and

● building costs of extension of sanitation and hygienepromotion services into general utility tariff structures.

● pro-active use of concessionary development fundsfrom External Support Agencies to finance or guar-antee micro-finance services.


For more details on some of the availablefinancial instruments

See: Mehta, M., (2003) Meeting the FinancingChallenge for Water Supply and Sanitation: Incen-tives to Promote Reforms, Leveraging Resourcesand Improve Targeting World Bank, WSP Waterand Sanitation ProgramNew Designs for Water and Sanitation Transac-tions: Making Private Sector Participation work forthe Poor WSP Water and Sanitation Program,PPIAF (2002)Varley, R.C.G. (1995) Financial Services and En-vironmental Health: Household Credit for Waterand Sanitation EHP Applied Study No.2, Arling-ton VA.Credit Connections: Meeting the InfrastructureNeeds of the Informal Sector through microfinancein urban India. Issues Paper and Field Notes,WSP Water and Sanitation Program South Asia

Get these references on the web from:www.wsp.org or www.whelpdesk.org

Reference Box 10: Financial instruments




5.11 Practical Examples from the Field:How will we pay for the programme?

Table 8 shows how the principles can be applied when designing financial instruments.

Whatever financing mechanisms are chosen, they willneed to be established through the programmingprocess. This might require a number of interventionsincluding:● the development of specific policies backed up with

regulations and possibly a regulatory structure formonitoring (this might be the case for subsidies forexample);

In Lesotho a quiet revolution has been underway for thepast twenty years. In that time, the government has suc-cessfully increased national sanitation coverage from 20%to approximately 53%. The goal of reducing morbidityand mortality attributable to diseases associated withpoor sanitation through health and hygiene promotionand the promotion of VIP latrines appears to be beingachieved. During this time the policies of the governmentof Lesotho have specifically shifted away from subsidiz-ing latrines; much more money is now channeled to-wards promotion and training.

Table 8: Applying the Principles to Financing


Use public funds tomaximise public bene-fits; private (house-hold) finance shouldgenerally be reservedfor private elementsof the system (soap,latrines)

Achieving Equity

Ensure the financialregime is stable andsustainable

Use subsidies onlywhere they increaseaccess for the exclud-ed

Distribute adequatefunds to ensure soft-ware support reachesremote and poor re-gions


Understand whatpeople want and arewilling to pay for andpromote appropriategoods and services


Involve potentialfunding partners inprogramming deci-sions


Use specialized finan-cial skills in pro-gramme design

Allocate specific re-sources to capacitybuilding

● the establishment of a specific fund mechanism forhandling either programmatic or household financ-ing;

● the strengthening of an existing subsidy or fundmechanism (for example social funds) to enablethem to handle the new arrangements for financingof sanitation and hygiene promotion; and

● capacity building.

Key financial aspects of this story include; consistent sig-nificant allocation of the regular government budget tosanitation; and earmarking of these funds for promotion,training local artisans, and monitoring. In rural areas, gov-ernment funds are also used “to supply basic latrine com-ponents ‘at cost’ to households” to keep prices as low aspossible. The government also provides a subsidythrough its operation of the “loss-making pit-emptyingservice”. No direct subsidies are provided to house-holds. The main challenge of the arrangement appears to

45




be that the sanitation budget is mainstreamed at districtlevel in the health budget – which means sanitation com-petes with curative care for allocation of funds and manydecision makers view the latter as a priority. The sanita-tion budget has therefore experienced a decline over re-cent years. In addition the government separately pro-vides a 50% subsidy to the school sanitation programme.The total investments made by households is estimatedto be in the range of 3 to 6 times the government con-tribution.

In Mozambique the success of the National SanitationProgramme has been attributable in part to the abilityand willingness of external support agencies to providefunds for the subsidized provision of the domed latrineslab. A 1999 review of the program estimated that donorfunds accounted for a little over 50% of the costs of theprogramme with users contributing a little less than 40%and the government less than 10%. Nonetheless, theability of the programme to deliver the direct subsidy ina transparent manner and without massive overheadcosts, appear to have resulted in a fairly cost-effectivetransfer of resources to households. Furthermore, thesubsidies appear to have been effective because theywere specifically linked to the delivery of the componentof hygiene improvement whose cost was the major bar-rier to many households accessing latrines at all. This un-derstanding, developed through thorough research atthe outset of the programme resulted in a well-designedand targeted subsidy, and consequently an effective pro-gramme delivered at scale.

By contrast, the high cost of twin-pit pour flush latrines,adopted as a standard technology in India, resulted in theneed for a massive subsidy programme. This resulted in“fundamental difficulties of sustainability, bureaucracy andsuppression of any real demand for sanitation”.

Micro finance (both credit, savings and insurance) canplay a part in supporting household investment in sanita-tion where there is demand. Micro finance providers inIndia have conventionally been excluded from providingcredit for infrastructure which is not deemed to be a pro-ductive asset. Recent efforts by micro finance providersand the government with support from the World Bankhave resulted in a realignment of policies and incentivesso that provision of services can become more effective.In the isolated cases where investments in householdsanitation have been documented, the productive valueof the increased safety and convenience afforded by a

household latrine are reported to be significant, particu-larly for those employed in the informal economy.

In South Africa the long-term reform process has beensupported by a consistent allocation of governmentfunds for capital works (mostly, it must be said, expend-ed on water supply). This ability of the government tosupport investments in parallel with a programmingprocess has had a significant positive effect on the levelof support for reform. Investment funds can be used tosupport reform in other ways too; in India the govern-ment is establishing a city challenge fund which will beavailable to support the activities of cities undertaking dif-ficult local reforms and reorganizing service deliveryarrangements. Where public funds are scarce, internalcross subsidies are sometimes used to support sanitation;Burkina Faso applies an internal cross subsidy in the formof a sanitation surcharge on the water bill of all connect-ed water consumers, the resultant resources are ear-marked to provide sanitation to excluded populations.


Case Study Box 3: How will we pay for the programme?

The description of the financing arrangements in Lesotho comes from Pearson, I. (2002) The National Sanita-tion Programme in Lesotho: How Political Leadership Achieved Long-Term Results Field Note 5 in the Blue-Gold Se-ries, Water and Sanitation Program – Africa Region, NairobiThe National Sanitation Programme in Mozambique is described in: Colin, J. (2002) The National Sanitation Pro-gramme in Mozambique: Pioneering Peri-Urban Sanitation Field Note 9 in the Blue-Gold Series, Water and Sani-tation Program – Africa Region, Nairobi and in Saywell, D. (1999) Sanitation Programmes Revisited WELL StudyTask No: 161 WELL – Water and Environmental Sanitation – London and Loughborough, London.The analysis of the impacts of India’s use of the TPPF latrine is based on Kolsky, P., E Bauman, R Bhatia, J.Chilton, C. van Wijk (2000) Learning from Experience: Evalutaiton of UNICEF”s Water and Environmental Sanita-tion Programme in India 1966-1998 Swedish International Development Cooperation Agency, StockholmMore information on microfinance for infrastructure can be found in World Bank (forthcoming) SustainablePrivate Financing of Community Infrastructure in India Report to the Government of India, World Bank, DFID. Ex-amples from India are in WSP-South Asia (2000) Credit Connections: Meeting the Infrastructure Needs of the In-formal Sector through microfinance in urban India. Issues Paper and Field Notes, WSP Water and Sanitation Pro-gram South AsiaReference is made to the city challenge fund in Mehta, M., (2003) Meeting the Financing Challenge for Water Sup-ply and Sanitation: Incentives to Promote Reforms, Leveraging Resources and Improve Targeting World Bank, WSPWater and Sanitation ProgramFor more information on South Africa’s Reforms see Muller, M. (2002) The National Water and Sanitation Pro-gramme in South Africa: Turning the ‘Right to Water’ into Reality Field Note 7 in the Blue-Gold Series, Waterand Sanitation Program – Africa Region, Nairobi and Elledge, M.F., Rosensweig, F. and Warner, D.B. with J.Austin and E.A. Perez (2002) Guidelines for the Assessment of National Sanitation Policies Environmental HealthProject, Arlington VA p.4The sanitation surcharge in Burkina Faso is described in Ouedraougo, A.J., and Kolsky, P. (2002) Partnershipamd Innovation for on-site sanitation in Ouagadougou, Burkina Faso Waterlines, Vol21, No2, pp9-11, October2002

47



Notes on Chapter 5:

i Capital costs for construction may be limited in rural areas to house-hold level facilities (although some investment in shared facilities, andfor the treatment and disposal of wastewater may be required). Inurban areas, in addition to household investments there may be sub-stantial costs associated with connecting to a sewerage network or informal collection and management of pit and septic tank waste. Labourand materials may be more expensive and attract greater overheadsif contractors are involved in construction. Where waste water treat-ment and disposal is included costs will rise significantly.

ii For simple rural schemes operation and maintenance costs may berelatively low but they will rise in urban areas and where shared facil-ities are constructed. In extreme cases with pumped sewerage, costsare likely to be prohibitively high.

iii In urban areas where there is an autonomous utility the costs of mar-keting sanitation to all consumers are likely to be covered from theutility budget (public or private). In those rural areas where the po-tential for local small scale provision is high, these costs may also ulti-mately be covered by small scales businesses which stand to recoupthem through the sale of sanitary goods. In the short term some sup-porting funding or credit may be needed from government to help pri-vate sector providers launch sanitation marketing efforts. Wherethere is no private sector with the requisite skills and where non-pri-vate sector solutions are to be used, then these costs will probably bepart of government support to the programme.

iv Note that in urban areas, there is almost always an element of sub-sidy, particularly where networked solutions are used. Even in West-ern Europe no cities fully recover the costs of wastewater treatmentfrom consumers.

v In rural areas or urban areas with on-site solutions this is easy to or-ganize through direct payment for pit emptying if it is required. In urbanareas the situation may become more complicated with some ele-ments of the costs being recovered directly (for example where house-holds pay a fee for emptying of septic tanks or pits), some through thetariff (where households have water connections as well as sanitaryservices they may pay a surcharge on the water bill for sanitation) andsome being subsidized (for example by grant payments from govern-ment to a utility which is operating a sewerage system.)

vi Types of Sanitation Subsidy

Subsidies for latrine construction

Direct Subsidies for latrine construction have been provided for manyyears in many countries. In this approach, public funds are usually madeavailable to households to cover all or part of the cost of constructionof a “standard” latrine. The funds may be delivered to the householdin advance, in installments during construction, or in arrears. Alter-natively, the household can apply for a latrine which is then built underthe direct supervision of government engineers with no money han-dled by the householder at all. These subsidy arrangements are char-acterized by a number of problems. They tend to be: expensive andcomplex to administer (usually a government engineer needs to certi-fy each latrine, often more than once);prone to cost related problems– standard designs may be over-designed and over-priced, or under-priced because standard rates used in the estimate may be outdated;and unresponsive to the bulk of demand, because costs are too high,or because there is insufficient capacity to respond.

Nonetheless they have proved popular because they deliver a quan-tifiable product and, particularly in rural areas, are one of the only waysin which many technical departments of government have been able torespond to the sanitation challenge.

Social subsidies

In a very few cases, social subsidies based on overall poverty indica-tors are available to the poorest households. These can then be spenton whatever services are most needed by the household. These sys-tems (of which Chile has the best known example) have lower per capi-ta costs than dedicated sanitation subsidy schemes and do not distortthe market for sanitation goods and services in the same way, as house-holds are free to purchase whatever they require on the open market.

However, such a system is only feasible if there is a national policyframework in place across all the social sectors.

Subsidised Consumption in Urban Areas

In areas with piped water and sewerage, government subsidies arecommonly delivered via the tariff. In these cases the subsidy on theuse of sanitation is usually achieved by proxy through subsidised con-sumption of water. The most common form of this is a cross-subsidylinked to overall water consumption (by means of an increasing blocktariff). This type of approach only benefits those people already con-nected to the network – which usually excludes the poor. It also con-tains a number of inherent biases against poor households who mayuse less water and thus benefit from a lower proportion of the sub-sidy, and against poor households who share connections and who maytherefore end up paying at the higher rate. It also does little or noth-ing to help households with the costs of in-house facilities (taps andtoilets) which are needed if private health benefits are to be realized.

Subsidised access to piped networks

More interesting approaches have been developed in some cases, tosupport new customers connecting to the water and sewerage net-work in urban areas. Historically, the real costs of connecting to urbanwater and sewerage networks were not borne by consumers. In con-trast much or all of the technical costs of connecting may now be trans-ferred to new consumers. This is unfair and contains a strong biasagainst the poor who are usually the ones who are not yet connectedto the network. In view of this, some utilities are attempting to struc-ture subsidies by increasing the general tariff and removing or reduc-ing the one-off connection fees associated with joining the network.This is an important step forward, recognizing as it does, that povertyand lack of access often go hand in hand.

vii A challenge fund, usually provided by central government, provides fi-nancial support to local administrations who show a willingness to re-form themselves in line with certain agreed general principles. Thefunds would usually be used to finance the actual process of institu-tional reform – including working out what needs to be done, and mak-ing the necessary policy, financial and organizational changes.



6.2 What will define successful organisations in your Programme?

With the right skills and well organized arrangements thevision of an effective sanitation and hygiene promotionprogramme can become a reality on the ground. Work-ing out which organisations should be involved, whatthey should do, and what support is needed to develophuman resources is a critical and exciting part of pro-gramming for change.

New organizational arrangements need to be:● consistent with your chosen vision and principles;● designed to make best use of government, NGOs, the

private sector, and grassroots organisations;● organised in a way which supports rather than sub-

verts community-level institutions and promoteshousehold decision making;

● staffed and funded adequately to deliver the agreedprogramme; and

● consistent with the political organisation of the coun-try, particularly the level of decentralization.

Building the right institutional arrangements is one of themost critical steps in programme development but it isusually the most difficult. Costly and difficult institutionalreorganizations should only be undertaken as a last re-sort. Much of what you need probably already exists.Programmers need to ask themselves:

● are there front-line units who can deliver elements ofthe programme?; and

● are there agencies/organisations who can supportthese units and provide the needed enabling environ-ment within which they can function?

The human resources you need may be found in a widevariety of places including:

● government agencies: including water and sanita-tion agencies, health departments, education depart-ments, environmental agencies, rural developmentteams, urban planning departments, local government.Human resources may be available at all levels of gov-ernment from the national down to the local level;

● civil society: households themselves, NGOs (work-ing in water supply , sanitation, social development,health, education etc), community based groups, self-help groups, local/community government, micro-fi-nance organisations etc; and

● private sector - small scale private providers, soapcompanies, building contractors, advertising agencies,media etc.

However, much of what exists may not be geared up toreflect the principles of good sanitation and hygiene pro-motion. Key aspects of many organisations may need tochange; the challenge is to find effective ways to makethis happen. Some of the characteristics of the newbreed of organisations include:

A focus on equity Organisations working locally, require specific skills andpersonnel to be able to focus on household needs andreach all segments of society (women and men, youth

and the elderly, different ethnic groups, those with accessto services and those without). One of the key and press-ing needs in many organisations is to realign responsibil-ities and build capacity so that the currently excluded seg-ments can become the focus of interventions. This lack of local level skill, is mirrored within organisa-tions, where ironically it is often staff with precisely theprofile to address these concerns, who are marginalizedbecause of their professional profile, or on the groundsof gender or age. It is crucial that the gendered natureof sanitation and hygiene promotion is acknowledged

6.1 Who is going to deliver your Programme?

Chapter 6 Roles and Responsibilities – Restructuring Organisations

49


Chapter 6: Roles and Responibilities – Restructuring Organisations

6.3 Allocation of Responsibilities

6.4 Capacity Building Approaches

and action is taken to change the orientation of tradition-al organisations, so that they can effectively work with thegroups who most need their support.

A focus on working in partnership It takes more than a single organisation to support sanita-tion and hygiene promotion. A huge number of peopleneed to start to act in a different way, which requires amassive realignment of the incentives which drive them.This discussion is about more than “inter agency coordi-nation”, it is about creating an interlinked web of people

all of whom are acting in response to the needs and de-mands of households.

Accountability and PerformanceFor this partnership to work the vision should be for in-stitutions which have:

● clear and distinct organizational responsibilities;● adequate accountability (checks and balances) to safe-

guard resources and ensure effectiveness; and● incentives to perform.

Examples of novel arrangements that emphasize a rolefor a range of partners do exist although few have ex-tended to national level. There is no “blue-print” solutionbut the following broad allocations of responsibility arecurrently a popular approach:

● National government: facilitation of programming,policy development, creation of facilitative laws andregulations, publication of verified national data oncoverage and progress, financing for technical assis-tance to small scale providers, community groups etc;

● Regional / local government: management ofhygiene promotion and community development ac-tivities (which may be carried out by in-house staff oroutsourced), monitoring of technical issues, licensingof small scale providers, certification of communitysupport organisations, coordination of local monitor-ing and collation of data for planning purposes, etc;

● Urban government: provision and managementof trunk services and facilities in some cases (either di-

rectly or through a utility), management of wastes, li-censing of small scale providers, oversight of creditproviders, technical assistance to communities etc

● NGOs: technical support to communities, delivery ofhygiene promotion and community development sup-port, provision of credit services, oversight of progressthrough participatory monitoring and evaluation etc;

● Small Scale Private Providers: sale and deliveryof sanitation goods and services, contribution to plan-ning and programming activities, may also providecredit directly or through dedicated credit providersetc;

● Communities; participatory planning, identificationof appropriate local institutions for management ofresources and facilities, assessment and negotiation oflocal demands, management of internal cross subsidiesif needed etc;

● Households; key investment decision making, fi-nancing and management of facilities, hygiene behav-iours and outcomes.

It has already been stated that capacity should be built inthe process of organisational change. While some ca-pacity building occurs because of structural changes toorganisations themselves, specific support can be pro-vided through two broad approaches. The first is train-ing to build individual skills, and the second could betermed organizational capacity building and would in-clude such interventions as strategic planning, manage-ment development, strengthening of systems and pro-

cedures (e.g. information and financial systems), devel-opment of technical approaches and methodologies, re-structuring, and staff developmenti.Capacity building can be particularly challenging when re-sponsibilities are decentralized. You may need to allo-cate a large percentage of resources and effort tostrengthen the performance of front-line teams if youwant the new vision of sanitation and hygiene promotionto become a reality.



Organisational change can be costly, time consuming and,if handled badly, deeply dispiriting for staff and the gen-eral public alike. While managers in the private sectorcan take unilateral decisions and act rapidly, this is rarelypossible in the public sector. Change may have to occurwithin the context of complex public- service rules andregulations. Organisational changes may only be possi-ble once wider policy/ legal changes have been made. Most commentators agree that the best approach to or-ganizational change involves eight broad steps: establish-ing a sense of urgency, forming a guiding coalition, creat-ing a vision, empowering others to act on the vision,planning and creating short-term successes, consolidatingimprovements; and institutionalizing new approaches.This list echoes the programming process discussed in

Section Two and suggests that reshaping organisationsshould be seen as an integral part of the new sanitationand hygiene promotion programme.

Different countries and contexts will demand differentapproaches, but you may consider some of the follow-ing tools:

● formal working groups at the highest level which main-tain transparency, ensure people feel represented andto lend legitimacy to the process;

● specialized sub-committees to represent specific in-terest groups (organized around services or interestgroups); and

● wide consultation.

6.5 Managing the Change Process

The principles of good programming can be used ot guide both the process and the outcome of organizational re-structuring as shown in Table 9.



Table 9: Applying the Principles to Organisational Restructuring


Reflect the central im-portance of house-hold decision making

Invest in capacitybuilding at local levels.

Build capacity of regu-lators and others set-ting public policy

Achieving Equity

Build capacity withinorganisations to en-gage with all segmentsof society

Change the orienta-tion of traditional or-ganisations to reflectthe gendered natureof sanitation and hy-giene promotion


Understand the exist-ing institutional land-scape

Look at non-tradition-al actors (small scaleindependent pro-viders, voluntary or-ganisations etc) whileanalyzing organisa-tions


Establish organisationswhich have: clear re-sponsibilities; ade-quate accountability;and incentives to per-form.


Invest in capacitybuilding and managingthe change process.

Allocate resourcesfor this up front

Organisational restructuring will rarely take place for san-itation and hygiene promotion alone. Ideally it shouldoccur within a wider review of how social sector supportin general is delivered. It may be appropriate to wait fora wider social development catalyst (such as the prepara-tion of a Poverty Reduction Strategy Paper for example).Once it is clear that organizational restructuring is re-

quired a number of long term programming instrumentscould be brought to bear including:

● Restructuring of organizational profiles of public agen-cies, through proactive hiring and redundancies, togradually shift the balance of skills;

● Realignment of resources and priorities in training or-

51



ganisations (schools and higher education) to changethe balance of skills entering the workforce;

● Provision of incentives (usually financial) to encouragestaff of public agencies to move into specific regions,or into the private sector, in response to program-matic priorities;

● Provision of incentives to encourage innovation andlocal level coordination between agencies;

● Hiring of specific management skills to support a shiftin the approach to service provision;

● Financial and other technical support to build the ca-pacity of potential programme partners (public sector,small scale private sector, NGOs etc);

● Explicit provision of funds (usually from central gov-ernment) to support the above restructuring inter-ventions;

● Capacity building of existing organisations specificallyto increase their effectiveness in sanitation and hy-giene promotion (for example, training water supplyregulators to work more effectively in sanitation, twin-ning utilities in different regions of the country so thatlessons learned in one region can be effectively passedon); and

● Linking as many staff as possible to participatory pro-gramming activities so that capacity can be built in ashared environment of learning and change.

For ideas on a range of approaches to organizing the sector and managing organizational change

See: Blokland M., Lilian Saade and Meine Pieter van Dijk (2003) InstitutionalArrangements for Municipal Wastewater and Sanitation - case studies from Argentina,India, Mexico, Philippines, South Africa, Switzerland and Zambia, Institutional andManagement Options Working Group, Water Supply and Sanitation CollaborativeCouncilBrocklehurst, C. (Ed) New Designs for Water and Sanitation Transactions: Making the Pri-vate Sector Work for the Poor, WSP Water and Sanitation Program, PPIAF (2002)Clayton, A., (1999) Contracts or Partnerships: Working Through Local NGOs in Ghana andNepal ,WaterAID, LondonCullivan, D.E. et al (1988) Guidelines for Institutional Assessment for Water and WastewaterInstitutions, WASH Technical Report No. 37, USAID, Washington.Edwards D.B. (1988) Managing Institutional Development Projects: Water and Sanitation Sec-tor, WASH Technical Report 49, USAID, Washington.Macdonald, M., Sprenger, E., Dubel, I. (1997) Gender and organizational change: bridging thegap between policy and practice. Royal Tropical Institute, The NetherlandsSaadé, C., Massee Bateman, Diane B. Bendahmane (2001) The Story of a Successful Public-Private Partnership in Central America: Handwashing for Diarrheal Disease Prevention USAID,BASICS II, EHP, UNICEF, The World Bank Group Sansom, K.R., Franceys, R., Njiru, C., Kayaga S., Coates S. and Chary S., J. (2003 - forth-coming), Serving all urban consumers – a marketing approach to water services in low and mid-dle income countries. Volume 1 - guidance notes for government’s enabling role, WEDC,Loughborough University, UK.Sansom, K.R., Franceys, R., Njiru, C., Kayaga S., Coates S. and Chary S., J. (2003 - forth-coming), Serving all urban consumers – a marketing approach to water services in low and mid-dle income countries. Volume 2 - guidance notes for managers, WEDC, LoughboroughUniversity, UK.

Subramanian, A., Jagannathan, N.V.& Meinzen-Dick, R. (eds) (1997) User organizationsfor sustainable water services (World Bank Technical Paper 354). World Bank,Washington, DC.

Reference Box 11: Organizational roles and responsibilities


>


WELL (1998) DFID Guidance Manual on Water and sanitation Programmes, WEDC,Loughborough University, UK.Yacoob M. and Rosensweig F., (1992) Institutionalising Community Management: Processesfor Scaling Up, WASH Technical Report No. 76, USAID, Washington.

Get these references on the web from: www.wsp.org or www.whelpdesk.org and good technical libraries

For more details on how to manage organizational change effectivelySee: Cockman P., Evans B. and Reynolds P. (1999), Consulting for real people – a client-centred approach for change agents and leaders, McGraw Hill, UK

DFID (2003) Promoting institutional and organisational development, Department for In-ternational Development, London, UK

Edwards D.B. (1988) Managing Institutional Development Projects: Water and SanitationSector, WASH Technical Report 49, USAID, Washington.

Edward D.B., Rosensweig F., and Salt E. (1993) Designing and implementing decentralisa-tion programs in the water and sanitation sector, WASH Technical Report 49, USAID,Washington.

Ideas for a Change (1997) Part 1: Strategic processes – how are you managing organisation-al change? Part 2: Organisational diagnosis – how well do you read your organisation? OlivePublications, Durban, South Africa

Russell-Jones, N. (1995) The managing change pocketbook. Management PocketbooksLtd, Alresford, Hants

Senior B. (2002) Organisational Change, second edition, Pearson Education Limited (), UK

Get these references from: good technical libraries and on the web at www.lboro.ac.uk and www.dfid.gov.uk

Examples of root-and-branch restructuring are rare,largely because such changes are politically difficult, tech-nically challenging and can also be expensive in the shortterm. Many governments would hesitate before insti-tuting a complete overhaul of service delivery arrange-ments. However, such reforms can yield impressive re-sults, and there have been successful examples. In Chilefor example, the government carried out a completeoverhaul of water supply and sanitation service delivery

arrangements for urban areas which paved the way forprivatization which occurred about ten years after the re-structuring. In Nicaragua, reforms have also been madein the way both water supply and sanitation are over-seen. There is a concensus that while Nicaragua did avery good job of addressing planning and regulatory func-tions, service delivery remains a problem.

6.8 Practical Examples from the Field:Who’s going to deliver our programme?

>

53



For many countries, such complete reforms may seemtoo daunting. In many cases it seems unlikely that realprogress can be made without some sort of reorganiza-tion, but some countries have managed to develop in-novative organizational arrangements within the frame-work of existing formal structures.

In 1995 and 1996 USAID carried out an evaluation of anorganisation which it had been supporting in Cambodia.The Program officer for USAID in Cambodia concludedthat the organisation, whose name is “Partners for De-velopment” “take their name…very seriously in work-ing with villagers, NGOs and the government of Cam-bodia”. The review noted that PFD had been instru-mental in “revitalizing and stablising some of the mostremote and under-served areas of Cambodia….using ademand responsive approach to rural community devel-opment.” The role of PFD has been to introduce andpromote technologies appropriate to the village com-munities. But PFD has gone beyond this, constantlyworking to improve the technologies and approachesand evolving their approach to fit with communitiesneeds. Here it is possible to see that a flexible but high-ly professional non-governmental organisation has beenable to influence the approach to rural community de-velopment within a government programme.

In the Swajal Project in Uttar Pradesh in India, the gov-ernment of Uttar Pradesh developed a highly formalisedapproach to selecting, training and contracting with sup-port organisations who then worked with communitiesto build their capacity to plan and implement rural watersupply and sanitation projects. The approach developedin Swajal is now widely applied across India – almost anyorganisation is eligible to apply to become a support or-ganisation – in Swajal the majority were NGOs but pri-vate sector and governmental organisations also partici-pated. The arrangement was challenging; many NGOswere uncomfortable with the contractual relationship,while government was often uneasy with the outspokenviews of the support organisations. Inherent in this ex-perience is the challenge of finding ways to work to-gether which safeguard public funds and agreed policies,while enabling the creativity and flexibility of non-gov-ernmental partners full play to influence the approach.

In Kerala, where the Dutch government supported theestablishment of decentralized support organisations,known as Socio Economic Units as part of a long-termproject, the SEUs were able to evolve into a permanent

and effective support organisation for rural developmentin the State. Here the SEUs themselves were instru-mental in devising approaches which then became partof a state wide programme.

Non-governmental organisations may also seek engageformal or government agencies in programmes they havedeveloped but here too the experience is mixed. Per-haps the best known urban sanitation programme, theOrangi Pilot Project in Pakistan, has persistently struggledto get the utility in Karachi to recognize the investmentsalready made by households in the Orangi neighbour-hood in sanitation, and this experience has been repli-cated in many places across the country.

On the other hand, in West Bengal the experience of theRama Krishna Mission, with support from UNICEF, hashad a fundamental influence on State and ultimately na-tional policy. The original project, which was launched inthe early 1990s and continues to this day, shifted insti-tutional responsibilities to the local level—successfullyforging an action coalition between local NGOs, com-munity-based organisations, and Panchayats (the lowestform of local government, usually covering three villages).Existing local youth groups and their cluster organisa-tions, working together with local panchayats, were gal-vanized by an effective intermediary NGO, the Ramakr-ishna Mission Lokashiksha Parishad (RMLP). The youthclubs conducted much of the implementation in coordi-nation with the panchayat, and a subcommittee calledthe “WATSAN committee” was responsible for com-munity-level implementation. Cluster organisations of theyouth clubs, at block level, backstopped with logistics andcoordinated hardware inputs. They were, in turn, sup-ported by RMLP. The role of the central and state gov-ernments and district officials was to provide financialand technical support and to help adjust appropriate sup-portive policies. UNICEF provided technical and financialassistance for the overall effort.

Formal partnerships for specific hygiene activities, whichinvolve both government, non-governmental and privatebodies, are gaining prominence. In Central America,USAID, UNICEF and the World Bank supported an in-novative partnership between private soap manufactur-ers and the public sector to promote handwashing withsoap. A 2001 evaluation of the partnership concludedthat the public and private benefits had been high com-pared with costs. The evaluation also listed the follow-ing critical factors in the success of the partnership; pres-



ence of an experienced and neutral catalyst; a goodcause; a clear road map; solid market research; publichealth backing; clear allocation of roles, responsibilitiesand expectations; joint decision making; sequencingwhich enabled timely progress to be made.

Working with private sector providers of goods and serv-ices is challenging however. The main problems seem torevolve around finding mechanisms to support privateproviders (for example, masons, pit emptying contrac-tors, vendors of soap and other hardware) which do notstifle the private sector market. A 2000 evaluation ofUNICEF’s water supply and sanitation programmes inIndia noted that support to the Rural Sanitary Marts (a“one-stop” retail outlet which sells sanitation constructionmaterials and hygiene products) was “an intuitively at-tractive idea” as it linked service provision to a revenuestream and would seem to reduce the need for publicsubsidy. However, progress in setting up RSMs was slow(between 1994 and 1999 UNICEF established only 558RSMs in various states). Many of these subsequently wentout of business or barely managed to break–even. Theproblem seems to have been that early successes with theapproach were not analysed in sufficient detail to deter-mine the critical features of success. UNICEF’s experi-ence with RSMs globally is extremely important for coun-

tries seeking ways to work with and support small scaleentrepreneurs in the hygiene improvement business.

In Honduras the government decided to reorganize thepublic utility to develop a flexible and responsive ap-proach to supporting rural water supply and sanitation atcommunity level. The “TOM” program established mo-bile “Technician in Operation and Maintenance” posi-tions, based in regional offices of the national utility.These regional offices have substantial authority to makedecisions. Based on the “circuit rider” model of the USA,the mobile technicians have been able to provide con-sistent support to communities seeking to manage theirown systems and the arrangement has been operatingsuccessfully since 1995. The arrangement was first pi-loted for two years in one department, and this is a use-ful lesson in how to test and then roll out innovative or-ganizational arrangements.

Most of these experiences show us that in any pro-gramme which relies on multiple organisations to deliv-er a coordinated array of goods and services, the qualityof the partnerships between them may be at least as im-portant as their individual performance in determiningthe outcome.

55



Case Study Box 4: Who’s Going to Deliver our Program?

The reforms in Chile are described in detail in Bitrán, G.A. and Valenzuela E.P. (2003) Water Services in Chile:Comparing Public and Private Performance World Bank Private Sector and Infrastructure Network, Public Poli-cy for the Private Sector Note No. 255The reforms in Nicaragua are described in Walker, I. and Velásquez, M. (1999) Regional Analysis of Decentrali-sation of Water Supply and Sanitation Services in Central America and the Dominican Republic Environmental HealthProject Activity Report No. 65, Washington D.C.More information on Partners for Development can be found in Environmental Health Project (2002) North-east Cambodia Community Water and Health Educational Program, USAID Grant No. 442-G-97-00008-0, Final Eval-uation.The Swajal Pilot Project is described in various publications. A useful starting point is WSP-SA (2001) Com-munity Contracting in Rural Water Supply and Sanitation: The Swajal Project, India Water and Sanitation Program.Further information on the government of India’s rural water supply and sanitation programme is availablewith the Rajiv Gandhi National Drinking Water Mission on the web at www.rural.nic.in/rgndw.htm . TheSEUs in Kerala are described in Van Wijk-Sijbesma, C. (2003) Scaling Up Community-managed water supplyand sanitation projects in India presentation to the IDPAD Water Seminar, IHE, Delft, The Netherlands, May12-13, 2003The Midnapore experience has been written up in many places, but an interesting perspective from the mid1990s can be found in UNICEF (1994) Sanitation, the Medinipur Story, Intensive Sanitation Project, UNICEF-Calcutta, India, and Ramasubban, K.S., and B.B. Samanta (1994) Integrated Sanitation Project, Medinipur, UNICEF,India.The handwashing partnership in Central America is described in detail in Saadé, C., Massee Bateman, DianeB. Bendahmane (2001) The Story of a Successful Public-Private Partnership in Central America: Handwashing for Di-arrheal Disease Prevention USAID, BASICS II, EHP, UNICEF, The World Bank Group The experience of RSMs in India is described in Kolsky, P., E Bauman, R Bhatia, J. Chilton, C. van Wijk (2000)Learning from Experience: Evalutaiton of UNICEF”s Water and Environmental Sanitation Programme in India 1966-1998 Swedish International Development Cooperation Agency, StockholmThe institutional arrangements in Honduras are described in Fragano, F.,C. Linares, H. Lockwood, D. Rivera,A. Trevett, G. Yepes (2001)Case Studies on Decentralisation of Water Supply and Sanitation Services in Latin Amer-ica Environmental Health Project Strategic Paper No. 1, Washington D.C.

Notes for Chapter 6

i Training approaches might include:

● Formation and strengthening of training networks – these mightinvolve numerous disciplines and attract participation from pub-lic, private and civil society organisations, or alternatively theymay be more focused, providing a “safe space” for colleagues towork together to build internal capacity;

● Twinning and/or secondment of staff – to facilitate practical shar-ing of experience and build up mutual understanding of how dif-ferent partners work; and

● Formal in-service and continuing education – one of the real con-straints in many public sector agencies and in NGOs is that staffare so focused on working at field level that they are not able tokeep up with new ideas and find time to think about how theymight undertake their jobs more effectively. Creating a cultureof inquiry is challenging, particularly where organisations have atradition of top-down command and control, but the capacity toquestion how things are done can be built. It may be best tolaunch efforts at a formal level – responding to the prevailing cul-ture of the organisation, if successful, the process can move onto become more acquisitive over time.



7.2 What is Monitoring and Evaluation?

Monitoring and evaluation enable programmers to seewhether things are happening on the ground as plannedand whether activities are resulting in the expected out-comes. Results from both monitoring and evaluation areneeded as inputs to the ongoing programming process.

While evaluations can be handled on a periodic basis,monitoring systems are needed to generate regular reli-able datasets which can provide a picture of what is hap-pening in real time and over time. As a general rule themonitoring system should be:

● simple – providing just enough information for deci-sions to be taken;

Monitoring systems provide a rapid and continuousassessment of what is happening. Monitoring is primarilyneeded at the implementation (project) level to showwhether:

● inputs (investments, activities, decisions) are beingmade as planned;

● inputs are leading to expected outputs (latrines built,behaviours changed); and

● inputs are being made within the agreed vision andrules.

Evaluation provides a more systematic assessment ofwhether visions and objectives are being achieved in thelong run in the most effective manner possible. “Forma-tive” evaluation aims to diagnose problems, and is bestdone internally for maximum learning and capacity build-ing. “Summative” evaluation is aimed at deciding whichoutcomes have been achieved (it measures, for example,

whether resources have been spent as intended) and isan important tool in generating confidence in the pro-gramme. It is usually best done externally, to increasecredibility.

Neither monitoring nor evaluation are designed to es-tablish causal links between interventions and outcomes(proving for example a link between handwashing andreduced incidence of diarrhoea). This type of causal con-nection is the subject of research which should be usedas the basis for programme design. Where there aregaps in the empirical evidence base for sanitation and hy-giene promotion, specific research may have to be com-missioned to prove such relationships.

Table 10 sums up the main uses of monitoring and eval-uation within both programmes and at the project (im-plementation) level.

● decentralised - operating at the lowest appropriatelevel and providing information where it is needed tomake necessary decisions;

● responsive – providing information where it is need-ed in real time;

● transparent – providing access to information bothupwards and downwards; and

● relevant – based on the vision and objectives of theprogramme.

There is some truth in the saying that “what gets moni-tored, gets done” – the design of the monitoring systemcould have a profound effect on how well the pro-gramme is actually implemented. For this reason key out-comes and activities must be monitored.

7.1 Thinking about Monitoring and Evaluation

Chapter 7 Monitoring and Evaluation

57


Chapter 7: Monitoring and Evaluation

7.3 What to Monitor and Evaluate?

At the programmatic level it is essential to monitor keyresults (ideally improved health) to ensure that public in-vestments are resulting in public benefits. However,monitoring long term health trends is difficult and can

probably only be the subject of periodic evaluation. In-stead, it is often more practical to measure service cov-erage, use of facilities and hygiene behaviors.

Table 10: Uses of Monitoring and Evaluation

Programme planning, development and design

Project level implementation

Monitoring

Measure crude inputs and outputs (usea progamme performance monitoringplan with agreed indicators) Track processes and instruments (usethe monitoring system, and informationmanagement systems with periodic re-porting)

Assess whether programme is ontrack, delivering services, conformingto standards and targeting the rightpeople (establish a routine monitoringsystem) Motivate communities to solve prob-lems (use participatory communitymonitoring) Quality assurance (through supervi-sion)

Evaluation

Asssess needs, problems and assets(through situation analysis) Establish a baseline reference point(use baseline quantitative data collec-tion) Explore programming options andidentify solutions (carry out formative,qualitative studies)

Check whether implementation is re-sulting in the delivery of the programmevision and objectives (mid-term evalua-tions or periodic reviews can be usedto correct approaches) Assess whether projects resulted inthe desired impact and outcomes (finalevaluations, covering quantitative andqualitative assessments) Solve technicalor programmatic problems (throughoperations research).

Based on available research and experience, most sectorexperts agree that if certain key behaviours occur at thehousehold level then it is reasonable to assume thathealth benefits will follow. The Environmental HealthProject suggest that the following four essential house-hold practices are key to the reduction in diarrhoeal dis-ease:

1. wash hands properly with soap (or local alternative)at critical times (includes the availability of a place forhandwashing and soap);

2. dispose of all faeces safely – especially those of youngchildren who cannot easily use a toilet;

3. practice safe drinking water management in thehousehold (includes the use of an improved watersource, safe water storage, and possibly water treat-ment at the point-of-use; and

4. practice safe food management in the household.

A sanitation and hygiene promotion programme willclearly influence the first two of these behaviours, and, ifwell designed, should also impact on water and food hy-giene.Monitoring and evaluation can thus focus on these keybehaviours, and on a selection of easy-to-measure inputsto generate a picture of what is happening on the groundand what are the primary results. While the exact ap-proach may vary with your programme Table 11 sug-gests a generalized framework for monitoring whichwould provide simple and robust information at the pro-grammatic and at the implementation level. While mostof these indicators can be monitored using regular mon-itoring tools (see Table 12) those marked in bold mayrequire verification through periodic evaluations.Note that at the implementation level you may need moredetailed information about changed behaviours at thehousehold level. These should be the subject of detailedproject monitoring systems. For more information on thedesign and use of indicators see Reference Box 12.



Table 11: Indicative Programme Performance Monitoring Plan for Sanitation and Hygiene Promotion

Improved Health

Essential Household Practice

Programming and Policy

Financial Instruments

Organisational Restructuring

Access to Sanitation technology

Hygiene Promotion

Objective

i) Reduced incidence or preva-lence of diarrhoeal diseaseii) Reduced incidence or preva-lence of other key disease groups

i) Incidence of handwashingii) Proper disposal of adult faecesiii) Proper disposal of children'sfaeces

i) Development of real partner-ships for optimum policy develop-mentii) improved equity of access

i) Improved efficiency ii) Financial sustainability (100% ofoperation costs for providing im-proved sanitation and hygienepromotion funded on a continu-ous basis)

i) Alignment of organisations tosupport household decision mak-ing

i) Access to improved sanitationfacilitiesi) Acces to improved sanitation facilities

i) All households show a substan-tial improvement in essentialhousehold practicesii) All primary schools complywith basic water supply, sanitationand hygiene standards

Suggested indicator(inputs)

i) total public investment instrengthening regulatory/oversightroleii) New policies dealing explicitlywith securing access for poor andvulnerable households

i) - total cost of programme-funding provided by source(government, private, house-hold)- number of agencies involved

i) front-line staff with skills towork effectively with householdsand communities in all necessaryorganisations.

i) - total household and public ex-penditure on sanitation facilities - communities covered by sanita-tion marketing

i) total public expenditure on hy-giene promotionii) communities with active hy-giene promotion through commu-nity-based promotors

Suggested indicator (outputs)

i) % of children under 36months with diarrhoea in thelast 2 weeksii) Incidence (number of newcases) of trachoma, guineaworm, etc.

i) % householders washinghands at appropriate timesii) % of adults whose feacesare disposed of safelyiii) % of children under 36months whose feaces are dis-posed of safely

i) number of positive changesmade in policy, legal and regulato-ry instrumentsii) distribution (on geograph-ic, social, gender and commu-nal grounds) of - improved sanitation cover-age - range of technologies avail-able and affordable by poorhouseholds - primary schools with safewater and improved sanita-tion

i) sanitation coverage - poorhouseholdsii) percent of operating costs re-covered from users/households

i) % of household heads know-ing: - who to contact to accesssanitation goods and service- who to contact if sanitationfacility breaks down

i) % of households with access toan improved sanitation facility

i) % of adults in householdswho know critical times forhandwashingii) % of households who useimproved sanitation facilitiesiii) % of schools with - sanitation facilities - separate sanitation facilities

for boys and girls - handwashing facility - sanitation and hygiene

teaching

Implementation Outcomes

Programme Results

Creation of Enabling Environment

59



7.4 How to do the Monitoring and Evaluation?

There are a wide range of tools available which can beused to generate information for monitoring and evalu-ation purposes. It is important to locate the responsibil-ity for these tasks in an appropriate institutional home.Where possible monitoring should be carried out byagencies who can make immediate use of the informa-tion. As mentioned above, some evaluation is best car-

ried out externally. Furthermore it is important to havein place a process for disseminating the results of moni-toring and evaluation exercises, to increase accountabil-ity and to ensure that data is used as widely and effec-tively as possible. Table 12 provides examples of thebroad range of tools available. Reference Box 12 pointsto sources of more information on this important topic.

Table 12: Some Tools for Monitoring and Evaluation

Tools

Responsibility

Dissemination of results

Monitoring

● Sanitation surveillance question-naires

● Network/ system operation andmaintenance checklists

● Supervision checklists● Financial summary/ audits● Participatory monitoring tools

● Ministry of health/ water and sanita-tion/ rural development/ urban de-velopment etc

● Utility● Local government· Communities

·● Public score cards and report cards● Publish in newspapers/ radio/ TV

spots● Provide fliers or other information

in community locations in rural andurban communities

·● Annual/ regular institutional report-ing

● Internet

Evaluation

● Situation analyses, technical, socialand institutional reviews● Participatory impact assessments/Participatory rapid appraisals● Sanitation and hygiene model ques-tionnaires● Qualitative studies, mid-term andfinal evaluations

● As for monitoring but use should bemade of independent public or privatesector organisations with skills in evalu-ation techniques● Non-governmental organisations·Umbrella/ apex professional bodies● Universities● National statistics or census bureaus

● As for monitoring plus● Journal articles/ conference papersetc● TV/ Radio profiles


For information on the global monitoring systemSee: Joint Monitoring Program of UNICEF and WHO and the Global Assessment (2000) ReportGet this reference on the web at: www.wssinfo.org

For ideas on setting up monitoring and evaluation systems including the selection and design ofindicatorsSee: Kleinau, E., D.Pyle, L. Nichols, F. Rosensweig, L. Cogswell and A Tomasek (2003) Guidelines for AssessingHygiene Improvement At Household and Community Level Environmental Health Project Startegic Report No. 8 on the web at: www.ehp.org

Reference Box 12: Monitoring and evaluation

>



Principles of good programming can equally be appliedto the monitoring and evaluation systems, both in the de-sign of the approach and in the aspects of the pro-

gramme which are the focus of monitoring and evalua-tion efforts (see Table 13).

Table 13: Applying the Principles to Monitoring and Evaluation


Design a systemwhich is

● Simple● Decentralised● Responsive● Transparent● Consistent with

the programme vi-sion and objectives

Measure public andprivate benefits

Achieving Equity

Ensure information isavailable upwards anddownwards to em-power participants asmuch as possible

Ensure coverage datatake into account dis-tribution of access be-tween differentgroups


Use existing monitor-ing and evaluationmechanisms andprocesses. Base onexisting evidence ofcausal relationships

Link upwards to in-ternational monitor-ing systems (ie JMP)


Make use of all avail-able institutional ca-pacity for monitoringand evaluation


Link monitoring infor-mation to capacitybuilding; make infor-mation available anduse it to analyse per-formance

WELL (1998) DFID Guidance Manual on Water Supply and Sanitation Programmes WEDC Loughborough Univer-sity, UK on the web at: www.lboro.ac.uk\wedc Kathleen Shordt (2000) Monitoring for Action IRC, Delft, Netherlands

For other ideas about monitoring and evaluation tools See: Naryan, D. n.d. Participatory Evaluation: Tools for Managing Change in Water Technical Paper No. 207, WorldBankRoark, P. (1990) Evaluation Guidelines for Community-Based Water ad Sanitation Projects WASH Technical ReportNo. 64, Arlington VA.Hutton, Guy (undated, c.2002) Considerations in evaluating the cost effectiveness of environmental health interventionscited in Appleton, Brian and Dr Christine van Wijk (2003) Hygiene Promotion: Thematic Overview Paper IRC In-ternational Water and Sanitation CentreGet this reference on the web at: www.irc.nl Dayal, R., C. van Wijk and N. Mukherjee (2000) Methodology for Participatory Assessments: Linking Sustainability withDemand, Gender and Poverty WSPGet this reference on the web at: www.wsp.org/english/activities/pla.html

Reference Box 12: Monitoring and evaluation>

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The most important programming decisions relating tomonitoring and evaluation are probably allocating ade-quate resources, elevating status to an M&E system, andcredible technical competencies. Programmers need todecide early on in the programming process:

● Who will be responsible for M&E;● What will be monitored and at what scale;● How will M&E be funded; and

● How and when will the information be used in theprogramming process.

Key to the success of monitoring and evaluation are sys-tematic planning and implementation. This means thatthese activities such the development of a performancemonitoring plan, a baseline and impact data collection,and the development of a monitoring system are includ-ed in the program strategy and work plans including thenecessary human and financial resources.

7.7 Practical Examples from the Field: How will we knowwhether our programme is working?Monitoring systems are only as good as the informationthey contain. Because of this, simple and relevant indi-cators must be identified and adapted for each situation,drawing as much as possible on existing indicators. Thisincreases the ability to compare findings within a coun-try and over time. A recent evaluation of definitions of“access” to “improved sanitation” in sub-saharan Africafound that there was little consistency between defini-tions used in different countries or with the definitionscontained in the Joint Monitoring Program (JMP). On re-flection this is not surprising, as national definitions will fallin line with national approaches to investment and withlocal cultural and social norms. So for example, while theJMP does not include “traditional latrines” in its definitionof improved sanitation, some African countries feel thatthis is a good first step on the sanitation ladder, and counthouseholds with access to a traditional latrine as covered.

Data collected can be used in many ways for making pro-gram decisions. Two environmental health assessmentsconducted by Save the Children and EHP in 2001 and2002 in the West Bank of Palestine found serious con-tamination of drinking water with thermotolerant fecalcoliform bacteria. The quality was much worse for waterdelivered by tanker than for other sources. These find-ings led to program interventions that focus on thechemical treatment of tanker water and cisterns used byhouseholds to store water.

Formative research and household surveys in the DRCongo suggested that soap was widely available tohouseholds in rural and urban areas, but that handwash-

ing behaviors were largely inadequate. Sanitation facili-ties were present, but mostly unusable. The SANRUprogram decided to start hygiene promotion by inte-grating behavior change for handwashing into an existingPrimary Health Care program and to address sanitationat a later point until the resources to improve sanitationfacilities were available.

While definitions of access and coverage must beworked out in each case, these must be translated intosimple formats to enable information to be collectedconsistently and reliably. In Honduras for example, theM&E system for water supply defines four categories ofsystem:

A – in full working orderB – possibly not working but actions of the Mobile Main-

tenance Technician could easily bring it up to “A”C – possibly not working and requires investments which

are within the economic capacity of the communityD – not working-substantial investment required prob-

ably beyond the economic capacity of the commu-nity.

This simple typology enables the mobile technicians whovisit them periodically to easily keep account of the sta-tus of all the systems under their remit thus rapidly build-ing up a national picture of who is covered with functionalsystems. The beauty of this approach is that it is simple;allows for continuous real-time monitoring, takes into ac-count the condition of the system, not just whether it wasoriginally constructed; and makes use of the existing op-



eration and maintenance arrangement to collect datarather than setting up a separate M&E function. Getting hold of information on sanitation coverage andhygienic practices is likely to be much more challengingthan getting information on water supply. A study inthree countries in East Asia used participatory techniques

to uncover a range of inherent biases hidden beneathgeneralized coverage statistics. Nonetheless, with care-ful design, a few key indicators can almost certainly be de-vised in most cases to generate manageable informationfor monitoring programmatic outcomes.

Case Study Box 5: How will we know whether our programme is working?

The Joint Monitoring Programme of UNICEF and WHO provides some guidance on what is to be monitored,and also gives access to global information on progress towards the Millennium Development Goals. It canbe found on the web at www.wssinfor.org.Definitions of Access are discussed in Evans, B. and J. Davis (2003) Water Supply and Sanitation in Africa: Defin-ing Access Paper presented at the SADC conference, Reaching the Millennium Development GoalsExperiences from the West Bank and DR Congo are summarised in the following two documents which alsoprovide links to other resources: Camp Dresser McKee (2003) West Bank Village Water and Sanitation Pro-gram: Findings from Environmental Health Assessments Environmental Health Project Brief No. 17, July 2003and Camp Dresser McKee (2003) Improving Urban Environmental Health in Democratic Republic of Congo Envi-ronmental Health Project Brief No. 16, June 2003.The institutional arrangements in Honduras are described in Fragano, F.,C. Linares, H. Lockwood, D. Rivera,A. Trevett, G. Yepes (2001) Case Studies on Decentralisation of Water Supply and Sanitation Services in Latin Amer-ica Environmental Health Project Strategic Paper No. 1, Washington D.C.Sanitation experiences in East Asia are described in Mukherjee, N. (2001) Achieving Sustained Sanitation for thePoor: Policy and Strategy Lessons from Participatory Assessments in Cambodia, Indonesia and Vietnam Water andSanitation Program for East Asia and the Pacific

Notes for Chapter 7:

i Additional monitoring indicators dealing with access to water and othersanitary facilities can be added, to provide a more comprehensive pic-ture of progress towards wider hygiene improvement goals (see Klein-au et.al. (2003) for detailed ideas on how to establish a full scale mon-itoring system at both project and programme level).


SECTION FOUR:PROGRAMMING FOR BETTER IMPLEMENTATION

This section focuses on the challenges of working with communities and households, hygiene pro-motion and selection and marketing of sanitation technologies. The practical implications ofadopting a new approach which focuses on household behaviour change and investment, are sig-nificant and will be briefly reviewed here. It is not the intention of this section to provide detailedguidance on project level implementation but rather to highlight where the realities of workingat the local level with households and communities, can impact on programmatic decisions. Byreviewing what is now known about working effectively at this level the recommendations of Sec-tion Three can be seen in their right context. Chapter 8 discusses the implications of the new approach in terms of how front-line units needto interact with both households and communities. The types of tools and resources they needto do this effectively are briefly discussed. Chapter 9 briefly introduces some approaches toHygiene Promotion – what is currently known about how to make it effective and how to or-ganize it so that it achieves the maximum possible impact are also covered. Chapter 10 talksabout how to select and market technologies. For detailed implementation guidance the readeris directed to other sources; the information presented here is intended as an introduction forthose professionals who do not have experience or knowledge about what has been learnedabout effecting sanitation and hygiene promotion and also to stimulate sector professionals tothink about the wider programming implications of what is known in the field.

The shift away from public construction of latrines to amore complete approach to sanitation and hygiene pro-motion places the household at the centre of decisionmaking. But it also implies a strong role for the commu-nity in planning and management of interventions. Whilemany of the needed changes will happen at the house-hold level, in some contexts some decisions and actionsmay need to be taken collectively by the community.Such shared action may relate to:

● local decision making about the most appropriaterange of sanitation solutions (communities may needto decide whether they are willing and able to man-

age shared facilities or whether they can all afford toinvest in private household facilities);

● local management and oversight of the household ac-tions as they relate to the communal environment(preventing discharge of household excreta in publicplaces for example);

● management of solid wastes, sullage and storm waterdrainage;

● management and financing for operation and mainte-nance of facilities which impact on the shared envi-ronment (this may include operation of shared facili-ties such as drains, but might also include a sharedcommitment to support maintenance and operation

8.1 The different roles for communities and households

Chapter 8 Working with Communities and Households


of household facilities such as latrines); and● organisation of joint action to lobby service providers

to perform at the margins of the community (for ex-ample, creating pressure for a utility service providerto operate and manage trunk sewers in an urban con-text, or lobbying for public support to regional oper-ation and maintenance service providers).

There are a range of approaches to management ofshared or community facilities including:

● direct community management through elected orappointed committees or other groups;

● delegated management to a trained member or mem-bers of the community;

● delegated management to a professional voluntary,private or public service provider.

Depending on the context (including whether the com-munity exists in a rural or urban environment, and thetype of technologies which are feasible) each communi-ty needs to work out the best way to approach issues ofshared responsibility.

8.2 Building capacity at the community levelWhile there are often clear advantages to collective com-munity action in sanitation and hygiene promotion, it isoften challenging to provide the right sort of support toenable communities to reach their full potential in thesenew roles. As well as the need to build up specific skills(such as planning or book-keeping), communities mayneed support to overcome entrenched biases and inter-

nal conflicts, or they may need support as they begin toengage with other local institutions (such as local gov-ernment bodies, field units of technical agencies, bankers,shop keepers, private suppliers of goods and servicesetc). Capacity building needs at this level will vary enor-mously, but will need to be addressed (planned for, fi-nanced, staffed and implemented), if collective action isto be successful.

8.3 Communicating EffectivelyTo achieve the vision of placing communities and house-holds at the centre of behavour change, service providersand other support agencies have primarily to become ex-pert at communication. Programmers may consider thatthe objective of working with the community is to:

● promote changes in hygiene behaviours;● market and deliver sanitation technologies; and ● build systems of community management.

However, communities and households may have differ-ence perspectives, and see a sanitation and hygiene pro-motion programme as an opportunity to engage with awider social development process. It may often bepreferable to organize work in the community in this

way, so that a range of social objectives can be achievedby the community, with the proper priority placed oneach.

Communication also has to be two-way because each ofthe areas of intervention above involve decisions tochange how things are done within the house and with-in the community. Facilitators of hygiene improvementwill not be able influence these decisions without a thor-ough understanding of the environment and contextswithin which they will be taken. Households and com-munities have much to offer programmers in terms ofproviding the keys which enable changes to take placethrough joint effort.


SECTION FOUR: PROGRAMMING FOR BETTER IMPLEMENTATION

Chapter 8: Working with Communities and Households

8.5 The Tools

Having identified the available resources and agreed onthe objectives of community level interventions, gener-ic tools and approaches can be selected and modified foruse in the specific context under consideration. Thetools commonly used in the water supply and sanitationsector include a full range from participatory planningand monitoring through to advertising and the use ofmass media (see Reference Box 13).

8.4 Selecting Community Level Tools

The type of community level interventions required willbe determined by a range of factors. These include:

● the types of behaviour that are to bechanged: for example where unhygienic practicesare deeply entrenched in cultural norms a more in-tensive hygiene promotion programme would beneeded as compared to a situation where personal hy-giene is good but sanitary facilities are lacking – in thiscase more emphasis might be placed on marketingsanitation goods;

● the magnitude of the problem and levels ofawareness: for example where the situation is verypoor and people are already aware of its impact onhealth, there will be more focus on facilitating changedbehaviours, whereas where awareness is low, thefocus will be much more on promoting awareness ofpreviously unknown risks;

● the nature of the communities (rural/ urban)and technologies likely to be used: for examplein scattered rural communities where on-site tech-nologies have been identified as appropriate, theremay be less need for up front mobilization of com-munity “organisation” for their installation than indense urban communities electing to use communallatrines or condominial sewers. Conversely, in thefirst case, more work may be needed to help the com-munity establish a viable long-term system for pit emp-tying and management of wastes, than would beneeded in an urban community using condominialsewers emptying into a working main sewer line;

● the institutional environment: for examplewhere the small scale private sector is likely to be a

key provider of services, marketing and local supportskills may derive from them, and additional communi-ty level interventions may not be required. Impor-tantly, where hygiene promotion is emphasized theremay need to be stronger involvement of health staffand a shift in roles for staff from technical water sup-ply and sanitation agencies;

● the skills available amongst field-workers lo-cally: what skills do field-workers (who may be lo-cated in government departments, NGOs or local or-ganisations) already possess, and what skills do theyhave the potential to learn;

● the nature of existing local organisations: vil-lage development committees, savings groups, wateruser and tapstand committees, handpump/waterpointcaretakers and mechanics, agricultural and forestrygroups, population and health committees alreadyabound, and sometimes their number and demandstax a community’s time and resources. Some of thesegroups could usefully place a priority on hygiene andsanitation. Linking into existing credit groups mayprove a valuable means to channel credit and subsi-dies for sanitation—and ensure equity as well as ac-countability—without creating a separate effort; and

● the availability of funds to support communi-ty level interventions: resources will ultimately de-termine what interventions can be used at what in-tensity for how long. In general local participatory ap-proaches will have higher costs than remote, massmedia type approaches but are likely to be an essen-tial element in achieving real change at the householdlevel.

Participatory Techniquesi

A range of participatory tools/techniques can be used inhygiene improvement programmes. Commonly usedtools include focus group discussions, neighbourhood so-cial mapping; transect walks; and household/school hy-giene self surveys.


Participatory Rural Appraisal (PRA), is a gener-alized description for a wide range of techniques espe-cially aimed at involving community members in decision-making and self-assessment and in the development ofstakeholder partnerships. PRA evolved through a simpli-fication of conventional techniques for data collectionand analysis. Community action planning, which requiresactive roles by community members, is well served byPRA techniques such as mapping of local problems andresources, wealth ranking, and similar tools. The “PRA”philosophy informs much of the thinking about partici-patory techniques in the sector and has been translatedinto a wide variety of contexts including urban slums.Many of the elements described above have been refinedfor the use of the water supply and sanitation sector andthe three the most commonly used combined ap-proaches are:

● PHAST (Participatory Hygiene and Sanitation Trans-formation) which was developed in Eastern andSouthern Africa in the mid-late 1990s. PHAST toolk-its can be used at the local level to bring about be-havioural changes in hygiene and sanitation.

● SARAR (Self-esteem, Associative strength, Respon-sibility, Action planning, and Resourcefulness) stimu-lates involvement in community-based activities of allkinds, not only by the more prestigious and articulateparticipants (such as community leaders or seriousstaff), but also by the less powerful, including the non-literate community members. SARAR is widely usedin participatory water, hygiene, and sanitation pro-grammes;

● Methodology for Participatory Appraisal(MPA) a selection of participatory techniques whichhave been refined and assembled for the participato-ry appraisal of projects and programmes.

Schools and Education systemsUse of schools, parent-teacher associations and childrenthemselves, are increasingly recognised as powerful toolsin promoting changed behaviours and greater awarenessof hygiene issues. These channels, and specialized toolsto utilize them, can be a key component in a communi-cation programme.

Mass Media and Advertising The use of mass media, and straight forward advertisingcan also play a role in hygiene improvement. These di-dactic interventions emphasize transmittal of messages topromote awareness, market products and transferknowledge. When used well these approaches can playan important role in overall behaviour change but shouldusually be used in tandem with more intensive local mar-keting techniques.

MarketingMarketing in the water supply and sanitation sectors haslong revolved around “social marketing” – where a rangeof tools are used in combination to target specific be-haviours such as hygienic practices or the use of a par-ticular technology. Once it is recognized that the mosteffective interventions in sanitation may be achievedthrough development of a viable sanitation business,marketing may become a major element of a hygiene im-provement programme. New approaches which linkcommercial marketing of goods and services at the locallevel, with national awareness campaigns and hygienepromotion programmes, may be effective in stimulatingthe demand-side of the market. The challenge will ofcourse be to match this demand-side support with suit-able approaches to build up the supply-side business toensure a ready supply of effective and appropriate goodsand services.

8.6 Scaling Up

Scaling up successful experiences of working with com-munities is notoriously difficult. By its very nature thistype of work is resource intensive – it requires a rangeof specialist skills, time and energy to build up real man-agement capacity within most communities in a new andchallenging field such as the management of sanitation.Most practitioners emphasise the need for a slow and

steady approach. This seems to contradict the urgentneed to scale up this type of work and roll it out to anincreasing number of communities. Furthermore, thetask may become progressively harder as the most chal-lenging (remote, poor, socially divided or technological-ly challenging) communities are likely to be left to thelast. Programmers can be proactive in ensuring that suc-




cessful pilot experiences are not translated into ineffec-tive “generic” packages for scaling up by:● emphasizing and planning for the fact that working at

the community level always requires time;● ensuring that capacity building of potential front-line

units and partners is built in to every positive experi-ence so that the number of skilled workers increasesexponentially as time passes;

● working to ensure coherence between efforts in arange of social sectors so that front line units buildingcapacity to organize education for example, can alsocontribute and reinforce community needs in sanita-tion management and vice versa; and

● allocating sufficient funds to this important aspect ofsanitation and hygiene promotion.

For: participatory tools and approachesSee: IRC. (1996). The community-managed sanitation programme in Kerala: Learning from experience. IRC, Danida,SEU Foundation, Kerala.NGO Forum for Drinking Water and Sanitation. (1996) Social mobilisation for sanitation projects. (Annual Report,1995-1996.), Dhaka, Bangladesh.Simpson-Hebert, M., R. Sawyer, and L. Clarke. (1996). The PHAST Initiative. Participatory hygiene and sanitation trans-formation: A new approach to working with communities. WHO, Geneva, Switzerland.Sawyer, R., M. Simpson-Herbert, S. Wood (1998). PHAST Step-by-Step Guide: a participatory approach for the con-trol of diarrhoeal disease. WHO, Geneva, Switzerland.Srinivasan, L. (1992). Tools for community participation. UNDP/PROWWESS. Ferron, S., J. Morgan and M. O’Reilly (2000) Hygiene Promotion: A practical Manual for Relief and Development Intermediate Technology Publications on behalf of CARE International

Reference Box 13: Communications approaches

8.7 Programming InstrumentsSelection of communications approaches to communityand household interventions are best made at the locallevel in the context of projects and local investments.However where the skills and knowledge of those or-ganisations and individuals charged with this interactionare weak, programmers may be able to influence the sit-uation through a number of simple programmatic inter-ventions including:

● Supporting institutional analysis at local level which en-ables realistic strategies for community intervention tobe developed;

● Carrying out an overall assessment into the local-levelconstraints and barriers to hygiene improvement sothat locally-tailored interventions can be designed ap-propriately based on a solid understanding of the de-mand side of the “market”;

● Supporting participatory research into the most ap-propriate field-based tools and approaches;

● Directing funds to training/ research bodies to devel-op and disseminate locally-specific versions of gener-ic tools;

● Providing funds for training of field-level generalists inthe specifics of the hygiene improvement programmeapproach so that they can use their skills effectively;and

● Earmarking funds for national/ programmatic level el-ements of the communications strategy (such as massmedia campaigns etc:

● Developing and disseminating manuals and guidelinesfor the development of local strategies;

● Providing adequate public funds at local level to sup-port participatory planning, local capacity building andongoing support to communities;

● Providing frameworks to support community opera-tion and maintenance and the development of con-federations of communities who wish to access sup-port services for sanitation; and

● Funding training and capacity building for (a) commu-nity development organisations in aspects of hygieneimprovement; and (b) technical service agencies incommunity development approaches.


8.8 Practical Examples from the Field:What will the community do?

A key challenge for sanitation and hygiene promotionprofessionals is to see how activities and communitymanagement organised around hygiene behaviours andsanitation hardware can and should be linked to existingcommunity and government structures. In Kerala, aDutch-government-supported sanitation programme, re-sulted in significant improvements in hygiene conditionsin a number of villages. Subsequently the approach wasadopted across the state, through pressure exerted byvillage panchayats (local government organisation) on thestate government. The strength of the initial project hadarisen in part because it took explicit notice of existingstructures and provided a clear role for the panchayatwhile also taking explicit action to support target groupsin the community, including women who wished to be-come masons and technicians.

In another Indian project; the Uttar Pradesh Rural Waterand Environmental Sanitation Project (SWAJAL), com-munities in the mountainous parts of Uttar Pradesh, wereempowered to plan and construct their own water sup-ply and sanitation systems. Groups from some villagestraveled to the plains to purchase pipes and other ma-terials, in some cases these journeys were undertaken bywomen-members of the Village Water and SanitationCommittees (VWSC) who had previously never lefttheir villages. Swajal also published a quarterly magazinefor participating villages which served as a news and com-munication tool in a dispersed rural area. While the spe-cific community-empowerment support-mechanisms setup in Swajal were clearly effective, there were someproblems because the institutional link to local govern-ment was not clarified. The government of India subse-quently took a much clearer line while rolling out someof the lessons from Swajal, in specifying the connectionbetween VWSCs and Panchayats.

In situations where water supply and sanitation institu-tions are stronger, it may be more challenging to devel-op local community-level capacity, unless the capacity ofthe utility itself is strengthened in this regard. In El Alto,Bolivia, a major investment of time and resources wentinto supporting the private water company as it devel-oped the condominial model for sanitation in the city.Input from a specialized support organisation, the Waterand Sanitation Program, was needed to build capacity forsocial mobilization, community contracting, participatoryplanning and monitoring, and in general to enable staff towork more effectively with communities.

In Burkina Faso, the Programme Saniya, used a combina-tion of local radio and face-to-face domestic visits, cou-pled with the transmission of messages in a traditional so-cial event called a djandjoba, to communicate well-craft-ed hygiene messages to carefully identified targetaudiences. In Zimbabwe, ZimAHEAD make use of theexisting structure of Environmental Health Technicians ofthe Ministry of Health who establish Community HealthClubs which become the focus for communication andcapacity building. In Mozambique the National SanitationProgramme took a low key approach to sanitation mar-keting, relying on word-of-mouth and the impact of fab-rication centres located in peri-urban localities to gener-ate demand. In central America a partnership with pri-vate soap manufacturers gave governments access tocommercial marketing skills for public health messages.

Key to any successful communication is clearly under-standing of what is to be communicated (what key prac-tices shall we try to change?); who is the target audience;and what are their existing communication habits andpractices. From this type of formative research tailoredcommunication strategies can grow.




Case Study Box 6: How shall we work with communities and households?

The description of the origins of the Clean Kerala Campaign is inVan Wijk-Sijbesma, C. (2003) Scaling Up Com-munity-managed water supply and sanitation projects in India presentation to the IDPAD Water Seminar, IHE,Delft, The Netherlands, May 12-13, 2003The Swajal Pilot Project is described in various publications. A useful starting point is WSP-SA (2001) Com-munity Contracting in Rural Water Supply and Sanitation: The Swajal Project, India Water and Sanitation ProgramThe El Alto experience is well documented on a dedicated website at www.wsp.orgFor an introduction to the programme, and information on the costs and benefits of the approach see Foster,V. (n.d.) Condominial Water and Sewerage Systems – Costs of Implementation of the Model Water and SantitationProgam, Vice Ministry of Basic Services (Government of Bolivia), Swedish International Development Coop-eration Agency. Programme Saniya and ZimAHEAD are described in Sidibe, M. and V. Curtis (2002) Hygiene Promotion in Burk-ina Faso and Zimbabwe: New Approaches to Behaviour Change Field Note No. 7 in the Blue Gold Series, Waterand Sanitation Program – Africa Region, NairobiThe handwashing partnership in Central America is described in detail in Saadé, C., Massee Bateman, DianeB. Bendahmane (2001) The Story of a Successful Public-Private Partnership in Central America: Handwashing for Di-arrheal Disease Prevention USAID, BASICS II, EHP, UNICEF, The World Bank Group

Notes for Chapter 8

i Much of this section draws on Brian Appleton and van Wijk, Christine(2003) Hygiene Promotion – Thematic Overview Paper IRC Interna-tional Water and Sanitation Centre


9.2 Making Sure Hygiene Promotion Works

Changing hygiene behaviours is a key element and, as wehave seen, may often be the most crucial step in achiev-ing health gains. Hygiene promotion is all about changingbehaviours. Despite this it is often neglected or margin-alized in programmes which state that they aim to im-prove hygiene; many of these programmes place muchgreater emphasis on the construction of hardware (oftenprioritizing water supply over sanitation). Not only doesthis mean that there is insufficient resources available foreffective hygiene promotion, but it also means that thehardware which is installed may be inappropriate be-cause it is not planned within an overall “hygiene im-provement” framework. In some cases these interven-tions may even make it more difficult for communitiesand households to improve hygiene and enjoy real healthbenefits. This may happen for example when designs areinappropriate and facilities cannot be used or where sec-tions of the community are excluded. To be effectivethen, sanitation and hygiene promotion programmesneed to be designed with the hygiene improvementframework in mind – ensuring adequate resources for allthree elements, and perhaps in some cases, focusing on

hygiene promotion ahead of construction of physical in-frastructure which may be a secondary, more long termstrategy.

Furthermore, hygiene promotion should be seen as amajor element in the programme requiring not only ad-equate financial resources, but also the requisite levels ofprofessional expertise and effort. Too often, engineersmay seek to “add on” a hygiene promotion componentto what is essentially a latrine construction programme,without due attention to the complexities of making hy-giene promotion effective. Importantly it is often neg-lected during the planning phase with insufficient atten-tion paid to gathering the types of information which areneeded to design really effective behaviour changestrategies. At the other end of the scale, insufficient timemay be made available for the needed changes in be-haviour to take root. Changes hygienic practices is oftena long term process, and it may not be achieved for ex-ample within the three year planning horizon of a con-ventional water supply project, or indeed the commonterm for a local political administration.

Much has been learned about making hygiene promotioneffective. Many of the key ideas are summarized in a use-ful Fact Sheet published by WELL i. These ideas aresummarized below:

● Build on what exists: A hygiene promotion pro-gramme should be based on a thorough understand-ing of: ● the most important risky practices which should be

targeted; ● who are primary/ secondary and tertiary audiences

for key messages;● who can most effectively motivate behaviour

change;● what may prevent behaviours;● how can audiences be most effectively reached;

and● how can the effectiveness of the programme be

measured.

Formative research is one approach which can be usedto develop the hygiene promotion strategy. Formativeresearch is a pragmatic approach to planning pro-grammes which has attributes that “make it a particular-ly useful component of…..sanitation programmes”. Theapproach is flexible and allows researchers to devise keyquestions which are specific to the community in whichthey are working. Answers can be used to develop a planof action ii.

● Target a small number of risk practices: Thepriorities for hygiene behaviour change are likely to in-clude handwashing with soap (or a local substitute)after contact with excreta, and the safe disposal ofadults’ and childrens’ excreta.

● Target specific audiences: audiences may includemothers, children, older siblings, fathers, opinion lead-ers, or other groups. An important group is those

9.1 Introduction

Chapter 9 Hygiene Promotion



Chapter 9: Hygiene Promotion

Table 14: Applying the Principles to Hygiene Promotion

Use hygiene promo-tion as a two-wayprocess of communi-cation to: (i) informand influence house-hold behaviours and(ii) gauge effectiveways of harnessingcommunal effort forthe public good

Support approachesto hygiene promotionwhich empower peo-ple rather than thosewhich present elitistor patronizing mes-sages

Support informationgathering so that hy-giene promotion canbe based on a thor-ough understandingof: key behaviours tochange; key audi-ences; key motivators;ways to change be-haviours; how toreach audiences; andhow to measure out-comes

Expand the range ofparticipants in hygienepromotion to ensurethat messages are re-inforced and deliveredin the long term

Invest in capacitybuilding to improveapproaches to hy-giene promotion


Achieving Equity Building on whatexists and is in demand



9.3 Applying the PrinciplesTable 14 shows how the principles of good programming can be applied to decisions about hygiene promotion.

people primarily involved with child care. Audiencesneed to be identified in each particular case.

● Identify the motives for changed behaviour:As mentioned elsewhere, these may have nothing todo with health. People may be persuaded to washtheir hands so that their neighbours will respect them,so that their hands smell nice, or for other reasons.Participatory planning with target groups can be usedto discover local views about disease, and ideas aboutthe benefits of safer hygiene practices. This can formthe basis for a hygiene promotion strategy.

● Hygiene messages need to be positive: peoplelearn best when they laugh, and will listen for a longertime if they are entertained. Programmes which at-

tempt to frighten audiences will probably alienatethem. Furthermore, messages consisting of “dos” and“don’ts” can be frustrating and demoralizing for thepoor particularly where they urge actions which areunrealistic for poor families iii.

As with all elements of the hygiene improvement pro-gramme, monitoring will be needed at the local level toensure that inputs are delivered and that they result inthe expected outcomes. At the programmatic level, itwill be essential to provide oversight that ensures that hy-giene promotion is integral to the overall programme,and that where hygiene promotion activities indicate theneed for additional inputs in terms of hardware these canfollow in a responsive manner (see Reference Box 14).

For: A summary of current thinking on hygiene promotion, and links to other resources and referencesSee: Appleton, Brian and Dr Christine van Wijk (2003) Hygiene Promotion: Thematic Overview Paper IRC Inter-national Water and Sanitation CentreCurtis, V. and B. Kanki (1998) Towards Better Programming: A Manual on Hygiene Promotion Water, Environmentand Sanitation Guidelines Series No. 6 UNICEFGet thes reference on the web at www.irc.nl and www.unicef.orgFor: Summary of seven “key messages” about hygiene which can be easily incorporated into a well-designed ad-vocacy campaign.See: Facts for Life UNICEFGet this reference from: Local UNICEF offices or on the web at http://www.unicef.org/ffl/09/

Reference Box 14: Hygiene promotion


In most cases the most important programming decisionto be taken will be to allocate adequate resources to hy-giene promotion, along with the needed institutionalanalysis, monitoring and feedback systems. In additionhowever, a recognition of the importance of hygienepromotion, should also be linked to decisions about: al-locating responsibility for overall programme manage-ment and project investments; institutional and organiza-tional arrangements; and coordination mechanisms. Spe-cific additional actions might include:● commissioning baselines studies on current hygiene

practices;

● commissioning formative research to determine keybehaviors to focus on;

● developing behavior change strategies including socialmarketing, social mobilization, and community-leveleducation;

● integrating hygiene promotion efforts in Ministry ofHealth programs;

● determining roles and responsibilities for carrying outhygiene programs;

● ongoing monitoring of program effectiveness; and ● training at all levels for program implementation


The Sanitation and Family Education Project was devel-oped and implemented by CARE Bangladesh, with tech-nical assistance from the International Centre for Diar-rhoeal Disease Research (Bangladesh). The SAFE proj-ect had no hardware component but was designed as asupplementary or follow-on activity after an earlier cy-clone relief project which provided tubewells and la-trines. SAFE worked by targeting a small number of spe-cific behaviours including: drinking pond or open wellwater, improper storage of tubewell water, adding pondwater after cooking, using unhygienic latrines, poor hand-washing practices and low use of latrines by childrenunder the age of five. The project area saw a two-thirdsreduction in diarrhea prevalence when compared withcontrol areas, and a substantial increase in hygienic be-haviours including handwashing and hygienic latrine use.What is interesting about the SAFE experience, was thatit operated in an area which had already been targetedwith hardware and showed significant health benefits.Without the additional push on hygiene promotion, it isunlikely that the investment in latrines and water supplywould have yielded expected benefits.

In comparison, the Environmental Health Project (EHP)was able to implement a full range of ‘HIF’ interventionsin Nicaragua during a two –year project which was setup in the aftermath of Hurricane Mitch. The project pro-vided: hardware, through water supply and environmen-tal projects implemented by local NGOs; hygiene pro-motion, using trained community members and schools

as the two primary mechanisms to deliver messages; andstrengthening of the enabling environment, through ca-pacity building of local water committees and at the na-tional level. Here the benefits were substantial and theadvantages of the coordinated approach did not pre-clude a range of innovative institutional arrangementsand partnerships being established.

In general hygiene promotion is a long-term process,which links an understanding of the current situation witha vision of what behaviours can be changed, and how thiscan happen. In Zimbabwe, ZimAHEAD have pioneeredthe Health Club approach to provide a framework forthis needed long-term change. Community Health Clubsprovide a forum for community-members to learn aboutsimple and effective ways of improving hygiene in thehouse and community, and they also provide the com-munity with a focus for planning and implementing watersupply and sanitation activities. But perhaps more signif-icantly the CHCs also provide support for wider eco-nomic activities, and provide a more interesting and stim-ulating framework within which the Ministry of HealthEnvironmental Health Technicians can see long termstructured change occurring in the communities withwhich they work. The CHC approach has proved to beextremely robust, and even with the recent decline in de-velopment budgets and the loss of funds from externalsupport agencies, the CHCs have been able to sustaintheir activities and keep operating.

9.5 Practical Examples from the Field:How will we promote hygienic behaviours?



Chapter 9: Hygiene Promotion

Case Study Box 7: How will we promote hygienic behaviours?

The Community Health Clubs and ZimAHEAD are described in Sidibe, M. and V. Curtis (2002) Hygiene Pro-motion in Burkina Faso and Zimbabwe: New Approaches to Behaviour Change Field Note No. 7 in the Blue GoldSeries, Water and Sanitation Program – Africa Region, Nairobi. Further discussion of CHCs, along with in-formation about NORWASP and the EHP project in Nicaragua is available in the case studies in the IRC The-matic Overview Paper (TOP) available on the web at www.irc.netVERC’s experience in Bangladesh is discussed in Kar, K. (2003) Subsidy or self respect? Lessons from Bangladeshid21insights, issue 45 on the web at www.id21.org/insights/insights45

Ensuring a robust structure for hygiene promotion is im-portant, but, as was the case in Bangladesh, this may beoutside or in parallel with a programme of hardware pro-vision. Investments in increasing access to hardware, andpromoting hygienic practices need to be coordinated butcan sometimes be successful when they are carried outby different agencies. In Ghana, the Northern WaterSupply and Sanitation Project (NORWASP) integratedhealth and hygiene into water supply and sanitation forrural communities. A thorough evaluation of baselinedata was carried out before a community-based hygieneeducation programme was developed, and this in turnwas first piloted, and evaluated by the community. Theapproach drew from PHAST and PLA methods, but wastailored to local conditions, and made use of a locally-de-veloped health and hygiene game. Identifying and train-ing a cadre of committed fieldworkers is crucial, and this

is a key strategy in NORWASP. The project was notbound to one particular agency, but sought out the bestinstitutional “homes” for different activities, while pro-viding an overall coordinating framework.

As well as getting the institutional structure right, hygienepromotion needs to apply appropriate approaches. Insome contexts for example, shocking messages maywork well; in Zimbabwe, the CHCs use a slogan whichis often “chanted at health club meetings” in the local lan-guage, which when translated states baldly “don’t shareyour shit”. In Bangladesh, VERC carry out village transectwalks during which households discuss where each fam-ily member defecates, and identify areas in the villagewhich are regularly soiled with faeces. Such approachesmay not work in other situations, and each case must beassessed on its own merits.

i This section draws heavily on Appleton, Brian and Dr Christine vanWijk (2003) Hygiene Promotion: Thematic Overview Paper IRC In-ternational Water and Sanitation Centre drawing particularly on Ap-pendix 2. This excellent reference is recommended as a starting pointfor more detailed programme planning.

ii Sidibe, M. and V. Curtis (2002) Hygiene Promotion in Burkina Faso andZimbabwe: New Approaches to Behaviour Change Field Note No. 7in the Blue Gold Series, Water and Sanitation Program – Africa Region,Nairobi

iii Appleton and van Wijk point out that messages such as “wash handswith soap” or “use more water for washing” may simply make peoplemore frustrated and disempowered in situations where for examplesoap is not commonly used or available or where every drop of waterhas to be carried long distances.


In many parts of the world conventional ‘sanitation’ pro-grammes have tended to focus on the public provisionof latrines, either through direct construction, or by pro-viding subsidies based either on a needs-assessment, oron the completion of a latrine of “acceptable” standard.In a few regions, where progress in the water supply andsanitation sector has moved faster, sanitation has beenviewed more as a “utility” issue often with a focus on reg-ulating to prevent ‘unauthorised’ construction or, inurban situations, to preserve the exclusive right of theutility to provide.

Once sanitation is seen within the context of hygiene im-provement however, it becomes clear that latrines aloneare not very effective, and their provision needs to becoupled with, and often subordinate to, an increase inawareness about hygienic practices in general and achange in the way hygiene is managed locally. Further-more, even where latrines are clearly urgently needed, di-rect public provision has been shown to be problematicin many cases. The sheer scale of the need swamps mostpublic providers i and this, coupled with suspicions of cor-ruption and inefficiency in many programmes, suggeststhat new approaches need to be tried, in tandem withan improvement in public provision where this appro-priate.

Where it exists, the small scale private sector providessome hope that provision can be scaled up, and mademore effective through local innovation and the ability oflocal providers to be more responsive to household de-mand. Where this small scale business does not exist,programmers may want to devote some of their effortand resources towards stimulating and supporting itsgrowth, to relieve the pressure on public provision. Thepotential for this sanitation “business” is easier to under-stand in rural areas or less congested urban slums, whereon-plot provision makes a straight forward business re-lationship between the household and the supplier pos-sible. In congested urban areas where off-plot provisionis needed, this relationship is less clear, and there will al-most certainly be a responsibility retained by the publicprovider or utility. Nonetheless new institutional andtechnical approaches mean that there may still be a rolefor an intermediary or small scale private provider at thelocal level to facilitate the development and managementof and appropriate local network system. For more in-formation on the basic technology issues of sanitation seeSection 10.2 below.

The key idea here is to move away from the direct pro-vision of a pre-determined technology, to a situationwhere households and communities can choose from arange of appropriate options, supported by a range ofsuppliers who are highly motivated and skilled to providethem.

10.1 Introduction

Chapter 10 Selecting and Marketing Technologies

10.2 Making Sure that Technology WorksBroadly, sanitation technologies fall into four main typesas shown in Table 15. The choice of technology will bestrongly influenced by a range of factors, of which thetwo most important are:

● How much used water (wastewater) must be re-moved from the household?

● Will the disposal of the excreta be on-site or off-site?

Sanitation Technology Choices

(a) Limited water use and on-site disposal (la-trines)Many poor people have limited access to water, and donot enjoy the relative luxury of a household connection.Water consumption is thus limited to around 20 lpcd orless, and little wastewater will be generated. On-site toi-let facilities offer substantial advantages over off-site fa-cilities in terms of convenience, privacy, and management(family-owned latrines are in most cases better main-tained than public ones). Basic pit latrines, pour-flush la-



Chapter 10: Selecting and Marketing Technologies

trines, or variants of these basic types (e.g. EcologicalSanitation, VIPs, etc.) are usually the most appropriatetypes of technology to consider for on-site disposal ofexcreta with little water.

Latrines protect the environment from faecal contami-nation by isolating excreta in a pit. When the pit is fullafter five to ten years, it must be emptied before it canbe used again. Where space permits, a new pit can bedug, and the contents of the full pit may be left to com-post. After a year or more of composting, the pathogensin the waste will have been neutralized, and the contentsmay be safely handled. These contents may be used asagricultural compost. Ventilated Improved Pit (VIP) la-trines improve on the basic design and limit nuisancefrom flies and odours.

Pour-flush latrines are those in which the excreta areflushed from the defecation area by water, and are par-ticularly appropriate in cultures where water is used foranal cleansing. The water may be used to create a waterseal between the wastes in the pit and the outside, thuseliminating problems with odours, flies and mosquitoes.

Pit latrines are difficult to build in areas of high ground-water table, or in rocky areas. High groundwater tablenot only makes construction difficult, but also raises therisk of groundwater contamination from the contents ofthe latrine These risks can, in most cases, be minimizedif the bottom of the latrine is at least 2 m above thegroundwater table, and the latrine is at least 15 m awayfrom any well used for drinking water. Finally, sludge man-agement (i.e. the transport and disposal of the latrinecontents after emptying) should be carefully consideredwhere space is limited, especially in urban or peri-urbanareas. A variety of ecological (“EcoSan”) toilets existwhich are designed to improve the composting of the la-trine’s sludge, and thus turn the problem of sludge man-agement into an opportunity to generate higher valuecompost.

(b) Limited water use and off-site disposal(bucket latrines, public toilets)Where access to water is limited, and excreta disposalon-site is not feasible (due to either cost or space con-straints), bucket latrine systems or public toilets are oftenused.

In the bucket system (or “conservancy system” as it isknown in South Asia) excreta are deposited in a bucket

or lined basket that is emptied several times a week bya “sweeper” who disposes of the waste elsewhere. Inearlier times, elaborate plans were made for the collec-tion of wastes to “bucket transfer stations” where thebuckets were emptied into larger carts and cleaned priorto their reuse. The larger carts, in turn, were meant totransfer the waste to a sanitary disposal site. In currentpractice, however, the disposal is almost always to a near-by drain (eventually leading to drain blockage) or to a pileof solid waste, exposing rag pickers and children to fae-cal wastes. The system is generally considered an ex-tremely unsanitary arrangement, and is officially illegal inIndia and a number of other countries. Where field sur-veys establish the continued existence of this system,however, sanitation planners need to address two ques-tions before simply banning it:

1. What more sanitary option can realistically be of-fered?

2. During the transition period to the more sanitary op-tion, how can the bucket system be rendered morehygienic?

Public or shared toilets are a second form of off-site dis-posal, and indeed, have been promoted in India byNGOs such as Sulabh International Inc, as an answer tothe defects of the bucket system. Public toilets may in-volve any number of technological options, from com-mon pits to sewer system connections. All public toilets,however, involve a number of difficult institutional ques-tions, which have previously weighed against its wide-spread adoption by sanitation professionals.

Management of public toilets is a daunting challenge, al-though recent experience in South Asia shows that it canbe overcome in some cases. While the responsibility for(and interest in!) cleaning private toilets clearly rests withthe owner, responsibilities are often less clear-cut forpublic or shared toilets. It is often difficult to establish aneffective maintenance regime for a toilet shared amongfive or ten families. Government or community run pub-lic toilets are often in an appalling state (in Europe andNorth America as much as anywhere else) because ofthe lack of interest and incentive for adequate mainte-nance.

Sulabh International has developed a public toilet fran-chising system whereby attendants and managers are re-imbursed from a small fee for use levied on adult malecustomers; women and children can use the toilet for


free. The fee is sufficient to ensure a reasonable incomefor the manager, who has an interest in maintaining aclean well-run establishment; Sulabh’s monitoring of per-formance means that s/he risks losing the job if per-formance slips. While the franchise arrangement worksin a number of settings (e.g. railway or bus stations) it isunclear that the financial model can work to serve theurban poor, when competing with “free” open defeca-tion.

Household toilets, where feasible, are preferable to pub-lic toilets for 3 main reasons:● convenience to the household, which encour-

ages use● clear accountability for cleanliness, which also

encourages use, as the cleanliness is within the con-trol of the household

● safe disposal of children’s faeces is more likelywith a household toilet. Although a number of publictoilet systems try to encourage use by children, it isless likely than a household toilet to work, especiallyfor the disposal of young children’s faeces.

(c) Substantial water use and on-site disposal(septic tanks, soakaways)As access to water increases, water use will also increase,along with the requirement for its safe disposal. Sullageand grey water are the technical terms for householdwastewater that is not used in toilets; sullage is made upof bathing water, water used for washing and cooking,etc. While it is less contaminated than toilet water, it isincorrect to think of it as “uncontaminated”; water usedfor cleaning the clothing and nappies of infants and veryyoung children, is often heavily contaminated.

Pouring large quantities of sullage into a pit latrine pit islikely to lead to pit overflow, bad smells, and insectbreeding. This is because latrine contents will quickly“plug” the soil, and limit the capacity of the soil to ab-sorb large volumes of sullage. The construction of a sep-arate soakaway for sullage is far more likely to work. Asoakaway is a large pit or trench filled with bouldersand/or gravel through which sullage may infiltrate into alarger surface area of soil. By keeping the sullage sepa-rate from the faecal wastes, the risk of soil plugging is re-duced, and the soakaway can serve for a much longertime.

Septic tank systems (with soakaways or drainfields) arean alternative on-site solution for combined wastewater

disposal. A septic tank is a concrete or masonry box inwhich some settling and treatment of faecal solids takesplace; the wastewater leaving the septic tank is relativelyclear and free of solids (although highly contaminated bi-ologically). Sullage enters the septic tank after the set-tling of the solids, and the combined flow is dischargedto the soil through a soakaway or drainfield. As the sep-tic tank removes the faecal solids from the flow, the in-filtration area of the soakaway is far less likely to becomeplugged.

Septic tanks are most commonly used by those with cis-tern-flush toilets and house connections for water.While traditionally each household has its own septictank, a number of households with individual toilets andplumbing arrangements can connect to a single septictank.

The capacity of both soakaways and septic tank systemsto remove wastewater safely from the plot dependsgreatly upon the infiltration capacity of the soil. Soak-aways and septic tanks work best in sandy soils, and can-not work well in tight clays. As with pit latrines, there isa risk of groundwater contamination, and this is particu-larly great when sullage and excreta are combined.

Sludge builds up in septic tanks as the faecal solids settle,and must be removed periodically. As with latrine sludge,the collection and disposal of septic tank sludge requiresattention. Without good sludge management and en-forcement, the public will be exposed to the effects ofclandestine dumping of sludge into drains and piles ofsolid waste.

(d) Substantial water use and off-site disposal(sewers)Sewers are common where water is readily available butsuitable land and soil for septic tank systems are not.Sewers are pipes that carry wastewater (toilet wastesand sullage) away from the household to a centralizedtreatment and disposal point. Sewers are very conven-ient for the user, requiring a minimum of maintenance.They are often, however, a relatively expensive solution,especially if the wastewater is treated (as it should be)before its ultimate disposal to surface water. Sewers re-quire a reliable water supply, and sufficient wastewaterto ensure reasonable flushing of the solids through thesystem. Large systems, or systems in flat areas, often re-quire pump or lift stations, to raise the sewage and thusreduce the depth and excavation costs of downstream




pipe. Such pump stations not only require careful oper-ation and maintenance, but also a steady source of cashto cover significant power costs. Sewers should only beconsidered in cities and small towns and are not viable inrural villages.

There have been a variety of innovations in sewerageover the last two decades, particularly in Latin America,which have reduced its cost and operational complexitythrough a range of “condominial” technologies and insti-tutional systems; Mara (see Ref. Box 15) is a good guideto some of the technical issues and debates involved inlow-cost sewerage.

Table 15: Range of Technology Choices

Off-site Conservancy/bucket system Public toilets

Sewers (including non-conventionalvariants)ii

On-site Pit latrine and variants, Pour flush latrines

Septic Tanks Pit latrines plus soakaways

Water supply volume

Disposal point

Limited (< 20 lpcd) Ample (>20 lpcd)

The programmers’ responsibility is to balance what iscurrently possible and desirable at the household or pri-vate level (ie what can be achieved in the short term)with long-term public policy objectives such as realizationof full public health benefits, protection of the environ-ment and maintenance of health and safety.

There is no such thing as an “ideal technology”. In manycountries standard designs and approaches, usually justi-fied on the basis of long-run public policy objectives, havebecome entrenched in widescale national latrine con-struction programmes. They may appear to be the onlyviable solution and technicians may aspire to constructonly facilities of the highest specification possible. How-ever, programmes promoting these “ideal” facilities rarelyachieve high rates of coverage – because demand for thehigh-cost technologies on offer is too low and there areinsufficient funds to provide them universally on the pub-lic budget. One look at the latrines that people build forthemselves however, illustrates that a wider range of so-lutions is possible. In many cases these home-built la-trines may fail to improve the situation at all – but theymay point to a viable first step on what is known as ‘thesanitation ladder’ ie the first intervention which will in-crease awareness of the benefits of sanitation, begin tolessen risks and start a household on the process that willlead to the installation and use of a sanitary latrine. In thelong-run this is likely to result in much greater coverage

and health improvement than would be the case if only“the best” were to be built or allowed to be built.

The balancing act for programmers is to judge what is ac-ceptable and likely to be used by households, promoteit appropriately and assess how best to move householdsas rapidly as possible up the sanitation ladder so that bothprivate and public benefits can be realized. To do thisgovernment may retain a prominent role, beyond simplyenforcing standards, in: promoting innovation; balancinglocal needs with national public policy priorities (for ex-ample intervening in emergency situations, enforcingstandards in public places and schools etc); and steeringhousehold choice by supporting sanitation marketing ef-forts (see below).

Climbing the sanitation ladder in this way may not seemvery glamorous but may in fact be the most effectivemeans of making rapid and visible improvements in thesituation. Furthermore the concept of the sanitation lad-der is particularly important for the poorest households,where local conditions, lack of money and low levels ofawareness may preclude the construction and effectiveuse of latrines. Programmers need to support any in-cremental improvements, and may choose to steer pub-lic resources to the provision of appropriate school san-itation and public facilities so that some access is achievedwhile awareness is built.

10.3 Selecting Technologies – the sanitation ladder


The interaction between technical constraints and orga-nizational issues is also important. For example if peoplehave no space but have proved that they can take con-certed action in some other development sphere thenthe possibility of constructing and managing shared facil-ities should be considered (shared latrines, communal

bathing facilities, condominial sewers etc). Where peo-ple are willing to give up space in their houses for sani-tation but are unwilling or unable to collaborate withtheir neighbours a different (on-site) solution may bepossible.

For: Details of sanitation technologies and guidelines on choice of technologySee: Pickford, John (1995). Low-cost sanitation. Intermediate Technology Publications: London.Mara, Duncan (1996). Low-cost urban sanitation. John Wiley & Sons: Chichester.Cairncross, Sandy and Richard Feachem (1993). Environmental health engineering in the tropics: an introductory text.(2nd edition) John Wiley & Sons: Chichester.Get these references from: Good technical libraries or the Water Engineering Development Centre(WEDC) at www.lboro.ac.uk

Reference Box 15: Sanitation technologies

It is quite obvious that capacity needs to be built amongsthouseholds, communities and even small scale inde-pendent providers so that they can participate more ef-fectively in the provision of sanitation facilities that doachieve health improvements. What may be less obvious,though, is that there may be a need to build capacityamongst technical staff also, many of whom may be welltrained in ‘conventional’ sanitation engineering. Unfor-tunately such conventional training tends to focus on ex-pensive solutions, often with a heavy emphasis on pipedsewerage (which is inappropriate in rural areas, and maynot work in urban areas with low levels of water supply,

unreliable power and low operating revenues). It mayalso place an emphasis on waste water treatment which(a) is inappropriate where on-site solutions are to beused; and (b) may be irrelevant where the public healthimperative is to get as many households as possible touse a latrine as the first step. These staff may lack ex-pertise in the complex area of ‘making-do’ and finding thebest compromise in a less-than-perfect world. They maylack the skills to identify the best innovations and, worse,they may, in good faith, create barriers to the type of in-cremental improvements which are needed.

10.4 Other Factors – community management

10.5 Building Capacity




Why do people pay for sanitation?As the emphasis shifts from “policing” and “providing”technologies to “marketing sanitation” and ‘promoting in-novation’ technical roles may shift. Marketing of sanita-tion as if it were a business is a relatively new idea. Fewcountries have forged effective links between privateproviders and public agencies. Nonetheless this is maybe infinitely more important, particularly in countries withvibrant small-scale markets for goods and services, thanthe ability of public-sector engineers to design and buildurban sanitation systems.

Because the public interest in sanitation is linked to itsrole as a primary barrier of disease prevention health isoften thought to be the principle driver of demand.However a World Bank survey iii in the rural Philippinesestablished the following reasons for satisfaction withnew latrines (in order of priority):

1. Lack of smell and flies;2. Cleaner surroundings;3. Privacy;4. Less embarrassment when friends visit; and5. Less gastrointestinal disease.

Some may regret that health education has been insuffi-cient to raise the concern about gastrointestinal diseaseto a higher priority. Others, however, will quickly realizethat all of the other reasons are excellent ways to mar-ket sanitation, and will accordingly review their market-ing and product development strategy to take such prac-tical concerns into account.

What influences household demand?Figure 5 illustrates in a simplified way, the relationshipbetween household demand and service delivery. It em-phasizes that, where household demand is a driver for in-vestment decisions, the role of the public sector (bothon the supply side and in creating an appropriate enablingenvironment) remains crucial and may be more chal-lenging than in traditional “public service delivery” typeapproaches.

In order to stimulate or create demand for a service, it isimportant in any situation to understand what is drivingdemand (or lack of it). Figure 5 suggests four main fac-tors which will influence the depth and breadth of house-hold demand for any particular good or service.

These are:

● Awareness: knowing that the goods/services existand that they have benefits. For example, knowingthat latrines exist and can be used to store excretaand knowing that a latrine can improve the health ofchildren and have a positive impact on household in-come;

● Priority: deciding that the service is sufficiently im-portant to merit needed investment For example, de-ciding to build a latrine rather than construct an addi-tional room in the house or invest in a bicycle. Prior-ity may be influenced by access to other priorityservices or a range of other factors such as status orsocial conventions. Priority may also vary betweenmembers of the households – and it is important totarget demand creation and assessment activities ap-propriately (for example building a latrine requires adecision by the member of the household responsi-ble for major capital investments in the home andthat person should be a key target of a latrine mar-keting campaign);

● Access: having access to a service provider who willmarket and provide the specific service. For examplehaving a local mason who knows what types of la-trines can be built, help decide what is the most ap-propriate and build it; and

● Influence: being able to take effective individual ac-tion, or being in a position to participate in effectivecollective action. For example, having space to buildan on-plot latrine, or being in a location where it ispossible to participate in a condominial seweragescheme.

Any sanitation marketing approach probably needs toaddress these four areas. While there is little empiricalknowledge to date of how this can be done most effec-tively some ideas and suggestions are laid out in Table16 which shows an indicative approach to breaking downthe four barriers listed above.

Sanitation marketing has to become more sophisticated.It has to move from the current approach which is heav-ily skewed towards public sector promotion of fixedideas, to a more innovative approach which explores the

10.6 Sanitation Marketing


Financing

Efficient delivery of appropriate goods and services

Assessment, aggregation &mediation of demand

Awareness

Policy, regulation and institutional

Resources (from households)

HouseholdDemand for goods and services

Priority Access Influence

Demand side(private)

Supply side(public)

Enabling environment

Figure 5: Household demand in the context of service delivery

potential of the market to provide some of the solutions.Marketing expertise can be linked to technical expertiseto create the right mix of messages and promotional ap-proaches which can start to make purchasing and usinga toilet a high-priority choice for households. The chal-lenge for programmers at the moment is to come upwith such new approaches almost from scratch since

there is so little experience to build on. Ultimately thechallenge is to turn toilets into attractive consumer itemsfor those with some money to spare, while maintaininga focus on the supply-side of the market to ensure thatcheap and appropriate versions are accessible by thepoorest households.

Importantly marketing latrines (along with all otherchanges in household hygienic practices) is a long-termundertaking and cannot be achieved in a short timeframe. Programmers need to establish marketing sys-tems that will have adequate resources to work with

households in the long term to improve their awarenessof sanitation, raise its priority, increase household accessto providers of goods and services, and equip householdsto influence those providers as required.




Table 16: Illustrative sanitation marketing approaches

On-plot/ rural

Mass media campaigns(based on a hygieneimprovement frame-work) linking hygienebehaviour change andhousehold invest-ments in sanitation toimproved lifestyle,higher earnings andstatus.

Household level par-ticipatory evaluationsand planning to em-phasise the need andpotential of HH sani-tation.

Link to primary healthcare and micro-finance interventions.

Public schemes tosupport mason /plumber training, including business-support to small scaleindependent serviceproviders.

Public marketing ofsmall scale privateservices.

Mass media campaignto emphasise the rela-tive ease of household/ shared sanitation inrural and some urbanareas.

Demand Factor

Settlement/Technology

Awareness Priority Access Influence

Networked/ urban

Household / community level par-ticipatory evaluationsand planning to em-phasise the need andpotential of communi-ty sanitation.

Public schemes to licence and supportsmall scale independ-ent providers (ie pitemptying services).

Public funds to trainsupport agencies pro-viding planning, microfinance and manage-ment support for lowcost networks.

House-to-house communication tomarket appropriate shared-or collective ap-proaches.

Community planningcoordinated with andsupported by the utility.

This chapter has emphasized that there needs to be amajor shift away from the idea of public provision of la-trines towards the idea of building, promoting, and sup-porting a sanitation business. Such a business will havethe following key elements:

● Informed demand from households;● Responsive supply from providers of goods and serv-

ices; and ● Appropriate support from the public sector on both

the demand- and supply- side.

In some countries this “business” already exists, and thereal need is to ensure that it is legalized, appropriatelysupported so that it scales up, and then (and possibly onlythen) regulated to secure long term public policy objec-tives. In other countries the ‘business’ does not yet exist.Even where this “business” is likely to remain well with-in the public sector, much more emphasis is needed onpromoting demand, supporting innovation and enabling

local choice to drive incremental improvements in sani-tation.

In most countries there will be a number of barriers tothis including;

● Inappropriate skills (in public and private sector agen-cies);

● Excess of technical staff in public agencies;● Lack of capacity in the small scale private sector (for

both delivery and marketing);● Lack of knowledge and experience of marketing san-

itation;● Technical norms and standards which preclude inno-

vation and drive up costs; and● Other regulations which hamper innovation including

outdated building codes, planning regulations and en-vironmental controls.

All of these barriers need to be addressed at the pro-grammatic level.

10.7 Key issues and barriers


Table 17: Applying the Principles to the section and marketing of sanitation technologies

Assess and promotesanitation technolo-gies which are accept-able and likely to beused by households inthe short term whiledeveloping longerterm strategies tomove households upthe sanitation ladder.

Ensure that sanitationtechnologies are avail-able which the poor-est can access and useeffectively. Specifical-ly make sure technicalnorms and standardsdo not preclude solu-tions appropriate forpoor households

Understand how peo-ple currently manage,what they aspire to,and invest in findinglocally-appropriatesolutions

Expand the range ofparticipants – so thatas much effort as pos-sible goes into devel-oping innovative newtechnologies and mar-keting approaches

Invest in building ca-pacity of technicalstaff. Emphasise theimportance and credi-bility of innovationand development ofappropriate local so-lutions


Achieving Equity Building on whatexists and is in demand



10.8 Applying the PrinciplesThe principles of good programming apply equally to the selection of technologies as can be seen on Table 17.

Recognising that approaches to technologies have tochange, may be difficult but could be one of the most sig-nificant programming decisions to be taken. Once it be-comes clear that a different range of technologies couldbe employed to tackle the sanitation challenge, thoseworking at field level may find a huge number of optionsopening up to make incremental improvements. But be-fore this can happen people need to feel that they willbe supported, that innovation will be rewarded ratherthan penalized, and that they are free to work with arange of non-traditional partners to develop new ap-proaches. Programmers can help to signal this shift by:

● Instituting consultative processes to review and up-date technical norms and standards;

● Earmarking funds for sanitation marketing;● Making funds available for training technicians in new

and non-traditional technological approaches;● Finding ways of working with small scale independent

providers, and possibly establishing funds which cansupport them as they build up and improve their busi-nesses;

● Making funds available for research and field-basedtrials of new technologies;

● Licensing providers and products;● Training regulators (where they exist) to help them

oversee appropriate sanitation interventions; and● Finding ways to publicise and promote new and in-

novative technologies and approaches.





The adoption of the Blair VIP latrine as a standard tech-nological choice in Zimbabwe in the 1980s had a pro-found impact on the ability of the government’s sanita-tion programme to go to scale. While the approachdoes allow for local innovation, in the choice of materi-als for the superstructure for example, the simplicity ofthe standard design, and the fact that it was developedin Zimbabwe from an analysis of the existing approachesand sanitation conditions, have both been significant fac-tors in its success. Once the design had been proven, anexplicit effort was made to roll out the program by build-ing the capacity of extension workers from the health de-partment, as well as through technical training of engi-neers and promotion of the technology at the nationaland local level. The impact of the Zimbabwean sanita-tion programme is clear; at the peak of the programmein 1987 nearly 50,000 latrines were built.

Despite the success of the Zimbabwean approach, stan-dardizing on a single technology may be problematic. Inmany countries, a range of technologies may be neededto reach all those households who are excluded. Whenthe NGO VERC started to work intensively in Bangla-deshi villages to identify sanitation and hygiene improve-ments, people themselves developed more than 20 vari-ations of low-cost latrines, which were both affordableand appropriate to their situation. By contrast the adop-tion of the TPPF as a standard in India led to high costsand constrained the roll out of the national program, de-spite the fact that the TPPF latrine is technically quite sat-isfactory as a rural technology. The TPPF was adoptedafter detailed research and benefited from the supportof UNICEF and other external support agencies active inwater supply and sanitation. But in this case technicaltraining of engineers, which focused on the TPPF left lit-tle room for local innovation.

The perils of defining “acceptable” sanitation technolo-gies may be avoided if policies and programmes focus onoutcomes rather than inputs. The Government of SouthAfrica defines “access to sanitation” in terms of the adop-tion of hygienic behaviours including safe disposal of exc-reta. This leaves projects and localities with freedom toadopt approaches which are locally appropriate, and forthe impact to be evaluated using simple indicators.

In many Latin American countries, levels of services forsanitation are relatively high and many urban householdsexpect to connect to a networked sewerage system. Inmany congested urban slums, this may be the only op-tion as there is no room for on-site disposal. But sewer-age is expensive. In Brazil an alternative approach to con-ventional sewerage, known as condominial sewerage,was developed over twenty years ago, and is now adopt-ed as standard in many cities and towns. Condominialapproaches are cheaper to build and operate than con-ventional systems, but have not expanded into neigh-bouring Latin American countries as fast as could havebeen expected. In Bolivia, the intervention of an exter-nal support agency (Swedish International DevelopmentCooperation Agency - SIDA) and support from theWater and Sanitation Program (WSP) enabled the gov-ernment and the private operator in La-Paz El-Alto toexperiment with the condominial approach. Externalsupport agencies in such a case can provide access toskills (technical or social development skills) and providefunds for activities which perhaps cannot initially be fund-ed from the governments’ own programme because therules and approaches being piloted fall outside the exist-ing government rules and standards.

In the arena of sanitation marketing, there is much lessexperience than in the area of direct technology devel-opment. Research from Africa shows that many small-scale-independent providers are relatively good at tai-loring their services to the needs of “customers”, but fewcountries have looked at ways to use the skills of the pri-vate sector, and marketing experts in particular, as partof a sanitation marketing effort. More work is needed toexplore this potentially important area of hygiene im-provement.

10.10 Practical Examples from the Field:What Sort of Sanitation do we Want?


Case Study Box 8: What Sort of Sanitation do we Want?

Information about the adoption of Blair VIP latrines in Zimbabwe is taken from Robinson, A. (2002) VIP La-trines in Zimbabwe: From Local Innovation to Global Sanitation Solution Field Note 4 in the Blue-Gold Series, Waterand Sanitation Program – Africa Region, NairobiThe analysis of the impacts of India’s use of the TPPF latrine is based on Kolsky, P., E Bauman, R Bhatia, J.Chilton, C. van Wijk (2000) Learning from Experience: Evaluation of UNICEF”s Water and Environmental Sanita-tion Programme in India 1966-1998 Swedish International Development Cooperation Agency, StockholmDefinitions of Access are discussed in Evans, B., J. Davis and Cross, P. (2003) Water Supply and Sanitation inAfrica: Defining Access Paper presented at the SADC conference, Reaching the Millennium Development Goals,August 2003South Africa’s systematic reforms are described in Muller, M. (2002) The National Water and Sanitation Pro-gramme in South Africa: Turning the ‘Right to Water’ into Reality Field Note 7 in the Blue-Gold Series, Waterand Sanitation Program – Africa Region, Nairobi and Elledge, M.F., Rosensweig, F. and Warner, D.B. with J.Austin and E.A. Perez (2002) Guidelines for the Assessment of National Sanitation Policies Environmental HealthProject, Arlington VA p.4The El Alto experience is well documented on a dedicated website at www.wsp.org For an introduction tothe programme, and information on the costs and benefits of the approach see Foster, V. (n.d.) CondominialWater and Sewerage Systems – Costs of Implementation of the Model Water and Santitation Progam, Vice Min-istry of Basic Services (Government of Bolivia), Swedish international Development Cooperation Agency. A discussion of the role of small-scale-independent providers is in Collignon, B. and M. Vezina (2000) Inde-pendent Water and Sanitation Providers in African Cities: Full Report of a Ten-Country Study WSP

Notes for Chapter 10

i In urban situations, the cost of providing what is sometimes the only‘allowable’ technology – conventional sewerage – also swamps theprovider (usually the utility) who may respond by doing nothing.

ii This option will have high operating costs if pumping is required. Non-conventional approaches to sewerage (variations on the “small bore”or “shallow” sewer) may reduce operating costs.

iii cited in Cairncross, A.M. Sanitation and Water Supply: PracticalLessons from the Decade. World Bank Water and Sanitation Discus-sion Paper Number 9. World Bank: Washington, D.C.

Water, Sanitation and Hygiene

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Programming GuidanceISBN 92 4 159303 2

This document was jointly produced by the following organisations:

London School of Hygiene & Tropical Medicine (LSHTM)Keppel Street, London WC1E 7HT, United KingdomTel: +44 20 7636 8636 Fax: +44 20 7436 5389Website: www.lshtm.ac.uk

Pan American Health Organization (PAHO)Pan American Sanitary Bureau,Regional Office of the World Health Organization525 Twenty-third Street, N.W.Washington, D.C. 20037, United States of AmericaTel: +1 202 974 3000 Fax: +1 202 974 3663Website: www.paho.org

United Nations Children Fund (UNICEF)Water, Environment and Sanitation Programme Division3 UN Plaza, New York, NY 10017, United States of AmericaTel: +1 212 824 6307; +1 212 326 7371 Fax: +1 212 824 6480Website: www.unicef.org

U.S.Agency for International Development (USAID)Bureau for Global Health, Infectious Diseases DivisionEnvironmental Health Team, USAID/GH/HIDN/IDRonald Reagan Building,Washington, DC 20523-1000, United States of AmericaTel: +1 202 712 0000 Fax: +1 202 216 3524Websites: www.usaid.gov www.ehproject.org

Water, Engineering and Development Centre (WEDC)Loughborough University, Leicestershire LE11 3TU, United KingdomTel: +44 1509 222885 Fax: +44 1509 211079E-mail: [email protected] Website: www.wedc.ac.uk

Water and Sanitation Program (WSP)1818 H Street, N.W.,Washington, D.C. 20433, United States of AmericaTel: +1 202 473 9785 Fax: +1 202 522 3313, 522 3228E-mail: [email protected] Website: www.wsp.org

Water Supply and Sanitation Collaborative Council (WSSCC)International Environment House, 9 Chemin des Anémones,1219 Châtelaine, Geneva, SwitzerlandTel: +41 22 917 8657 Fax: +41 22 917 8084E-mail: [email protected] Website: www.wsscc.org

World Health Organisation (WHO)Avenue Appia 20, 1211 Geneva 27, SwitzerlandTel: +41 22 791 2111 Fax: +41 22 791 3111Email: [email protected] Website: www.who.int

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