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Do we learn enough and does learning lead to improved sector performance?

Published on: 24/02/2015

The 2014 update on Progress on Sanitation and Drinking-Water (WHO and UNICEF, 2014) mentions that between 1990 and 2012, open defecation decreased from 24 per cent to 14 per cent globally. However, the update also states that more than one third of the global population – some 2.5 billion people — do not use an improved sanitation facility, and of these 1 billion people still practice open defecation. The conclusion that progress is simply not fast enough raises the questions: are we doing enough and is what we are doing good enough?

Blog written by Ingeborg Krukkert and Erick Baetings

In the coming weeks and months you can expect a series of blogs in which we will share what we have learned while supporting three large-scale rural sanitation and hygiene programmes in Asia. In this first blog we reflect on what we learned during a recent trip to Vietnam.

The Hanoi meeting is proof that we do learn. However, as overall sector progress has been slow, it is questionable whether learning translates into better performance.

From 24 to 29 January 2015 we were invited to participate in the 2015 Sanitation Partners’ Workshop organised by the Bill and Melinda Gates Foundation together with our partner BRAC WASH from Bangladesh. The workshop organised for the Building Demand for Sanitation grantees and attended by more than 50 people – comprising of researchers, evaluators, knowledge management experts, field implementers and others – was meant to share information, discuss challenges, and to plan for the future.

The workshop provided a great opportunity for sharing and learning and the main take home messages that we have gathered during the event include:

1) Sanitation uptake depends on the existence of three indispensable and mutually supportive elements: demand, finance and supply

Interventions that focus on only one or two of the three elements will be at risk of being ineffective. It is therefore essential that a sanitation programme starts with a thorough assessment of these three crucial elements and that the results of such an assessment are used to design effective intervention strategies. Some examples of one or two dimensional programme approaches are:

  • CLTS programmes using the triggering methodology may be very effective in creating household demand for sanitation facilities, however, sanitation facilities are often neither environmentally safe nor long-lasting. Sustainable access to improved sanitation will additionally require access to finance mechanisms especially for the poor and access to reliable sanitation supply chains to ensure that reliable, durable and environmentally safe toilets are put in place.
  • The Government of India’s rural sanitation programme focuses primarily on providing latrine subsidies to a large part of the population. Unless demand and supply chain challenges are resolved this will not lead to a larger uptake of and continued use of sanitation facilities.  

2) Hygiene promotion or behaviour change communication interventions may not be as effective in realising long term behaviour change

Current interventions are or appear to be effective in ‘triggering’ one-off decision making processes at household level to invest in sanitation and/ or hygiene facilities such as toilets and hand washing devices. However, the interventions may be less effective in ensuring sustained habit forming in terms of long-term behaviour change. Understanding that these are two different processes will help in developing more effective intervention strategies.

3) It is necessary to change the behaviour of a multitude of players to be successful

Behavioural change communication strategies and interventions almost always focus solely on the targeted beneficiaries: households and individuals. It rarely focuses on the key change agents such as field workers (for example hygiene promotion staff) and their superiors. Without a fundamental change in attitude, behaviour and practices of the service providers, behaviour change interventions are unlikely to be successful.

4) Additional financing options are required for the poor

An ever increasing range of financing options are being tested and applied in rural sanitation programmes. Examples presented in Hanoi were: subsidies, rebates, rewards for communities, commissions to hygiene promoters and so on. However, if we want to ensure equity in service provision, there is an urgent need to think about other alternatives such as linkages with microfinance programmes, toilet leasing mechanisms such as rent-a-toilet, and insurance schemes for toilet maintenance or pit emptying, etc.

5) New intervention strategies are required to reach the last mile

Most - if not all - the programmes that were present during the workshop showed remarkable progress in increasing sanitation coverage. However, it was unclear whether the approaches applied will achieve 100% coverage in the foreseeable future. The BRAC WASH programme has been very effective in mixing demand, finance and supply chain interventions. But even so experience has taught us that it is extremely difficult to achieve 100% sanitation coverage. It is clear that an approach that has proven to be effective for achieving up to 80% or 90% coverage may not be appropriate or effective to cover the last 10% or 20%. It is expected that the last mile will be disproportionately expensive and time consuming. Consider for example poor households (the lowest wealth segment) in slum areas and/ or remote or difficult to reach areas with possibly relatively low and dispersed population densities.

The 80-20 rule (Pareto principle which means that 80 per cent of our outcomes come from 20 per cent of our inputs) comes to mind. If we take this rule literally it would imply that to reach the last 20% for sanitation coverage would require 80% of our inputs. It is clear that alternative strategies are required to achieve universal coverage. Instead we may opt for a somewhat lower coverage percentage in the short term to allow for a more effective spread of limited resources, even though we all are determined to reach the goal of universal access to improved sanitation in the near future.

6) There is still unclarity about the critical threshold that is required to be able to measure health impacts

A number of presentations by research projects did not show a clear relationship between an increase in access to sanitation facilities and improvements in health. Research carried out by WSP[1] has revealed that children are generally shorter in villages where people defecate in the open or use unimproved latrines. It is, however, not clear what the critical threshold in terms of minimum sanitation coverage should be to measure the effects of stunted growth in children.

7) In the end it is all about creating a safe and healthy environment

Possibly guided by the MDG targets most of the sector advocacy messages have focused on increasing access to sanitation facilities and achieving open defecation free (ODF) environments. It is widely accepted that we need to take some big steps beyond the containment of human faeces in toilets to ensure that everybody can live in safe and healthy environments. It is therefore manifest that the entire sanitation chain – from containment to safe disposal or and reuse – needs to be considered and addressed. To avoid that our advocacy efforts only support the installation of toilets and neglect the other elements of the sanitation chain, we will have to ensure that our messages focus on creating safe and healthy environments and not on creating ODF environments. It is expected that the upcoming Sustainable Development Goals (SDGs) will help the sector to look at all the relevant issues that go beyond containment.


[1]       For example WSP (August 2014) Investing in the Next Generation, children grow taller, and smarter, in rural villages of Lao PDR where all community members use improved sanitation.

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