Lessons learned from a review and synthesis of three sanitation approaches. A. Hellier
- 1. Allison Hellier BA, Grad dip Int Health, Masters Int Health Lessons learned from a review and synthesis of three methodologies aimed at increasing access to and utilization of improved sanitation: Community-led Total Sanitation (CLTS), Participatory Hygiene and Sanitation Transformation (PHAST) and Sanitation Marketing (SanMark). The three methodologies reviewed are aimed at increasing peoples’ access to and utilization of improved sanitation. They are community-based and household centred programs (as opposed to targeted/specific programs such as sanitation in schools). The motivation for the review was to assist aid and development agencies or organizations with their choice of sanitation approach/es. This choice is vital if the problems of poor hygiene and sanitation related diseases are going to be addressed in an effective and timely manner. The review was conducted as a narrative literature review and synthesis of the CLTS, PHAST and SanMark approaches. It aimed to extract information along themes, focus on how outcomes were achieved and then synthesize the findings in order to generate fresh insights to inform the practice and methods of implementation and evaluation that are used in the field. It was achieved by: a) examining the reported reduction of diarrhoeal diseases; b) studying proxy indicators of basic sanitation hardware; c) reviewing the adoption and maintenance of sanitation behaviours; d) assessing the progression of communities up the sanitation ladder; and e) considering the contribution of some program components. A thorough investigation of the internet, relevant international bodies, government and non-government organizations’ publications and documents written by international experts in the field were sought. The extensive document search was augmented by contacting experts and organizations working in the sanitation field in order to unearth as many quality evaluation documents as possible. The review was limited by the lack of published evaluations. The author limited the focus to literature that only documented evidence of impact, determined by quantitative or qualitative methods. After scrutinizing evaluation methodologies and screening the documents to determine if they contained adequate information to answer one/some/all of the above five questions, the process yielded six CLTS evaluations, four PHAST evaluations and two SanMark evaluations. The review results/discussion yielded some valuable insights. It found that regardless of the time frame of either projects or their evaluations, there was little or no attempt to quantitatively measure (even in a very basic way) reductions in diarrhoeal diseases (with one exception). When anecdotal evidence was included in evaluations, the CLTS and PHAST approaches both reported reductions in and a prevention of diarrhoeal diseases in the project communities. The SanMark approach evaluations did not attempt to ascertain changes in diarrhoeal diseases.
- 2. Other areas of discussion included; the inadequate use of sanitation hardware as a proxy indicator of sanitary health; hand-washing with soap (and other hygiene behaviours) was neither a particularly strong focus within the three approaches nor a focus of the evaluations; the sanitation ladder appears to be a conceptual ideal rather than a measurable progression by a community; and the contribution of six program components (subsidies, community participation, institutional involvement, gender, sustainability and the poor). The review concluded with a number of implications for practice, particularly for evaluation methodology, baseline surveys, the collection of data surrounding sanitation hardware (other than latrines) and the pressing need to measure behaviour change. The review concluded with the recommendation that for the initial stages of a sanitation project, Community-Led Total Sanitation is the most effective for triggering rapid uptake of latrine use and reducing the practice of open defecation. For the longer phase of hygiene promotion, sustained behaviour change and community development, the Participatory Hygiene and Sanitation Transformation approach principles (albeit streamlined) produce tangible and positive results. And lastly, the supply of sanitation hardware is always going to be superior when in the hands of private enterprise, and Sanitation Marketing makes that possible, including for the poor.
- 3. Approach descriptions CLTS: Community-Led Total Sanitation1 CLTS is a demand creation strategy which focuses on “triggering” the community to take action and stop open defecation. The role of implementing partners is to train CLTS facilitators who then help communities to assess their own sanitation situation, come to their own conclusions and then decide which action they are going to take. There are no standard models or prototypes of hardware recommended to communities, no subsidies offered and construction is by self-help (whether hardware is purchased or not) (Chambers, 2009, p. 11) PHAST: Participatory Hygiene and Sanitation Transformation2 A behaviour change and participatory community action vehicle. The organizations that utilize the PHAST approach usually do so as a component of a broader water, saniation and hygiene (WASH) program. Latrine installations and other hardware components are often subsized and target numbers are decided upon by the implementing organization (rather than individual households or the community). “PHAST is a participatory planning approach suitable for low literacy groups to promote hygiene, sanitation and community management of water and sanitation facilities” (Willetts, Halcrow, & Carrard, 2009, p. 7). PHAST utilizes a seven step methodology. SanMark: Sanitation Marketing3 Sanitation Marketing is a “supply” focussed strategy inasmuch as a primary goal of the implementing partner is to train, develop and encourage the suppliers of sanitation hardware. It has been described as an approach, “to create demand for sanitation and improve the supply of sanitation-related products and services to increase household access to safe and sustainable sanitation; create open- defecation free communities; and promote improved hygiene practices.(WSP, 2010, p. 13) It is a strategy based on the four P’s; Product, Price, Place and Promotion. These three will be referred to as the Approaches. The term sanitation can refer to both hardware and software. “Hardware” is the physical and environmental equipment required to conduct sanitary and hygienic behaviours. These behaviours and the training required to promote them are understood to be the “software” component of sanitation. Both sanitation hardware and software are required if the problems of diarrhoeal diseases are to be addressed.4 1 For a full description of CLTS go to http://www.communityledtotalsanitation.org/ 2 For a description of and to download the PHAST handbook go to http://www.who.int/water_sanitation_health/hygiene/envsan/phast/en/ 3 To learn more about Sanitation Marketing and view the WSP’s Toolkit http://www.wsp.org/wsp/toolkit/toolkit-home 4 “This document defines hygiene and sanitation “hardware” as toilets, pipes, sewers, taps, soap and ancillaries such as pit-emptying equipment. The term “software” is now widely used in the sector to encompass activities that focus on the hygiene and/ or sanitation promotional activities. Other “software” activities include policy development, training, monitoring and evaluation; in short, everything that allows a programme, project or intervention to take place. However, for the purposes
- 4. Review Methodology Each document was reviewed using a five question matrix with additional information: document details (including category, title, date, Review reference name and reference), project type and evaluation methods used. Some questions had sub categories to capture deeper data. The five question review matrix is as follows: 1. Reduction of diarrhoeal and other diseases Diarrhoea Skin disease Eye disease Malnutrition Vomiting Worms 2. Proxy indicators of basic sanitation hardware and statistics on hardware: e.g. percentage change from baseline/actual numbers/proportion of target population Latrines Hand-washing with soap facilities Wash/bathroom 3. Adoption and maintenance of sanitation behaviours Latrine use Hand-washing with soap Disposal of infant faeces Environmental sanitation 4. The sanitation ladder Open Defecation Free (ODF) Improvements in hardware 5. Contribution of program components Subsidies Community Participation Institutional involvement Gender Sustainability Poor of this document hygiene and sanitation “software” is limited to social interventions and/or interactions that do one (or more) of five things: empower individuals, schools and/or communities with knowledge, enable a change in behaviour, create demand for services, facilitate establishment of supply chains, or improve the planning and implementation of hygiene and sanitation projects. Most importantly, “software” is about human behaviour and interaction, and is therefore highly culturally and socially sensitive.” (p.4 Peal, Evans, & Voorden, 2010)
- 5. Discussion The objective of the thesis was to complete a narrative review that sought to analyze three Approaches agencies use to address the problems of poor sanitation and sanitation related diseases by extracting information along themes, focusing on how outcomes are achieved, and then synthesizing the findings in order to generate fresh insights that can inform the practice and methods of implementation and evaluation used in the field. Reduction of diarrhoeal diseases The reduction of sanitation related diseases, of which a primary one is diarrhoea, is difficult to measure and in fact rarely is. In a systematic review and meta-analysis published in the Lancet in 2005, water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries were examined. It was found that, “All of the interventions studied were found to reduce significantly the risks of diarrhoeal illness. Most of the interventions had a similar degree of impact on diarrhoeal illness, with the relative risk estimates from the overall meta-analyses ranging between 0·63 and 0·75.” (Fewtrell, et al., 2005, p. 42). The Lancet article did not disaggregate on the basis of program approach and looked at very specific measures of diarrhoea. This Review sought to discover whether any of the three Approaches measured or reported on any reductions in diarrhoea or other sanitation related health indicators such as skin and eye disease, malnutrition, vomiting and worms/parasites. All of the CLTS, PHAST and SanMark Review results on the reduction of diarrhoeal diseases fit into one of two categories. Either no reporting on diarrhoeal disease reduction or if reductions are reported they are anecdotal and were not quantitativley measured during the evaluation. A quote from the Concern Worldwide Laos Houaphan Health Development Project perhaps best encapsulates this, “It is not known whether the pilot contributed significantly to the projects overall goal of sustainable improvement in the health status of villages in the two districts as it is really too early to tell. Although it is expected that the achievements will have a positive effect on the health conditions of participating villagers, and in particular by reducing faecal-oral transmitted diseases, this was not credibly established during the review, apart from anecdotal responses given by household respondents.” (SNV Lao PDR, 2009, p. 23). This quote suggests that it was “too early to tell” if the health status of the Laos villages had improved. However this Review has found that regardless of the time frame of either projects or their evaluations, there was little or no attempt to quantitatively measure (even in a very basic way) reductions in diarrhoeal diseases (with one exception). If the anecdotal5 evidence is used then the CLTS and PHAST approaches both report reductions in and a prevention of diarrhoeal diseases in the project communities. The SanMark Approach evaluations did not attempt to ascertain changes in diarrhoeal diseases. 5 The use of the word anecdotal in the Review refers to unsubstantiated results (meaning they are circumstantial or self-reported to the evaluation team rather than quantitatively measured).
- 6. Other health indicators Only one document in the three Approaches was able to report statistically reliable data supporting positive changes in the “Other health indicators” category. It must be acknowledged that the Uzbekistan Cohort study is the only document of the Review that reports on a program specifically targeted at a health focused outcome. The results are valuable to this Review inasmuch as they emphatically show a link between the PHAST Approach and a reduction in the risk of reinfection by parasites. Considering PHAST is not a “hardware” based approach it is significant that such a strong link was established between sanitation “software” and a direct health benefit. Similar to the “reduction in diarrhoea” results, all other health indicator results in this section were anecdotal; e.g. “people reported of reduction”; “communities were asked”; “communities listed a reduction”; district leadership “reported positive correlations” and so on. While there is no doubt that change has occurred within project communities, all other evidence of positive changes are circumstantial although perhaps no less powerful and meaningful to those reporting them. It is clear that the documents support the hypothesis that the three Approaches do have positive impacts on health, albeit unsubstantiated and in some cases impossible to attribute to the introduction and use of one of the three Approaches. Proxy indicators of basic sanitation: hardware Sanitation hardware is often used as a proxy indicator for improved sanitary health and while measuring improvements in health as a direct result of a given sanitation Approach is rarely done, changes in the coverage of latrines in a project area is much more likely to occur. The assumption that more latrine use and less open defecation will lead to improved health is reasonable6 . The Joint Monitoring Program (JMP) is the official UN mechanism commissioned with monitoring progress towards the MDG’s. In terms of access to basic sanitation, the JMP measures the, “proportion of population using an improved sanitation facility” 7 however only three out of twelve reports showed any measure of latrine use. This Review was able to show some clear differentiation between the three Approaches in changes in latrine coverage/access (if not usage). There is no questioning that CLTS and (to a lesser degree) SanMark are effective at realizing rapid increases in latrine construction in communities in comparison to PHAST. The Review revealed that the quality of latrines that the CLTS Approach triggers is, at times, questionable, as evidenced by the Plan Nepal report which stated, “ In most cases, too little emphasis were placed on the quality of latrines, particularly their durability, hygiene, and child and gender friendliness.” (Plan Nepal, 2007, p. 33) However, the SanMark latrines seem more likely to meet higher (and sometimes government sanctioned) standards (at least at the point of sale if not at installation) 6 http://www.lboro.ac.uk/well/resources/fact-sheets/fact-sheets-htm/Household%20Sanitation.htm 7 http://www.wssinfo.org/about-the-jmp/introduction/ for a detailed description of the JMP
- 7. and hence be of a better quality. It also seems more likely that CLTS latrines will need to be repaired, replaced and reconstructed more frequently than the SanMark latrines. This is perhaps due a number of factors including the initial financial outlay of owners to purchase hardware (hence wanting value for money); the expectation that businesses selling products must provide some sort of guarantee of quality; the SanMark Approach providing training for masons and other manufacturers of hardware; the greater level of access to “SanMarks” (sanitation markets/stores) which provide a greater range of hardware choices, and; it is likely that masons and other providers in SanMark projects are doing a higher proportion of installations than in CLTS communities. In terms of other proxy indicators of improved sanitation, there was a dearth of information in the documents so it is not possible to reach conclusions or make definitive statements regarding hand-washing with soap facilities and washing/bathing facilities. This is perhaps a reflection on the varying evaluation processes and objectives than on the actual situation in project areas. Of those documents that did make some comment, the range of availability of hand-washing with soap facilities ranged from “most”, 55.2%, and to 22 out of 28. It could be argued that, in terms of breaking the faecal-oral route of disease transmission and reducing the risk of diarrhoeal diseases, the practice of hand- washing with soap at critical times (and hence the facility to do so) is, in the author’s opinion, at least as important as latrine construction. Adoption and maintenance of sanitation behaviours In a systematic review done in 2003, it was found that, “On current evidence, washing hands with soap can reduce the risk of diarrhoeal diseases by 42–47%, and interventions to promote hand-washing might save a million lives.”(Curtis & Cairncross, 2003, p. 275) Given that this review was conducted eight years ago it is extraordinary that more attention has not been given to this component of WASH projects. The Review found that hand-washing with soap (and other hygiene behaviours) was neither a particularly strong focus within the various Approaches nor a focus of the evaluations. And while the Joint Monitoring Program (JMP) measures latrine use, the evaluations did not follow suit and any reporting on latrine use was marginal, at best. Disposal of infant faeces results were hardly mentioned, nor were there findings environmental sanitation. The only document which definitively links behaviour change with a positive health result is the Uzbekistan Cohort Study. The Study concluded that, “Although adopting new hygiene behavior is a long-term process, results from this study indicate that with targeted training meaningful positive improvement can be achieved even within a 1-year period.” (Gungoren, 2007, p. 568). The encouraging aspect of this outcome is that PHAST was the sole hygiene promotion tool used for the Study and such positive results are very reassuring for organizations choosing to use this approach in their program areas.
- 8. The sanitation ladder The process of sanitation improvements can be described as a sanitation “ladder” and defined as, “a continuum from open defecation to fixed place defecation with some sharing, then on to the use of private hygienic toilets and finally to the use of a hygienic system with adequate treatment and re-use or disposal of all wastes.” (Peal, et al., 2010, p. 13) The first step of that process is for people to move from openly defecating to defecating in a fixed place (whether private or shared). The Review found that that, in terms of a continuum, the focus of CLTS (and to a lesser extent SanMark) was on communities becoming open defecation free and very little movement “up” the ladder to hygienic systems. And while an ODF status is, in practice, perhaps more useful than simply counting numbers of constructed latrines, the Review found that being ODF or declared a NOD community has become an end in and of itself rather than just a step onto the first rung of the sanitation ladder. It is also possible that communities are moving up the ladder and that the evaluations are simply failing to ask the questions that would reveal this. Contribution of program components Subsidies CLTS and SanMark are “no subsidy” approaches, while PHAST is often a full subsidy approach when latrine construction is included in the project goals. This has meant that the numbers of latrines constructed in PHAST projects are minimal compared to the need (and CLTS/SanMark) but possibly more effective at targeting strategic sites such as schools, public facilities and the poor/vulnerable in the community. Evaluations found that CLTS is not as effective in areas where previous subsidies have been provided (either in the project areas or nearby). People will often delay, defer or simply not build a latrine in the hope/expectation that a subsidy will become available. This was also found to be the case in the Cambodian SanMark project. The Review found that none of the Approaches seemed to have struck an effective and appropriate balance in terms of providing subsidies for the poor. Suggestions on how to provide hardware subsidies effectively ranged from providing “hidden subsidies”, to the need for financial mechanisms (such as revolving funds), to providing up to half of the value of necessary hardware (such as concrete rings or pans). Community Participation CLTS is a process which is designed to bring the community together to bring collective understanding of the sanitation situation and consequently make collective decisions about how to address it. CLTS is particularly powerful at bringing the community together in the initial stages of a sanitation improvement initiative. The documents clearly describe how CLTS communities strongly felt ownership of the program, pride at the results and that it was “theirs” as opposed to the result of an NGO or government led intervention. Community participation seemed to be
- 9. somewhat confined to the “triggering” activities of CLTS and declined further when issues around durability and sustainability of latrines began to emerge. In urban or peri-urban settings there is sometimes a lack of the sense of a cohesive, identifiable “community” which has consequently significantly diminished the effectiveness of the CLTS approach. SanMark is less of a community based approach but a strategy which targets individual households and institutions (such as businesses) rather than communities as a whole. The PHAST approach, which is by its name is participatory in nature, generates strong community participation in areas such decision making, cost sharing, behaviour change, creating “space” for discussion and attitude shifts. It promotes strong community leadership and involvement. Institutional involvement The involvement of institutions in the three Approaches ranges fairly significantly. Aside from the training of community facilitators (who are usually from an institution – be it government or non-government), CLTS deliberately avoids becoming too involved at the institutional level preferring to entrust the process to the community directly. Where CLTS does engage institutions there seems to be a range of experiences. Some evaluations reported good working relationships within and through existing local authority and community structures while others reported “hardly any effort” and “not enough attention” given to strengthening and forming networks within and between those same types of structures. It is not possible to draw definitive conclusions around institutional involvement and the CLTS process as the degree and effect of it is most likely more contingent on the type of NGO/Project partner than on the process itself. As PHAST is often used as more of a component of a larger water and sanitation program it consequently requires a greater level of collaboration between the various institutions. The Review found very positive accounts of PHAST facilitating cooperation, building institutional capacity within stakeholders, and assisting local leadership to enable the community adopt and improve good hygiene practices. The most interesting finding from the SanMark review was the lesson that, “Sanitation markets benefit from active government support but need not depend on it” (Baker, Roberts, Cole, & Jacks, 2011, p. 4). Gender Perhaps the best summary of the gender considerations of nine of the twelve Review documents is from the CLTS Nigeria evaluation which stated, “One of the key findings of this evaluation is that gender considerations have been accidental rather than intentional” (Burton, 2007, p. 15). Most of the Review results around gender were vague and relatively inconclusive and while there was some positive reporting around improvements in the involvement of women in things like decision making and roles in implementation and maintenance, the general consensus was that for
- 10. sanitation improvements to be sustainable more effort will need to go into gender equity considerations. There were two exceptions in the Review to the above synopsis. One was the Vanuatu Gender Study and the other was the IDE Vietnam pilot. The Vietnam pilot was an exception because the implementing partners deliberately targeted women both through a women’s CBO (the Vietnam Women’s Union) and through a network of female health workers. The Vanuatu Gender Study clearly illustrated that there were multiple links between positive gender equity outcomes (practically and strategically) and WASH projects. The PHAST planning process involved both men and women and resulted in both contributing to collective decision making on a number of choices. The PHAST processes improved the respect men have for women, assisted with changing attitudes, increased women’s relative power and status in their homes and in the community and finally, the evaluation showed a reduction in physical violence associated with disputes over water management. It could be argued that unless gender outcomes are specifically included in a project design, results will be more closely related to pre-existing attitudes and involvement in and of the cultural, political and social organizations/structures of the project location. Sustainability The sustainability of the sanitation improvements (both hardware and hygiene behaviours) a community makes is largely dependent on three things; the degree of realization of the problem; the amount of motivation to resolve the problem; and the quality of the “enabling environment”8 needed to address the problem. CLTS stimulates the first two of these components very effectively and hence initial rapid action is taken to address the sanitation problem. However, the sustainability of CLTS is lessened because the environment required to consolidate the changes is often not developed. Participation in sanitation improvement measures (such as latrine building) wanes because communities grow weary of having to frequently repair or replace temporary, unsubstantial latrines. Additionally, the hygiene and sanitation behaviour messages are often not reinforced over time. Consequently, the sustainability of CLTS is fundamentally dependent on the post-triggering activities. SanMark is perhaps less strong on the initial realization and motivation aspects however one of its strengths is in creating a superior “enabling environment”, especially in terms of sanitation hardware. Because the provision of hardware is reliant on the success of sanitation businesses, it is the sustainability of those businesses that is a key to the long term viability of the Approach. 8 An enabling environment at the household level includes the hardware and software necessary for sanitation improvements (such as pans, concrete rings, soap, water, knowledge, information, and attitude). At a macro level the WSP defines the enabling environment as the policy, institutional and financial framework that is necessary for sustaining and replicating large scale sanitation programs. http://www.wsp.org/wsp/global-initiatives/global-scaling-sanitation-project/Sanitation-core-components
- 11. The Review discovered that private industry is perhaps best placed to be the provider of sanitation hardware as the sustainability of sanitation businesses is dependent on factors such as risk, self-motivation and the ability to be independent of NGO/government support, all of which are not as necessary in the NGO/public sector. While the hardware aspect of Sanitation Marketing may be more sustainable due to a greater availability of quality products, the software/behaviour change messages may also be jeopardized by the lack of “post-triggering” activities such as ongoing training, market research, promotional materials and the funding for such activities. PHAST is quite different in its approach to sanitation improvements and has a greater focus on behaviour change than hardware installation. The time taken to implement PHAST, as well as a greater level of community and institutional involvement in the process perhaps contributes to more substantial and longer lasting behaviour changes. The lack of focus on sanitation hardware improvements will make the sustainability of PHAST interventions much more difficult and much less able to scale up. Poor The Review found that both CLTS and SanMark, in particular, lack a pro-poor strategy which endangers the sustainability of sanitation improvements (particularly hardware). The literature reveals that a distinction between poor and “ultra-poor” is being made. The primary purpose for the distinction in this context is that those considered “poor” still generally have some resources to step onto the sanitation ladder (even if in a temporary way) but the ultra-poor do not. While the ultra-poor (and many considered poor) can take action to improve their sanitary situation they still often need to be “scaffolded” a little through the process. Just as construction scaffolding is removed when the building is stable enough, so too the supports required to assist the poor can be removed once the sanitation hardware and behaviour changes are established and at a sustainable level. Full subsidies do not appear to be the solution as they don’t encourage individual household responsibility for behaviour change however a “no subsidy” approach doesn’t help the ultra-poor or vulnerable to make vital, sustainable changes. As the Special Rapporteur (on the Human Right to safe drinking water and sanitation) appointed by the UN’s Human Rights Council, Catarina De Albuquerique9 , says, “I’ve seen people devoting 20%, 18% of their household income to paying for water and sanitation, and that’s unacceptable.” (Albuquerique, 2011, p. 13). These kinds of costs and the frequent collapse of latrines are a significant disincentive for the poor as they can neither afford to repair temporary nor build permanent latrines. Data from the SanMark evaluations do show, however, that some very poor households were able to buy latrines without subsidies and that market-based latrine promotion is able to, and does, reach some poor households. 9 http://www.ohchr.org/EN/Issues/WaterAndSanitation/SRWater/Pages/SRWaterIndex.aspx
- 12. Conclusion Implications for practice, i.e. choice of Approach The Review found that the choice of Approach could not be explicitly made on the basis of an evidenced-based reduction in diarrhoeal diseases or other health indicators. If the anecdotal reporting of change is used as a guideline, then the CLTS and PHAST approaches both report reductions in and a prevention of diarrhoeal diseases in the project communities. If, however, a choice of one Approach had to be made on the results of this Review, the choice would be PHAST. This would be based on the strength of the results in the Uzbekistan Cohort Study which showed an unequivocal link between the PHAST methodology of hygiene promotion and a reduction in the rates of parasite reinfection (a hygiene and sanitation-specific related illness). PHAST would also be the Review’s choice of Approach in the adoption and maintenance of sanitation behaviours, which is logical considering behaviour change is a primary focus of the PHAST methodology. One of the key ways in which the PHAST Approach could be improved upon is to apply some of the CLTS triggering methods which utilize the “shock” and “disgust” motivators. PHAST has always incorporated “good behaviour/bad behaviour” exercises however the collective realization moment does not appear to be as powerful as during a CLTS triggering session. If the choice of Approach were to be made on proxy indicators of improvements in sanitation conditions, i.e. latrines and other sanitation hardware, then CLTS has the greatest capacity for rapid increases in latrine coverage. And while the quality and sustainability of latrines can (at times) be questionable, the results in terms of sheer numbers cannot. SanMark has the capacity to have a significant influence on the quality (and hence sustainability) of latrines and sanitation hardware as the project “recipients” change from being beneficiaries to customers. This mindset shift is valuable in a number of ways as when people consider themselves beneficiaries there is less motivation to contribute to the outcomes (be it for behaviour change or hardware improvements) however, “customers” may be more likely to demand more from themselves (in terms of behaviour change) and more from their “products” (because of the personal financial investments). PHAST is a methodology which is usually incorporated into a larger water and sanitation project and does not have a sanitation hardware focus. The choice of Approach when considering sanitation behaviour change is a choice of degree. All three Approaches have elements of behaviour change incorporated into the methodologies and it is not easily disaggregated from other components. A criticism of CLTS and to a lesser extent SanMark has been that the infrastructure (or enabling environment) required to ensure long-term effective changes in sanitation behaviours is present at the beginning of a project but lacking as time passes. A criticism of PHAST has been that implementation of the seven step process, while relatively effective, takes too long to see results. In the past, hygiene promotion has often not been prioritized in water and sanitation programming (as most poignantly observed in project budgets). This has been changing as the critically important contribution of hygienic behaviours become more evident in evaluations and community experiences. The sanitation ladder is a good (particularly visual) concept and is a fairly recent addition to the sanitation sector language. The Review did not find abundant
- 13. evidence to support the idea that communities and individuals are being greatly encouraged to “climb” this ladder, other than getting onto the ladder by moving from open defecation to using an improved latrine. Generally speaking the initial choice of latrine/toilet seems to be the one that households remain with and repair or replace with a similar design, rather than “climbing” the ladder and upgrading to a better quality latrine or hygienic facility. Sanitation Marketing shows perhaps the strongest potential for assisting households to climb the sanitation ladder, as the greater range of products give consumers greater choice and the hence the option to progress. While there is no question that communities should be encouraged to aim to be Open Defecation Free (ODF) or be places of No Open Defecation (NOD), the Review found that there is a great deal of confusion around definitions of latrine coverage, when (or to what extent) a community has reached an acceptable level of open defecation, how long a community should have sustained being ODF before being “declared”, what it means to be “declared” ODF, how ODF is verified and so on. It is the author’s view that too much focus is given to these “declarations” and that a greater emphasis on breaking the faecal-oral routes through changes to hygiene behaviours would serve such communities better. It is to be acknowledged that behaviour change is more difficult to measure, however the end goal of healthier communities needs to be kept in focus when sanitation projects are designed. Important considerations for project planners are subsidies and the poor. The Review revealed that CLTS and SanMark are not as effective in areas that have been influenced by previously subsidized programs (WASH projects or otherwise) because the expectation of financial assistance (not always from the poor themselves) is a difficult mentality to change and must be considered in any sanitation project. A second, and related, definitive and significant outcome is the finding that the poor can, and often do, take action to improve their sanitary situation. As noted in the Discussion, the Review found that none of the Approaches seemed to have struck an effective and appropriate balance in terms of providing subsidies for the poor. A blanket “no subsidy” policy has the potential to both leave the poor behind in the initial construction of a latrine but also become a greater burden on households that find themselves consistently rebuilding or repairing temporary latrines. The use of the PHAST methodology in a community has the potential to address some of the difficulties associated with meeting the needs of the poor; inasmuch as the involvement of the whole community in identifying and assisting those within its’ ranks reduces the risk of “top-down”, institutional (and sometimes corrupt-prone) programming. Regardless of the mechanisms of providing subsidies, it is clear from the Review that a pro-poor subsidy/assistance package needs to be made available after the triggering phase of a sanitation project. To persist with a no-subsidy strategy is to fail to recognize the reality of the situation the poor find themselves in and will inevitably endanger the sustainability of the sanitation improvements. Water and sanitation projects, such as those incorporating PHAST and those that utilize a 100 percent subsidy methodology (usually targeted at the poor in a community) are generally unable to scale up latrine coverage to the levels seen by the CLTS and SanMark Approaches. Hence it is critical that project planners develop a culturally relevant, socially acceptable pro-poor policy and strategy from the outset.
- 14. The Review identified several findings about community participation, institutional involvement and gender outcomes that program planners can take into consideration in their choice of Approach. CLTS instigates strong community support and involvement during the initial stages of implementation which sometimes declines after a period of time. PHAST is strong in participatory methodologies resulting in positive community development while Sanitation Marketing less so. The Review found that the range of institutional involvement is reasonably significant with the conclusion that in order to be sustainable in the long term, there must be good collaboration and cooperation between all stakeholders at all levels and that an isolated, independently implemented project approach does not ensure sustainability or long term effectiveness. The Review’s results on gender show that, like other components, clear, thoughtful goals and aims in the project design are vital if significant gains are to be made and that without strategic planning sometimes positive results are a fortuitous (if not welcome) outcome. Sustainability (both in terms of sanitation hardware and hygiene behaviours) is one of the most significant components of WASH projects and one that all stakeholders must contemplate carefully. The Review found that the sustainability of communities aiming to be Open Defecation Free is reasonably high when CLTS is used, that the sustainability of behaviour change is more likely when PHAST is used and that the sustainability of sanitation hardware is presumed to be most likely when Sanitation Marketing is implemented. Implications for evaluation methodology Epidemiological studies of diarrhoea and other health indicators are costly, take a lot of time and to be done properly require high degrees of expertise. This is perhaps why most evaluations do not attempt to measure health outcomes. Despite this, future evaluations could consider including some very basic, simple measures of diarrhoea and other health indicators, particularly in the individual household questionnaires. Most of the evaluations included in this Review incorporated household questionnaires or interviews and the addition of extra questions of this nature would be relatively straightforward. A second recommendation which is paired with the first is the clear need for projects to complete baseline surveys. Knowing the latrine coverage at the end of a project is not particularly useful if the baseline coverage was not measured. Both baseline and end of project data could include the three aspects of diarrhoea/health, hardware, and behaviour. A third recommendation is that evaluation surveys include the collection of data surrounding sanitation hardware other than latrines. The enabling environment for sanitation improvements is broader than latrine construction however this is not reflected in the current collection of information. Additional questions around facilities for bathing, washing hands with soap, food preparation, animal faeces disposal and the like will give the community and program staff the opportunity to understand the bigger picture of sanitation improvements. The final recommendation for evaluation methodology is the pressing need for measuring behaviour change. Hardware improvements can only contribute to
- 15. improved sanitary conditions if there are equal, and possibly greater, changes to sanitation behaviours. Finally When the author was in discussion with water, sanitation and hygiene practitioners at the WASH 2011 conference in Brisbane, Australia10 , it was very evident that they did not feel compelled to choose a “single” approach for their WASH projects. In practice they adopt different approach components to suit their situation. Additionally, they were not necessarily constrained by the “branding” of a given strategy, such as CLTS, which is promoted as a methodology that should be used as a whole (and not discombobulated with other approaches). The concept of “principles not programs” is one the author has employed in many contexts and will do so again here. It is a concept which suggests that any given program/approach will comprise a number of different principles that contribute to its success. If those principles can be clearly identified they can then be replicated in many and varied contexts, often where a branded, entire “program” cannot. This Review makes the following recommendations on sanitation improvement Approach principles. For the initial stages of a sanitation project, Community-Led Total Sanitation is the most effective for triggering rapid uptake of latrine use and reducing the practice of open defecation. For the longer phase of hygiene promotion, sustained behaviour change and community development, the Participatory Hygiene and Sanitation Transformation approach principles (albeit streamlined) produce tangible and positive results. And lastly, the supply of sanitation hardware is always going to be superior when in the hands of private enterprise, and Sanitation Marketing makes that possible, including for the poor. 10 For details go to http://www.watercentre.org/research/research-themes/water-sanitation-and- hygiene/wash-2011/wash-2011
- 16. Appendix Documents Reviewed. Table 1 Documents summary table. For a detailed summary of the documents please refer to Table 2 in the Appendix. Title Project type Evaluation methods Review reference Reference CLTS An Assessment of CLTS Projects and Formulation of the Strategy on Sanitation Promotion. Final Report CLTS Pilot Project Household interviews Focus group discussions Checklists Observations Literature review Nepal NEWAH (Nepal Centre for Economic and Technical Studies, 2007) Community Led Total Sanitation (CLTS). An Evaluation of the WaterAid’s CLTS Programme in Nigeria CLTS Second Phase Pilot Project Household questionnaires Focus group discussions One to one interviews Observations Document review WaterAid Nigeria (Burton, 2007) Evaluation of Community Led Total Sanitation Plan Nepal. CLTS Project Key informants interviews Focus group discussions Transect walks Staff interviews Plan Nepal (Plan Nepal, 2007) Community-Led Total Sanitation (CLTS) in Cambodia Draft Final Evaluation Report CLTS Project Literature review Household interviews Focus group discussions Observations Facilitator/staff interviews CLTS Cambodia (Kunthy & Catalla, 2009)
- 17. Concern Worldwide Houaphan Health Development Project. Community-Led Total Sanitation Pilot Programme Review - Laos CLTS Pilot Project Household interviews Household questionnaires Observations Concern Worldwide Laos (SNV Lao PDR, 2009) A study of recent WaterAid- supported programmes in Bangladesh Sustainability and equity aspects of total sanitation programmes CLTS Project Key informants interviews Community meeting Transect walk Focus group discussions Household interviews Observations WaterAid Bangladesh (Colin, 2009) Title Project type Evaluation methods Review reference Endnote reference PHAST Evaluation of the effects of PHAST training and community health interventions on the hygiene behaviour of children and women to prevent diarrhoeal diseases – in the Locality of Rashad/South Kordofan/Republic of Sudan Water and Sanitation Project utilizing PHAST Cross-sectional case/control study Structured interviews Observations Group interviews Key informants interviews Health Indicators Sudan PHAST Evaluation (Weidner, 2009) Ahanta West Area Development Programme End of Project Evaluation Ahanta Health and Sanitation Project Phase II Health and Sanitation Project utilizing PHAST Focus group discussions Semi-structured questionnaires Staff questionnaire Key informants interviews Ahanta West Ghana (World Vision, 2005)
- 18. How do we better address gender in Pacific water and sanitation initiatives? Research project: Making the invisible visible - documenting successes, enablers and measures of engendering water and sanitation initiatives in the Pacific to inform policy and practice. Gender Equity in Water and Sanitation Project (utilizing PHAST) Paired/small group interviews Group reporting/synthesis Problem tree analysis Ranking exercises Quantification activities Group visions exercises Collaborative analysis Vanuatu Gender Study (Willetts, et al., 2009) Effect of hygiene promotion on the risk of reinfection rate of intestinal parasites in children in rural Uzbekistan Intestinal Parasites Reduction Project utilizing PHAST Controlled prospective cohort study Random household sampling Stool sampling Household questionnaires Individual child data collection Uzbekistan Cohort Study (Gungoren, 2007) Title Project type Evaluation methods Review reference Endnote reference Sanitation Marketing Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sanitation Marketing Pilot Project Local sanitation statistics Key informant semi-structured interviews Stakeholder interviews Focus group discussions Field visit/observation by Study Team. IDE Vietnam (Sijbesma, Truong, & Devine, 2010) Sanitation Marketing Pilot Project End of Project Report Sanitation Marketing Pilot Project Latrine sales calculations Latrine installations calculations Enterprise surveys Household surveys IDE Cambodia (Baker, et al., 2011)
- 19. Bibliography Albuquerique, C. D. (2011, 10/2011). The human right to water and sanitation: the view of the UN's independent expert. Water 21, October 2011, 3. Baker, T., Roberts, M., Cole, B., & Jacks, C. (2011). Sanitation Marketing Pilot Project End of Project Report (pp. 204): International Development Enterprises, Cambodia. Burton, D. S. (2007). An Evaluation of the WaterAid’s CLTS Programme in Nigeria. 23. Retrieved from http://www.wateraid.org/documents/plugin_documents/clts_evaluation_report __final__sept07.pdf Chambers, R. (2009). Going to Scale with Community-Led Total Sanitation: Reflections on Experience, Issues and Ways Forward (U. o. S. B. B. R. UK, Trans.) (Vol. 2009 pp. 52). Brighton, UK: Institute of Development Studies. Colin, J. (2009). A study of recent WaterAid-supported programmes in Bangladesh Sustainability and equity aspects of total sanitation programmes 33. Retrieved from http://www.wateraid.org/documents/plugin_documents/Bangladesh_CLTS_sy nthesis_report.pdf Curtis, V., & Cairncross, S. (2003). Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. The Lancet Infectious Diseases, 3(5), 275-281. Fewtrell, L., Kaufmann, R. B., Kay, D., Enanoria, W., Haller, L., & Colford, J. J. M. (2005). Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. The Lancet Infectious Diseases, 5(1), 42-52. doi: Doi: 10.1016/s1473-3099(04)01253-8 Gungoren, B. (2007). Effect of hygiene promotion on the risk of reinfection rate of intestinal parasites in children in rural Uzbekistan. Transactions of the Royal Society of Tropical Medicine and Hygiene, 101(6), 564-569. Kunthy, S., Dr., & Catalla, R. N. F. (2009). Community-Led Total Sanitation (CLTS) in Cambodia Draft Final Evaluation Report 105. Retrieved from http://www.unicef.org/evaldatabase/files/Jan_30_09_CLTS_FE_Revised_DFR _Cambodia.pdf Nepal Centre for Economic and Technical Studies. (2007). An Assessment of CLTS Projects and Formulation of the Strategy on Sanitation Promotion (pp. 46). Kathmandu: Nepal Water for Health (NEWAH) Lohasal, Kathmandu Nepal. Peal, A., Evans, B., & Voorden, C. v. d. (2010). Hygiene and Sanitation Software: An Overview of Approaches. 156. Retrieved from http://www.wsscc.org/node/745?rck=b6b2de39debc1a19e79db256b3b7be90 Plan Nepal. (2007). Evaluation of Community Led Total Sanitation Plan Nepal. 37. Retrieved from http://www.communityledtotalsanitation.org/sites/communityledtotalsanitation. org/files/Plan_Nepal_CLTS_Evaluation.pdf Sijbesma, C., Truong, T. X., & Devine, J. (2010). Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Global Scaling Up Sanitation Project, 92. Retrieved from http://www.wsp.org/wsp/sites/wsp.org/files/publications/WSP_SustainabilityCa seStudy_TSSM.pdf
- 20. SNV Lao PDR. (2009). Concern Worldwide Houaphan Health Development Project Community-Led Total Sanitation Pilot Programme Review. 47. Retrieved from http://www.communityledtotalsanitation.org/sites/communityledtotalsanitation. org/files/SNV__CWW_CLTS_pilot_evaluation.pdf Weidner, A. (2009). Evaluation of the effects of PHAST training and community health interventions on the hygiene behaviour of children and women to prevent diarrhoeal diseases in the Locality of Rashad/South Kordofan/Republic of Sudan. Master of Public Health Masters, Hamburg University of Applied Sciences, Hamburg. Retrieved from http://opus.haw- hamburg.de/volltexte/2010/1002/pdf/LS_Ges_MA1.pdf Willetts, J., Halcrow, G., & Carrard, N. (2009). How do we better address gender in Pacific water and sanitation initiatives? Research project: Making the invisible visible- documenting successes, enablers and measures of engendering water and sanitation initiatives in the Pacific to inform policy and practice 32. Retrieved from http://genderinpacificwash.info/system/resources/BAhbBlsHOgZmIjwyMDExL zAxLzExLzIxLzMyLzQ5Lzc3Ni9pc2ZfaXdkYV92YW51YXR1X2Nhc2Vfc3R1Z HkucGRm/isf_iwda_vanuatu_case_study.pdf World Vision. (2005). Ahanta West Area Development Programme End of Project Evaluation Ahanta Health and Sanitation Project Phase II (pp. 43). Ghana: World Vision Ghana. WSP. (2010). Case Study on Sustainability of Rural Sanitation Marketing in Vietnam. Global Scaling Up Sanitation Project, 92. Retrieved from http://www.wsp.org/wsp/sites/wsp.org/files/publications/WSP_SustainabilityCa seStudy_TSSM.pdf