5.3 Ways to face the challenges

While water, sanitation and hygiene promotion interventions are clearly linked in their effects, the problems addressed by each are fundamentally different. Water supply, sanitation and hygiene promotion require different skills and approaches, and a style that works well for one may not work for another.

To most people, and especially to the poor, the need for a convenient and safe water supply is self-evident. It is not hard to “generate demand” for drinking water supply among the poor; they already calculate the time it costs to fetch water, and are often willing to pay vendors far more than affluent families pay the public utility for superior service. There is no lack of demand for water supply among the poor or anybody else, and historically this is almost always the first priority for communities.

The current challenges in water supply involve the development of appropriate institutional, economic and financial arrangements to attract initial investment and ensure continued sustainability. These challenges are usually met through collective efforts by governments, commerce, community, or civil society; they almost always involve sharing resources (such as water treatment works or handpumps), regardless of the technology or scale of the system.

In contrast, the construction and maintenance of sanitation facilities is often an individual or household affair. In some cases, sanitation systems mirror community water supplies, with an extensive piped network in the urban environment. By and large, however, such solutions are too expensive for the people currently without service, and would require a radically improved water supply service to function. On-site sanitation (pit latrines, septic tanks, etc.) is appropriate for the unserved population in many rural areas, and is increasingly common in periurban and urban areas. On-site sanitation is, however, a household affair and its development consequently requires a different promotional approach from that required for water supply. Experience suggests that a marketing approach is needed. That is, there should be a focus on developing and distributing products that match consumer demands in both quality and price. This in turn requires understanding the reasons why people want sanitation, which may differ significantly from the agendas of national or international agencies (see Box 5.4). To be successful, sanitation programmes need to provide education for behavioural change and to ensure community participation. Because of high levels of illiteracy, conventional training methods may be ineffective. Many local projects are not achieving the expected results because of a failure to provide effective education.

The importance of hygiene (the behaviour of individuals in the management of excreta and cleanliness) has only recently returned to the fore in the sector. Concerns about hygiene and the use, rather than simply the construction of latrines are not new. What is new, is the rapid increase in epidemiological evidence pointing to the importance of relatively small behavioural changes in protecting families from faecal-oral disease (reviewed in 17).

There is an increasing consensus that much of the health benefit of water supply and sanitation comes from the changes in hygiene they promote. People wash more often when water taps are conveniently located on their property, and people are more likely to practise safe excreta disposal when there is a nearby latrine. Yet other practices, such as handwashing with soap and preventing contamination of drinking-water, are also important, and these behaviour changes do not come about automatically through the provision of hardware. Promoting and motivating people to make these changes requires skills that differ from those required to develop and manage an effective water supply system, or to promote a successful sanitation facilities programme.

Ironically, while epidemiologists agree about the importance of hygiene improvement for health protection, it is at present often not well understood and is not sufficiently documented. None of the data presented in this report directly describes or reflects hygiene practices. While the observation of hygiene behaviour has become an increasingly well-documented field (e.g. 18), these observations are not routinely included as a component of household surveys.

From the above, it is clear that water supply, sanitation and hygiene are not simply “collective goods,” but rather affect each person as an individual. This means that progress in the sector requires a focus on results at the household level. The need to focus on household results is precisely why the use of household survey data in this report is so important. A focus on the household has been recognized as critical in sanitation and environmental health (19). In setting priorities, and establishing “next moves” to improve services, the question must always be: “How does this affect the individual household?” The household-centred approach is not merely an evaluation method. As the data in this report show, individual households are the primary actors in the extension of sanitation coverage - sometimes even without the knowledge of the formal “provider” agencies. To build on household capacities and initiative, there must also be a household-centred approach to implementation.

Access to house connections for water supply and sewerage, handpumps or latrines is not random. Overwhelmingly, those currently not served by improved water supply and sanitation are the poor and powerless. Not surprisingly, public health statistics for water-related and sanitation-related disease also vary with income, leading to the painful conclusion of Hardoy, Cairncross & Satterthwaite (20) that the poor die young. The relationships between health and services are complex, and involve many other factors besides simple access to environmental services; but bad water supply and sanitation certainly contribute to the cycle of disease, poverty and powerlessness. Interventions in water supply and sanitation, through their impact on health and development, are powerful elements of efforts to enable the poor to escape poverty.

Even among the relatively powerless, those with the least power suffer the most. Children and women are the most affected by failures in water supply, sanitation and hygiene promotion. The major portion of the burden of death and disease falls upon children under five years of age; the major burden of care falls upon the mothers, although they may not be explicitly targeted with messages such as the need for safe disposal of stools from children under five. Similarly, there are 40 million refugees and 100 million people displaced from their homes within their own countries as a result of disaster, civil war and conflict. These populations face problems with water supply and sanitation that they may already have solved in their own homes.

Despite the grim statistics of inadequate coverage presented in Chapter 2, this report also reflects the tremendous capacity of society to solve these problems. Simply maintaining a given percentage of coverage often reflects extensive mobilization of skills and resources to keep pace with population growth. Although considerable resources are being provided by external agencies to the water supply and sanitation sector, these are still insufficient. While sanitation coverage in rural India is still far too low, planners were shocked when they first recognized the significance of individual and household investment. Government-funded sanitation could only reach 2% of the population in the 1980s, but household surveys revealed that four times as many households had made the decision to invest in basic sanitation themselves without government assistance. This suggests that governments and external support agencies, including nongovernmental organizations and the private sector, need to understand how water supply and sanitation improvements actually come about; how their activities can help or hinder the process; and need to learn how to work with that.

According to information provided by governments to this Assessment about US$ 16 billion have been spent annually in constructing new water and sanitation facilities over the past 10 years. Yet at the end of the 10 years, huge numbers of people are still without services. In contrast, US $11 billion is spent each year in Europe on ice cream, US $17 billion is spent each year in Europe and the United States on pet food, and US $105 billion is spent each year in Europe alone on alcoholic drinks (15). National budgets for armaments are also large. Water supply, sanitation and hygiene are low-cost essentials compared with these items. It should not be beyond human capacity to achieve a safe, reliable water supply, and sanitation and hygiene for all.

Lack of water supply, sanitation and hygiene causes both social and individual problems. There is increasing consensus that solutions are only achieved in a local context, in which the appropriate mix of government, private sector, individual and civil society contributions must be locally appropriate; that all sectors have a part to play; and that the part must be locally determined. In contrast, much of the debate during the 1990s focused upon the limits of governmental capacity to provide water supply and sanitation services. Some have seen the private sector or civil society (led by nongovernmental organizations or the community itself) as the preferred provider of the services that government could not provide in a more efficient and more accountable way. The evidence is only now beginning to trickle in and the results are mixed.

For example, preliminary studies show that multinational companies are playing an increasing role in water supply in developing countries, and it is plausible that the private sector outlook promotes greater efficiency. These same studies suggest, however, that multinationals are not necessarily bringing much new capital investment to the sector. In any discharge of responsibility from the public to the private sector, care must always be taken to ensure that enforceable regulatory, contractual mechanisms are in place to meet public objectives, and to provide the private sector with sufficient stability to attract continuing investment in extending and upgrading service. Without such mechanisms, it is unrealistic to expect the private sector to invest in services and not maximize their return or investment. Similarly, field studies have suggested that community-managed systems are not necessarily more effective or fairer than systems run by traditional government agencies.

Much of the rhetoric on both sides of the public-private debate has been confused because it does not always consider the full diversity of the private sector. While large multinational water companies are significant players, many other players are much smaller in size. These include local water vendors, contractors and masons who build latrines. While none of these smaller actors may bring in large amounts of capital, all can have a direct impact upon the quantity and quality of services provided.