|Sanitation Promotion (SIDA - SDC - WSSCC - WHO, 1998, 292 p.)|
|The challenge - A sanitation revolution|
The challenge before us is to begin a sanitation revolution. This part outlines the nature of the challenge before us. The articles are purposefully short and ideas are presented in a crisp, to-the-point way.
The first article. The problem of sanitation, is a combination of two papers written in the first and last meetings of the Working Group on Promotion of Sanitation. The first part of the article presents an analysis of the problem and the second part points to a direction for the future. This article is an opinion piece based on Working Group discussions. However, it has been successfully used in a number of countries as a promotional tool to bring to the attention of key decision-makers that sanitation is a global problem needing urgent attention. It presents to the reader the complexity of the task ahead but tries to simplify it by advising that we adhere to three key principles: equity, health protection and environmental protection.
The second article, Commonly held wrong assumptions about sanitation, reminds us that much of the problem in this field derives from misconceptions and harmful attitudes. This piece can be used to stimulate discussion at promotion workshops or in programme planning meetings.
The third article, Sanitation research needs, is included to inspire external support agencies and national governments to fund research in these areas. This list is not exhaustive and should be regarded as initial, based on discussions to date.
This introductory part of the book, probably more than any other, makes us realize that the promotion of sanitation will not be easy. It will be difficult to agree on the way forward: what technologies? what promotional methods? who knows best? Use the articles contained in this section as discussion-starters at meetings, as discussion and debate are forms of raising the profile of sanitation.
The burden of poor sanitation
Every year, 2.5 million (1) children die of diarrhoea that could have been prevented by good sanitation: millions more suffer the nutritional, educational, and economic loss through diarrhoeal disease that improvements in sanitation, especially human excreta management, can prevent. Human excreta are responsible for the transmission of diarrhoea, schistosomiasis, cholera, typhoid, and other infectious diseases affecting thousands of millions. Overall, WHO estimates that nearly 3.3 million people die annually from diarrhoeal diseases, and that a staggering 1.5 thousand million suffer, at any one time, from parasitic worm infections stemming from human excreta and solid wastes in the environment (2). Heavy investments have been made in water supply since 1980, but the resulting health benefits have been severely limited by poor progress in other areas, especially the management of human excreta. In additional to this toll of sickness and disease, the lack of good excreta management is a major environmental threat to the world's water resources, and a fundamental stumbling block in the advancement of human dignity.
Characteristics of the problem
Like all complex problems, poor sanitation can be analysed on many interrelated levels. The Collaborative Council Working Group on Promotion of Sanitation has identified problems, barriers, and themes that appear to operate on three levels.
Level 1 - The basic problem: sanitation isn't happening
Despite years of rhetoric, good intentions, and hard work, we are, in fact, making little or no progress in improving sanitary conditions for much of the world's population. Without major changes, the number of people without access to sanitary excreta management will not change in the next 40 years, remaining above 3000 million people (3). This is astonishing, given the human capacity to solve problems, the fundamental nature of this basic need, and the enormous suffering caused by our failure to meet it. Yet those of us working in sanitation agree that, with some notable exceptions, we are either losing ground or barely holding the line in our ability to dispose of our wastes in a healthy and ecologically sound, and safe, manner.
Level 2 - Barriers to progress: why improvements in sanitation aren't happening
Given the magnitude and importance of the problem, why is there so little progress? The barriers to progress found by the Working Group were varied and complex, but could generally be grouped into the following linked and overlapping categories.
Lack of political will. There is little political incentive for governments to deal with this difficult subject. Politicians rarely lose their jobs because of poor sanitation programmes, particularly as the people most in need have the least political power. Political commitment is needed to create an environment in which demand for sanitation can grow, and which, in turn, can strengthen political will. The issue of political will is thus both a cause and an effect of the other problems, and a key to successful sanitation promotion.
Low prestige and recognition. Promoting low-cost sanitation facilities and hygiene education has never been prestigious; politicians and movie stars do not demonstrate latrines. Among professionals, many of the best and the brightest avoid working on approaches to excreta management that are readily affordable because of the low-status and low-pay of such work. Others, recognizing the frustration of dealing with extremely limited resources, public apathy, and lack of political will, often seek the more professionally rewarding route of higher, more exciting, and better-funded technologies. Even among potential consumers, low-cost solutions to excreta management have little prestige compared to the conventional sewer systems used by the world's more affluent populations.
Poor policy at all levels. Agencies responsible for creating a supportive environment for sanitation, in general, have had ineffective and counterproductive policies at all levels. These include too much attention to water supply at the expense of excreta management and hygiene education, a focus on short-run outputs (hardware) rather than long-term behaviour change, and subsidies that favour middle- and high-income communities. More fundamentally, a philosophical approach to the problem, upon which sound policy can be based, is often lacking.
Poor institutional framework. Many players are affected by sanitation, and many more could be involved in its promotion. However, the institutional frameworks in place often fragment responsibilities in a multiplicity of government agencies and departments, neglect the needs of the most vulnerable segments of the population, and ignore the powerful role that NGOs and the private sector can play. It is clear that governments by themselves have failed to promote sanitation, and that existing institutional frameworks need to change.
Inadequate and poorly used resources. Excreta management and hygiene education attract only a fraction of the resources needed to do the job. Sanitation is at least as important for health as water supply, and is a far more demanding problem; yet sanitation receives far fewer resources. Increasing resources are required just to maintain the status quo, since urbanization and population growth are making the hazards of poor sanitation more acute. Where resources are available, far too much goes into hardware, and not enough into community mobilization and hygiene promotion.
Inappropriate approaches. Even where the promotion of sanitation is attempted, the approach taken is often wrong. Frequently, attempts are made to find universal solutions. These fail to acknowledge the diversity of needs and the cultural, economic, and social contexts in which they occur. For example, although the expectations of urban populations often differ from those living in rural settings, the technological options offered are often the same. Critical issues of behaviour are frequently ignored or handled badly. Short-term fixes have been generally favoured over long-term solutions, and we fail to learn from collective experience. This situation is further aggravated by a lack of awareness among engineers and government decision-makers on the performance characteristics of on-site excreta management systems. This lack of awareness is, in large part, due to the focus of traditional engineering education on conventional sewerage systems. Rejection of an on-site excreta management approach is also often based on the belief that the available hardware for on-site management is technically inferior, less sophisticated, and a managerial and administrative burden on households and government agencies alike.
Sanitation also fails by being defined and applied too broadly or too narrowly within a specific environment. In some cases, for example, the scope of environmental protection and pollution control becomes so broad that the focus on basic household excreta management is lost. In others, a narrow focus on a single technology, such as pit latrines, may ignore other community needs (such as drainage) that may exacerbate disease transmission during floods.
Failure to admit disadvantages of conventional excreta management systems. The collection and transport of human excreta by water carriage has been usefully employed in many parts of the world, and has resulted in the development of extensive social, political, and technical infrastructures. Nevertheless, the disadvantages of this system should be considered as well. These include: costs, the volume of water required for carriage, and the energy needed for treating the collected wastewater. Other disadvantages include the health, economic, and environmental effects of inadequately treated wastes and the loss of potentially valuable nutrients for small-scale agriculture.
Neglect of consumer preferences. Too often we try to promote what people do not want or cannot afford or both. Low-cost technologies are often seen by consumers as low-status technologies. Others, found appropriate by their promoters, are far beyond the financial reach of those in most need. Promoters try to sell excreta management systems based on health benefits, when most people are really more interested in the privacy, comfort, and the status that such technologies can offer. Further, much hygiene promotion is based on messages that ignore existing knowledge, belief, and experience. Put simply, most of us promoting sanitation simply do not hear what the people we serve say they want or believe.
Ineffective promotion and low public awareness. Although people have opinions about excreta management, they are reluctant to talk about the management of their excreta. Thus, selling the idea of improvements in sanitation is difficult. Engineers and health care professionals who are responsible for promoting sanitation are often unaware of effective promotional techniques and continue with top-down approaches that alienate the target populations by denying their voice, desires, and involvement in the process. Those who are charged with promoting sanitation are seldom prepared to do so in their education of others or in their professional practice. Adoption of social marketing and participatory approaches to sanitation is promising, but is still in its infancy; we have much to learn.
Women and children last. Women are potential agents of change in hygiene education and children are the most vulnerable victims of poor sanitation. Yet it is men who usually make the decisions about whether to tackle the problem and how. Many sanitation programmes ignore the need for safe management of children's faeces, even though they are a major source of pathogens. Women, more than men, often want privacy and security in their excreta management systems but are unable to express needs effectively in many societies. Hence, those with the most at stake have the weakest voice.
Level 3 - Cross-cutting themes: demand and taboo
Little effective demand. If more people expressed a desire for improvements in sanitation loudly enough, many of the problems would resolve themselves. This seeming lack of demand is often considered a constraint. People may want sanitation very badly, yet be powerless to express that desire in financial or political terms. Some may want safe excreta management facilities, but not at the available price. Others may not want the available improvements at any price. We need to examine critically the factors that limit demand, especially those with economic or political roots. Where sanitation is poor, we need to understand why the effective demand is low and to determine whether it is most amenable to political, financial, technical or information change.
Cultural taboo and beliefs. In most cultures, the handling of excreta is considered as taboo, and viewed as a disgusting or a dangerous nuisance not to be discussed openly or seriously or both. No one wants to be associated with excreta; even those who reduce its offensive characteristics for others are stigmatized by association. Problems cannot be solved if people do not want to talk about them and do not want to be associated with their solution. In many contexts, taboos, including modern technological ones, block the safe recovery of valuable agricultural resources from human wastes. The excreta taboo lies behind many of the barriers to progress in this area. To counter this, sanitation promotion and hygiene education should link the value of excreta (faeces and urine) with ecology. They should promote an understanding of the essential roles it plays in the life cycle of plants and animals, as well as the damaging effect that it can have on health and environment when improperly handled, discharged or reused.
A sanitation revolution
What is needed to turn this sector around is no less than a revolution in thought and action. The sector simply cannot continue as in the past. It is necessary to define principles, make priorities, create strategies and search for new technological, financial and institutional solutions. Advocacy and mobilization of new partners will be large parts of this revolution.
An approach to the sanitation challenge
An approach to the sanitation challenge is emerging that is not only human-centred, but also ecologically sustainable. It is concerned with equity, the protection of the environment, and the health of both the user and the general public. Its goal is to create socially, economically, and ecologically sustainable systems. To reach this goal, three key principles have been identified as critical to designing successful sanitation systems for the future.
Equity, within the sanitation sector, means that all segments of society have access to safe appropriate sanitation systems adapted to their needs and means. Currently, inequities are found at many levels, between rich and poor, men and women, and urban and rural. Equity implies that:
- access to safe sanitation systems is ensured for all communities;
- sanitation systems are being implemented that are safe and adapted to the economic means of the users;
- genuine community involvement takes place in both planning and management of systems;
- political will is mobilized to assure the rights of all in sharing needed resources for improved sanitation; and
- the information required for decision-making is available to all segments of user communities.
Health promotion and protection from disease, within the sanitation sector, means that systems are capable of preventing people from contracting excreta-related diseases as well as interrupting the cycle of disease transmission. Health promotion and protection from disease implies that:
- the importance of social and behavioural dimensions in achieving health benefits is given priority; and
- future sanitation technologies have the demonstrated capacity to prevent the transmission of pathogens.
Protection of the environment, within the sanitation sector, means that future sanitation systems must neither pollute ecosystems nor deplete scarce resources. Environmental protection implies that sanitation systems:
- do not lead to water or land degradation, and, where possible, ameliorate existing problems caused by pollution; and
- are designed to recycle to the maximum extent the renewable resources, such as water and nutrients present in human excreta, as well as non-renewable resources.
Programmes that fulfil all these principles simultaneously should lead to long-term sustainability.
Operationalizing the approach to the sanitation challenge of the 21st century
The unprecedented sanitation challenge requires that new strategies and methods to improve sanitation be applied to ensure equitable access for everyone, that human health be protected, and that environmental resources be protected and conserved, while moving towards the goal of achieving sustainability. This requires:
- to learning from personal experiences and those of others;
- to new and innovative approaches;
- to applying a mix of technologies and systems;
- to considering the impact of a sanitation system on equity and the environment;
- to consider the alternatives if a proposed sanitation system cannot be implemented completely; and
- to be aware of changing situations/crises.
Change in attitudes
- towards conservation and protection of resources;
- towards participatory approaches; and
- towards accepting waste as a resource.
This means adopting two operational strategies:
- flexibility in developing and applying sanitation systems, incorporating respect for community values, perceptions, and practices; and
- considering sanitation on its own merits and not as a sub-set of another sector.
The time has come to cease perceiving sanitation as an afterthought of water systems. To handle the magnitude of existing and future sanitation requirements, the sector should be restructured so that sanitation, as an essential public service, can be given appropriate consideration.
Recommendations for sanitation programmes
For implementation of sanitation programmes the following recommendations are made:
· Develop mechanisms to ensure that sanitation systems help prevent environmental pollution and degradation.
· Provide impetus for innovative research and development for a range of systems applicable to differing cultural and environmental conditions.
· Treat sanitation as a major field of endeavour in its own right, with sufficient levels of investment to revitalize training programmes and professional standing.
· Create a demand for systems that move increasingly towards reuse and recycling of human excreta.
· Encourage a review of sanitation policies within government, nongovernment, private, and sector donors.
· Involve people for whom the systems are being built in the design process.
(1) WHO. Health and environment in sustainable development. Five years after the Earth Summit. Geneva, World Health Organization, 1997 (unpublished document WHO/EHG/97.8).
(2) WHO: Community water supply and sanitation: needs, challenges and health objectives. Report by the Director-General. Forty-eighth World Health Assembly, Provisional agenda item 32.1. Geneva, World Health Organization, 1995 (unpublished document A48/INF.DOC/2).
(3) WHO/UNICEF Water supply and sanitation sector monitoring report: sector status as at 31 December 1994. Geneva, World Health Organization, 1996 (WHO/EOS/96.15).
This list of commonly held wrong assumptions about sanitation is offered to provoke thought and challenge all those involved in sanitation, irrespective of the different stages of development that exist worldwide. The list can be a useful tool for promoting sanitation; for example, in meetings where it can be used to stimulate discussion and challenge people to agree or disagree.
Commonly held wrong assumptions
At all levels:
· Improved water supply alone leads to better health. There is no need for sanitation.
· Sanitation improvements have minimal health benefits and no socioeconomic benefits.
· All good sanitation options are expensive and difficult to implement.
· Water, air, and soil are free goods and we should not have to pay for improving them.
At the level of donors and implementing agencies:
· Safe and adequate water supply is a pre-condition for good sanitation.
· Message-giving will change behaviours and automatically create demand.
· Sanitation improvements mean simply building latrines.
· People are not willing to pay for sanitation improvements.
· Design and construction of a latrine is simple and does not require expertise.
· There are standard formulas and quick-fixes for achieving sanitation, which can be universally applied.
· There are two right low-cost technologies: VIP latrines and pour-flush latrines.
· Traditional cultural attitudes are a barrier to good sanitation practices.
· Water supply institutions are automatically suitable for developing sanitation.
· The private sector is not interested in sanitation.
· People are not capable of moving fast enough to meet programme goals.
· There is no need for additional specific research since the situation in developing countries today is the same as that of industrialized countries at the beginning of the century. We just apply the same solutions.
At the level of beneficiaries:
· Improved sanitation has no immediate benefits.
· Sanitation systems are never reliable.
· Responsibility for sanitation lies somewhere else.
· Children's faeces are harmless.
Sanitation has special features and requirements that distinguish it as a field in its own right. Therefore, research and scientific study specifically on sanitation are necessary to help enable practitioners to make better decisions. Ultimately, this will lead to more successful and sustainable sanitation programmes. Donor organizations can make a significant contribution to improving sanitation programme performance by supporting research aimed at filling the current information gaps. The following areas in which research is urgently needed have been identified by the Working Group on Promotion of Sanitation.
- for integrating sanitation into other social programmes (literacy, population, nutrition).
Indicators for monitoring and evaluation
- behaviour-change indicators, health-impact indicators, long-term success indicators;
- the percentage of a population that would need to be covered (critical mass) to ensure full coverage for purposes of disease control;
- development of criteria and a monitoring and evaluation framework for measuring success at national and community levels;
- development of methods for assisting communities in identifying and using indicators.
Private sector involvement
- the key barriers to private sector involvement;
- the optimal mix of responsibilities between the public and private sectors.
- how to choose an appropriate mix of technologies to suit urban areas with low, middle and high income;
- how to achieve low-cost, culturally-sensitive technologies, including dry-latrine systems;
- critical review of low-cost and least-cost technologies;
- new technologies that recycle nutrients.
Participatory methods, social marketing, and social mobilization
- models for how social marketing and participatory methods can best be combined;
- critical review of methodologies to change hygiene behaviours.
Success stories and models
- through case-studies of countries, determine the characteristics of high achievers and low achievers in sanitation and from these derive lessons learned.
Finance, cost-effectiveness and cost recovery
- alternative financing and cost-recovery mechanisms;
- the cost-effectiveness of alternative strategies for the control of faecal-borne diseases;
- a critical review of the value of willingness to pay (WTP) studies and alternative mechanisms to determine WTP.