Cover Image
close this bookSanitation Promotion (SIDA - SDC - WSSCC - WHO, 1998, 292 p.)
View the document(introduction...)
View the documentAcknowledgements
View the documentAcronyms
View the documentWelcome
Open this folder and view contentsThe challenge - A sanitation revolution
Open this folder and view contentsGaining political will and partnership
Open this folder and view contentsPromotion through better programmes
Open this folder and view contentsPromotion through innovation
View the documentBibliography
View the documentBack cover


WSSCC Working Group on Promotion of Sanitation

Edited by
Mayling Simpson-Hrt and Sara Wood

Original: English
Distr.: General

© World Health Organization 1998

All rights reserved. This document may be freely used, copied, distributed and translated, in whole or in part, for education and other non-commercial purposes. Please acknowledge the source of material taken from this document in the following way: Simpson-Hrt M & Wood S, eds. (1998) Sanitation Promotion. Geneva, World Health Organization/Water Supply and Sanitation Collaborative Council (Working Group on Promotion of Sanitation) (unpublished document WHO/EOS/98.5). Any other dealing, including the adaption into electronic form, requires the permission of WHO, and requests should be directed to WSH, World Health Organization, 20 avenue Appia, 1211 Geneva, Switzerland. Please note that there are certain parts of this document of which WHO is not the copyright holder. Permission to use these parts outside the usage stated above must be sought directly from each copyright holder concerned. The address information for contacting each copyright holder appears on the last page of each such part. It is the responsibility of the user alone to obtain permission from the copyright holders.

Any dealing, in whole or in part, for commercial or promotional purposes (including distribution for a fee to a third party) is strictly prohibited.

The views expressed in parts by named authors are solely the responsibility of those authors. Designed by WHO GRAPHICS

Sanitation - interventions to reduce people's exposure to diseases by providing a clean environment in which to live; measures to break the cycle of disease. This usually includes disposing of or hygienic management of human and animal excreta, refuse, and wastewater, the control of disease vectors and the provision of washing facilities for personal and domestic hygiene. Sanitation involves both behaviours and facilities which work together to form a hygienic environment.

Promotion - to raise or advance a cause, raise the profile and status of the cause, further the growth and expansion of the cause and to further its popularity. In the public health sense of the word, it also involves providing the enabling mechanisms to others so that they may take up the cause armed with effective tools.

Ordering information

Sanitation Promotion
1998, xv + 277 pages [E]
WHO/EOS/98.5 40.–/US $36.00; in developing countries: 28.–
Order no. 1930147


This book represents the contributions of many individuals and organizations in the water supply and sanitation sector. The WSSCC Working Group on Promotion of Sanitation and its editors wish to thank sincerely the many who wrote articles, reviewed articles and reviewed the draft as a whole. Every attempt was made to consider seriously the inputs of every person and organization, to reach a consensus and to make revisions accordingly. Not every viewpoint expressed here is held by every member of the Working Group or the World Health Organization. In the end, the responsibility for errors and the inclusion of articles and points of view that may not be held by everyone in the sector is that of the editors alone. This responsibility we gladly accept.

Firstly we would like to thank the many authors who contributed articles, most of them without any financial remuneration. Without them, there would be no book.

We wish to thank the following people who reviewed the draft in whole or in part and provided us with written comments: John Adams, Arthur Archer, Ali Basaran, Albert Birgi, Isabelle Blackett, Vicky Blagbrough, Bjorn Brandberg, Ben van Bronckhorst, Sandy Cairncross, Leonie Crennan, Franz Drees, the Environmental Health Project of USAID, David Evans, Franz Giler, Christoph Geisler, Gourisankar Ghosh, Brian Grover, J. Hazbun, Udo Heinss, Pierre Hirano, Peder Hjorth, M. M. Hoque, Sahmsul Huda, Raquiba A Jahan, Dick de Jong, Ratna I. Josodipoero, K. Balanchandra Kurup, Nii Odai Laryea, Susan Lee, Palat Mohandas, Mosabala Lipholo, T. V. Luong, Arben Luzati, Duncan Mara, Josarlines, Walter Mason, Nilanjan Mikherjee, Eric Mood, Rees Mwasambili, Nguyen Huy Nga, John Pospisilik, Claude Rakotomalala, Jennifer Rietbergen-McCracken, Pia Rockhold, Beatrice Sakyi, Roland Schertenleib, Tova Maria Solo, Maria Sotomayor, Koo Ue, Jean Michel Vauillamoy, Philip Wan, Dennis Warner, Uno Winblad, Asunwontan Winclaire, Ranjith Wiransinha, Regional Water Supply Group, Western and Central Africa, and UNICEF and World Health Organization offices in many countries.

A big thanks goes to Working Group members who contributed to the discussions and thinking that lie behind this book. These are H. Alkhandak, Astier Almedom, Mustapha Bennouna, Anthony Brand, Bjorn Brandberg, Ato Brown, Lucy Clarke, Steven A. Esrey, Mariela Garcia, Jean Gough, Derrick O. Ikin, Vathinee Jitjaturunt, Mary Judd, M. Salissou KanDan Kaseje, Peter Kolsky, Patric Landin, Bryan Locke, S. P. Mathur, Alain Mathys, Fati Mumuni, Helen Murphy, Shungu S. Mtero, Janusz Niemczynowicz, Antoinette Nyomba, Bindeshwar Pathak, Eduardo Perez, B. Mogane-Ramahotswa, M. Ramonaheng, B. B. Samanta, Gunner Schultzberg, Homero Silva, P. K. Sivanandan, Nguyen Cong Thanh, Vanessa Tobin, Cheikh TourKoo Ue, Hans van Damme, Ineke van Hooff, Christine van Wijk, and H. Wihuri. Many of these people attended as representatives of their agencies: the Environmental Health Project of USAID, IRC Water and Sanitation Centre, UNDP-World Bank Water and Sanitation Program, UNICEF and World Health Organization.

Mary Falvey, Elizabeth Garfunkel and Jacqueline Sawyer provided editorial support.

Finally, there are not words strong enough to express the gratitude that the Working Group on Promotion of Sanitation and the Water Supply and Sanitation Collaborative Council feels for the generous financial support given to the Working Group. These donors stood behind the autonomous thinking of the group every step of the way and continuously offered words of support in addition to their financial contributions. We therefore give our heartfelt and deepest thanks to the Swedish International Development Cooperation Agency (Sida), the Swiss Development Cooperation (SDC) and the World Health Organization for their contributions.



acquired immunity deficiency syndrome


African Medical Research Foundation


Autonom Descentralisimo y GestiAC


Cooperative for Assistance and Relief Everywhere, Inc.


Centro de Investigaci Capacitaciural, AC


community mobilization and sanitation


Danish International Development Agency


Expanded Programme on Immunization


External Support Agency


Espacio de Salud


Fundacicuatoriana del Htat


International Drinking Water Supply and Sanitation Decade (1981-1990)


information, education and communication


Institute of Health Management (India)


International Water and Sanitation Centre


Institute of Water and Sanitation Development (Zimbabwe)


knowledge, attitudes, beliefs and practices


Kenya Water and Health Organization


liquid organic fertilizer


management information system


Network for Water and Sanitation


nongovernmental organization


Participatory Hygiene and Sanitation Transformation


participatory rural appraisal


Promotion of the Role of Women in Water and Environmental Sanitation Services


Rural Water and Sanitation Project of the Government of Uganda


Regional Water and Sanitation Group for East Asia and the Pacific


Self-esteem, Associative strengths. Resourcefulness, Action-planning, and Responsibility


Sanitation Research (Sida-funded project)


Swiss Development Cooperation


school health education project


Swedish International Development Cooperation Agency


traditional birth assistant


Uganda Community-Based Health Care Association


United Nations Centre for Human Settlements (HABITAT)


United Nations Development Programme


United Nations Children's Fund


United States Agency for International Development


Water and Sanitation for Health (of USAID)


Water Engineering Development Centre


World Health Organization


World Resources Institute


Water Supply and Sanitation


Water Supply & Sanitation Collaborative Council


Water Supply and Sanitation Project for Low-Income Communities (Indonesia)


water-user committee



The objective of this book is to help water supply and sanitation professionals and others who care about advancing sanitation to promote it effectively.

What is promotion? Promotion involves all the things one must do to raise or advance a cause, raise the profile and status of the cause, further the growth and expansion of the cause, and to further its popularity. Promotion, in the public health sense of the word, also involves providing the enabling mechanisms to others so that they may take up the cause armed with effective tools. This book has been designed to try and meet this need with regard to the promotion of sanitation.

This is not a press kit or an advocacy kit to be placed directly on the desk of a minister or politician. It is a group of articles and tools to guide the user in promoting sanitation to others and to help the user strengthen his own programme or project so that it will be a showcase example of good practice. It does not provide directly-usable advocacy materials, such as overhead transparencies but does provide enough guidance for the user to make his or her own.

Intended audience

This book has been prepared for policy makers and strategic planners at national, district and municipal levels who are responsible for securing investments for sanitation, and planning, commissioning, monitoring and evaluating sanitation programmes.

Other potential users are external support agencies and nongovernmental organizations that make large investments in sanitation or have a role in providing expertise in sanitation to other large investors. A few items can be used directly at project level by senior field staff to check whether their projects are applying principles of good practice and thus should be successful showcase examples.

Box 1. Intended Audience

- policy makers
- strategic planners
- external support agencies
- nongovernmental organizations
- senior project-level field staff


The idea for this book and its contents were developed by the Water Supply and Sanitation Collaborative Council Working Group on Promotion of Sanitation, which worked between 1994 and 1997 through periodic meetings and correspondence. During these meetings the Working Group decided that water supply and sanitation professionals need to do at least three things to raise the status and profile of the sector to attract more activity and investments in countries.

· Gain the commitment of politicians and other partners.

· Do showcase programmes and projects as examples of what can be accomplished with the support of these partners.

· Innovate, research and trial new approaches in the field and share these innovations with others. This exchange of ideas and information will greatly stimulate the sector.

This book is designed to meet these three needs. Doing all three will give the greatest boost to sanitation. The articles in the book should be used to make these three things happen.

After a careful review of existing literature on topics identified as important for such a book, it was decided that very little literature existed on how to promote sanitation, and that articles should be produced to assist water supply and sanitation professionals in promotion. Most articles in the book, therefore, are new and unique and were written specifically for promotion. They do not duplicate existing literature on sanitation, however, some articles and checklists, such as on hygiene education and gender, are summaries and overviews to achieve a quick understanding of a complex topic, so that these concepts can be practically applied without pouring through a great deal of literature. A list of references and further reading, is provided for those who would like to read more in depth.


The book focuses exclusively on promotion and does not attempt to give guidance on programming, how to run sanitation institutions or choosing sanitation technologies. There are other recently produced guidance materials on these areas and these are listed in the bibliography. Included is advice on best practices in the form of principles and features of better sanitation programs, a list of some commonly-held wrong assumptions upon which programmes are sometimes based which can lead to failure, and checklists and worksheets based upon what is thought to be state-of-the art in these areas. On the other hand, it is recognized that this is an ever-changing field of work, and that there is no one way or right answer for the wide variety of cultures that need to be served for sanitation. Therefore, these guidance materials should not be viewed as prescriptive but rather only as advisory based on current thinking.

Sanitation involves excreta disposal, water supply, hygiene behaviours, drainage, solid waste, and health care waste. The book pays a great deal of attention to excreta disposal, as it is the major problem in environmental sanitation. However, most of the articles would apply to the entire field of environmental sanitation. The principles and features of better programmes, for example, could apply equally to excreta disposal, solid waste or drainage. The articles on gender and hygiene behaviour change are certainly generic in scope. This book, therefore, should not be viewed as a tool for the promotion of excreta disposal only.

Box 2. What this book is and is not.

This book IS:

- A source of ideas on promotion
- Guidance on “best practices”
- A sharing of innovative approaches
- Tools to strengthen skills in promotion

This book IS NOT:

- Prescriptive
- A press kit
- An advocacy kit
- A sanitation programming guideline
- An overview of sanitation technologies
- A book exclusively on promotion of excreta disposal
- A review of existing sanitation literature
- An endorsement of certain sanitation technologies

Overview and structure

The book is divided into four main parts.

· The challenge - A sanitation revolution
· Gaining political will and partnerships
· Promotion through better programmes
· Promotion through innovation

The Challenge - A sanitation revolution. This part explains the scope of the challenge before us. It contains a statement of the problem and a possible way forward, some commonly held wrong assumptions about sanitation, and research needs.

Gaining political will & partnerships. This part provides ideas on promotional techniques that may be applied to sanitation. The section is divided into two sections, Principles and guidelines and Case studies. The first section explains the major concepts in advocacy, mobilizing the media and mobilizing partners. The second part contains two case studies on how political will and partnerships were achieved in Uganda and India.

Promotion through better programmes. This part is intended to help you strengthen existing sanitation programmes for which you are responsible. We cannot promote sanitation until we can do good programmes and projects as showcase examples. We cannot win the support of politicians and other partners to invest in sanitation until we can prove to them their investments will be well spent and sustainable. This section is not a complete guide to doing better programmes, but rather a focus on strengthening areas known to be commonly weak. The section is not intended to be a programming guideline nor to be comprehensive on every aspect of sanitation programmes. Other literature already exists in these areas and there was no need to duplicate it.

The part begins with Principles which should form the foundation of all good programmes. The principles and other articles in this section were derived from an analysis of good sanitation programmes. They are statements of “best practices.” It then follows with a section on Empowerment which highlights the importance of putting people at the centre of sanitation programmes. Articles focus on gender, hygiene behaviour change, participatory approaches and household financing. These articles reflect the good practice of many of the principles. This part ends with a section on Checklists, derived from principles and the empowerment articles, to help you apply these in a practical way.

Promotion through innovation. This final section illustrates some of the newest innovations that show promise for promotion of sanitation. While there have been many achievements in sanitation over the last thirty years, such as new low cost technologies, and guidelines on hygiene education, communications and gender considerations, we need to continue to search for new ways and to innovate. Research, field trials and the sharing of results should be a never-ending process.

The section is divided into three sections: Child-centred approaches, Participatory approaches, and Innovative technologies.

A book on sanitation promotion would be incomplete if it did not address the role of technologies in the advancement of sanitation. Some of the barriers to achieving better coverage have to do with cost, lack of sufficient water supply for flushing and transport, concern over water pollution, and an inability to dig or construct in certain physical conditions. These barriers, as well as a growing movement to recycle nutrients back into soil, has stimulated research and trials into new and innovative sanitation technologies. Most of these technologies have an ecological focus and are provided here in the hope of stimulating even more research and innovation. Most of the case studies on technologies also describe how they were promoted in the context in which they were trialed and many valuable lessons on promotion are drawn.

The technologies described in this book are not necessarily endorsed by the World Health Organization nor is their inclusion intended to suggest that these are the only acceptable technologies for the future.

How to use this book

Sanitation Promotion is intended to be used as a “pick-and-choose” book. You do not need to read the entire book, or read from front to back to benefit from it. Use the table of contents to determine what interests you and your programme. The articles, worksheets and checklists may be photocopied and passed along to others. The contents may also be used for training courses and sanitation promotion workshops. You may use the book as a model to create you own local sanitation promotion book. To do so, you may wish to translate articles into a local language, to scale down the language to a simpler level, to format it with larger font and more illustrations and to pick and choose articles relevant to your situation. For your local book, you may wish to commission promotional articles such as an article on winning the support of local politicians using country-specific statistics, articles on innovative promotional techniques and showcase sanitation projects. The more you localize your promotion book, the more people will notice it and relate to it.

Box 3. How to USE this book:

· Pick and choose articles that suit your needs
· Photocopy and share articles
· Discuss and debate issues raised in the articles
· Use articles for sanitation training courses
· Use articles for sanitation promotion workshops
· Try the worksheets and checklists
· As a model to make your own local promotion book

Pick and choose, photocopy, share, discuss and debate. These are the main things you should do with the contents of this book. Then decide what to do on your own to promote sanitation. This book is a first step, a source of ideas for the promotion of sanitation. It is certainly not the last word on sanitation promotion. However, it will be up to you whether the ideas in this book are actually applied in your own country or local area.

May ling Simpson-Hrt

Sara Wood


Communications Consultant

Promotion of Sanitation Working Group

Water, Sanitation and Health Unit

Water, Sanitation and Health Unit

World Health Organization

World Health Organization

Geneva, Switzerland

Geneva, Switzerland


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 problem of sanitation - WSSCC Working Group on Promotion 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:

More openness

- 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).

Commonly held wrong assumptions about sanitation - WSSCC Working Group on Promotion of Sanitation

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 research needs - WSSCC Working Group on Promotion of Sanitation

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.

Planning models

- 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.

Sanitation technologies

- 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.


A fundamental requirement for the promotion of sanitation is gaining the political commitment of key policy-makers and forging partnerships with various individuals and organizations in society. This part is designed to help you achieve both.

The ideas presented here are based upon good marketing practice. We have tried to adapt these good practices to the field of sanitation. This part is divided into Principles and guidelines and Case studies.

The first section, Principles and guidelines, explains the major concepts to be used in promotional activities. These include advocacy, mobilizing the media, and mobilizing partners (also called social mobilization). Ideas are offered on different ways the private sector can promote sanitation, and applying social marketing to sanitation.

The second section contains two case studies on how political will and partnerships were achieved.

Little has actually been done in the field of sanitation promotion to draw upon. Thus, the articles are a starting point upon which the sector should build, and, over time, create even better principles and guidelines for gaining political will and partnerships and provide more case studies.

Advocacy for sanitation - Sara Wood1 and Mayling Simpson-Hébert2

1 WHO Consultant, Geneva, Switzerland.
2 WHO, Geneva, Switzerland.

There are few mysteries about why we need to have environmental sanitation. Lack of sanitation makes people ill and kills. More than three million people die every year from diarrhoeal diseases alone (1). It is said to be easier and cheaper to treat every patient with a sanitation-related disease, but is it wiser? What dignity is there living in filth and having chronic epidemics causing great suffering and death if all of this is totally preventable? What is development if it is not helping human beings to live in health and cleanliness with dignity?

Lack of environmental sanitation probably causes more illnesses and death than any other single factor in the world today. Human excreta is probably the world's number one pollutant. We are not only spoiling our water supplies, contaminating our food, and killing our children, but many countries are suffering economic loss from embargoes on their exported foods and loss of tourism owing to cholera outbreaks.

Half of the world's population lacks basic sanitation and within a few years it will be more than half (2). Yet it does not have to be this way. One of the main reasons for lack of investments in sanitation is lack of political will. Investments in sanitation lag far behind investments in water supply, even though the two should go hand-in-hand. Sanitation departments are under-staffed and under-paid, their workers often having the lowest status in public service. All of this must change. This is what advocating for sanitation is all about.

Advocacy is one of the main tools used to mobilize politicians and other partners for a cause. “Advocacy is speaking up, drawing attention to an issue, winning the support of key constituencies in order to influence policies and spending, and bring about change. Successful advocates usually start by identifying the people they need to influence and planning the best ways to communicate with them. They do their homework on an issue and build a persuasive case. They organize networks and coalitions to create a groundswell of support that can influence key decision-makers. They work with the media to help communicate the message”(3).

The future of sanitation and the incidence of sanitation-related diseases rests more on the behaviour of politicians than on sanitary engineers. If we are to have good sanitation programmes and technologies to meet the varying geographical, climatic and socio-cultural conditions found in the world today, we must have national policies on sanitation and funding for research and development.

There are at least two messages we need to get across to politicians and other key partners. Lack of sanitation is responsible for most of the diseases and death in developing countries today. Sanitation together with hygiene education will break the cycles of these diseases. Different messages may be needed for the general public based upon prestige, comfort, convenience and privacy. Whether health should also be a message for the general public will depend upon the outcome of the market research required to target the general public.

This article outlines four basic steps that are essential for effective advocacy.

Steps to effective advocacy

The objective of advocacy is to raise awareness and convince others of the need to take action. To do advocacy well, one must follow a series of time-proven steps.

1. Target audience identification

Successful advocacy begins with the identification of groups that need to be influenced and working out the best way to communicate with each group. For example, different ways to communicate could include personal contact, asking others more influential than yourself to carry your message, through the media (newspapers, television or radio), or through traditional channels of communication such as churches, temples or mosques, festivals or street theatre. The methods are numerous. The key is to work out which methods will be the most effective in reaching your target group.

2. Developing an information base

An effective advocacy campaign requires information that demonstrates the extent of the problem and the effectiveness of the proposed solution. To do this you will need facts and figures. Emotional pleas which are not substantiated will be put aside. Facts and figures provide evidence of the problem and are more difficult to ignore or refute. They also attract the interest of the news media which then gets the attention of the general public. Public attention can influence politicians to act, because if they don't, they risk losing their popular support.

If possible, try to gather location-specific or country data which will show:

- the significance of the problem and its future trend;

- current spending on treating people with diseases related to poor sanitary conditions;

- current spending on sanitation;

- the benefits of sanitation for health, education or other issues;

- that spending on sanitation makes economic sense and is feasible in your country;

- the impact of not taking action (such as on health costs, quality of life, the economy, attendance of girls at school).

Box 1. Some examples of information to have on sanitation

· Percentage of people in the country (or city, town, district or province) without sanitary facilities.

· Percentage of people predicted to be without sanitation by the year 2020.

· An estimate of the number of people (in your country, city or district) who die from diseases related to poor sanitation.

· An estimate of the number of children who die per year (in country, city, or district) from diseases related to poor sanitation

· An estimate of the percentage of children 5-15 infested with intestinal worms.

· An estimate of the number of school days lost per year from diseases related to poor sanitation.

· An estimate of the number of girls who do not attend school owing to lack of sanitation facilities at school.

3. Building a persuasive case

You will be competing with many others for attention. Therefore, you need to present your information or message in such a way that it stands out from the crowd and is so memorable that your target group cannot ignore it. The following are some practical suggestions for increasing the effectiveness of your messages.

· Choose only a few key messages. Multiple messages are not remembered. By keeping to a few messages, your messages will not be competing with each other for attention. You will be able to repeat a few messages more often, making people more familiar with them, more quickly. Your aim is to have your messages become part of local discussion on the subject.

· Keep messages simple. Messages which are easy to understand are much more likely to be remembered than those that require thinking about. You may have only a few seconds of time to put your message across, so it is important that its meaning is clear and easy to understand. Think of your message as something that can fit on a T-shirt.

· Make your messages relevant to your target audience. Information that is linked to a subject area that your target audience is already interested in will be much more relevant, persuasive, and interesting to them. For example, most politicians are concerned about maximising the economic productivity of the country. Therefore, one way to make sanitation messages relevant to them is to present the economic impact of ignoring the problem of sanitation.

Examples of economic messages:

12 000 worker days were lost last year due to diarrhoeal diseases.

Last year's outbreak of cholera cost the country one billion dollars in lost tourist trade.

You can maximise the relevance and interest of your messages simply by looking for ways to frame your sanitation messages in terms of how it might affect a particular target audience's area of specific interest.
· Time the release of messages. Your messages can be more effective if you time the release of them to coincide with another event likely to attract attention. To help achieve this, it is a good idea to make a list of the dates when other events are taking place so you plan your advocacy around them. Other events might include health conferences. World Health Day, World Water Day, International Labour Day, release of new statistics and new documents or reports.

· Say something new. There is a lot of competition for attention. One way to grab attention is to tell your target audience something new. This is often not as hard as it sounds. Sanitation is a specialized field. What may be common knowledge to you is unlikely to be widely known by others. Another way to say something new is to present information from a new angle. For example, sanitation information can be presented to show its impact not just on health, but on education, on equality for women, on earning tourist dollars, on generating business opportunities, and on increasing worker productivity. This can be particularly effective if you link it to issues which are currently attracting a lot of attention.

· Use powerful language. Messages must be strongly worded to be noticed and memorable. They should be a responsible presentation of the facts, suggest the response, and still convey a sense of urgency.

· Say what should be done. Messages should always be presented in a way that makes the audience feel they can do something, otherwise a sense of being overwhelmed and powerlessness to help is created. This has a paralysing effect. Instead your message should indicate that with any little bit of help, progress can be made. Make people feel that their contribution, in whatever form, counts.


An increase in public spending of just one-half per cent will result in expansion of sanitation services to 50 000 more families.

If every citizen gave 2 cents a month for the rest of the year to the sanitation fund, every school in our community could have water supply and toilets.

· Aim for impact. Messages which put a human face to the problem can touch people more deeply. Provide real-life stories, not just ones that show the negative effects but also ones which give hope and show that people, even with very little, can achieve great things. Inspire people into action. Excite them with the possibility of what they can achieve.

· Call for action. Include in your messages what action you would like to see taken. More often than not, your suggestions will be acted on. Community leaders often are busy and helping them with suggestions of appropriate actions enables them to act more quickly.

· Be creative. Doing things differently attracts attention. Study what others are doing in different sectors, in private business, and in other countries. Identify things that worked well and see if you can adapt them to your situation. Not everything effective will be appropriate. You have to consider the sensitivity of the issue and cultural and religious values in your country and make your decisions based on this understanding.

4. Continuous Action

Just as soft drink companies NEVER stop advertising, advocacy for sanitation should also never stop. Populations continue to grow and existing systems need to be maintained. The job is never done, but if advocacy stops, the funds to support sanitation may start to disappear along with public interest.

5. Build partnerships with influential supporters

Advocacy requires that the subject must seem important to important people. Movie stars and presidents of large corporations, for example, should be persuaded to become partners in an advocacy campaign. Some can become spokesmen and women for the cause. How to mobilize partners is explained in Mobilizing partners for sanitation.

6. Work with the media

The media is probably the most influential advocacy vehicle available. By putting the problem of sanitation before the people through television, newspapers, magazines and radio, politicians and decision-makers will take notice. Politicians are very sensitive to public opinion, they have to respond, explain the actions they intend to take, or risk losing popular support. The media, therefore, plays a key role in mobilizing public support and setting the political agenda. How to mobilize the media is explained in Mobilizing the media for sanitation.

BOX 2. Tips for effective advocacy

· Identify the persons and groups you need to influence in order to bring about change.

· Concentrate your efforts and start with those you know are sympathetic.

· Develop an information base of facts presenting the sanitation problem and the solutions.

· Choose only a few key messages.

· Make sure the messages are simple to understand.

· Increase the relevance of sanitation messages by expressing them in terms of their social, economic, and political impact.

· Time the release of your messages to coincide with other events that will attract additional attention.

· Make news by saying something “new”.

· Get support for change by using powerful messages which touch peoples' everyday lives.

· Provide evidence to prove your point.

· Suggest practical actions that leaders could take.

· Inspire people; don't present the case as beyond hope.

· Make people and institutions feel that their contributions can make a difference.

· Attract the attention of the media.

· Multiply your efforts by finding partners, building coalitions and recruiting influential supporters.

· Never stop trying, persistence pays off.

· Be opportunistic, and take advantage of situations which come up to promote sanitation.

· Be innovative and think of new ideas, but don't miss the opportunity to borrow the good ideas of others and adapt them to your own situation.

Box 3. 10 Tips for effective presentations

· Check out the physical set-up of the room before speaking. Note the room size, acoustics, microphone and audio-visual set-up.

· Focus your presentation on one or two main messages. Repeat these main messages in different ways again and again.

· Don't turn your presentation into a recitation of facts and data. Your main message could be lost if you bombard your audience with too much information.

· Practice, practice, practice! The more comfortable you are with the presentation, the more dynamic you will be. Practice giving your presentation before a colleague who can offer comments on how to improve your delivery.

· Make a good first impression. Memorize the first part of your presentation. Be confident.

· Make eye contact with your audience. Change your pace, tone, and hand gestures at key points to make an impact.

· Use powerful visual aids to emphasize main points. One well-planned photograph or chart can be worth a thousand words.

· Make sure overheads or slides can be quickly understood. Avoid complex graphs, small type and lots of words. As a rule of thumb, print no more than 50 words on any visual. Be sure everything can be clearly read from the back of the room.

· Your enthusiasm and concern about the issue will often be remembered more than the words you say.

· Keep to your time limit and allow time for questions. This is a critical opportunity to keep your audience engaged and excited about the topic.

Source: (3).

Monitoring and evaluating change as a result of advocacy

It is crucial to measure whether advocacy and other techniques are achieving change. Indicators of change should be developed for each target group. As an example, a list of indicators of increased political commitment from politicians may include:

- creating a national sanitation policy;
- creating a sanitation department with a responsible chief;
- well-maintained toilets in government buildings; and
- more government funds allocated to sanitation and hygiene education.

Source: (4).

Box 4. Other advocacy techniques

Job performance awards. In Indonesia in 1993 the political commitment of provincial governors was obtained by making the infant mortality rate a factor in assessing job performance. Governors were advised that there were several factors responsible for high infant mortality, a major one being diarrhoeal disease, best prevented by high latrine coverage and good hygiene behaviours. Many governors became more active in promoting sanitation. Awards were given to governors whose provinces have low infant morality rates (5).

Putting sanitation on the agenda of other sectors. In 1994, the Indonesian Department of Health launched the Clean Friday Movement to mobilize the support of religious leaders for sanitation and improved hygiene behaviours. While the movement was targeted at all government departments concerned with sanitation, NGOs, and political leaders, it was designed especially to call upon religious values in creating a clean environment. Religious leaders were asked to lead the movement from their Friday sermons. It was formally launched by the President of Indonesia.

Bringing politicians to successful sites. In 1994, the Department of Environmental Health of Zimbabwe brought political leaders to successful project sites to see progress and hear from communities how success was achieved. Zimbabwe had been conducting field trials of participatory methods and found them very successful. As a result Zimbabwe has decided to expand the approach nationally (6).

National high-level conferences. The Prime Minister of Bangladesh inaugurated a national conference in 1992 on Social Mobilization for Sanitation and Hygiene. Nationally televised, it greatly strengthened sanitation and hygiene promotion in the country. In 1994, the Prime Minister launched a National Sanitation Week to promote sanitation and hygiene nationwide. During the inaugural function, she called for a new Mid-decade Goal of 50 percent coverage by 1995, since the Mid-decade Goal of 35 percent sanitation coverage had been achieved in early 1994. The Minister of Finance immediately responded to the promotion of sanitation by allocating substantial funds to sanitation activities.

Inter-country workshops. In 1994, UNICEF held a four-day Sanitation Workshop for Eastern and Southern Africa in Zimbabwe, in which UNICEF staff and their government counterparts decided on what they could do personally and collectively to promote sanitation (7).

Inter-ministerial conferences. Sanitation advocates in Zimbabwe used the opportunity of a Regional Ministerial Conference in 1994 to produce a statement of intent from the ministers to go for full latrine coverage of the southern African region, with appropriate low-cost designs.

A condition for grants and loans. In 1993, a WHO consultant negotiated into an agreement for health centre equipment that the government build a latrine at each health centre prior to receiving the equipment. The agreement received the highest endorsement from the government, construction began immediately, and latrine coverage of health centres increased rapidly.


(1) 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).

(2) 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).

(3) Owens B, Klandt K. TB advocacy: a practical guide 1998. Geneva, World Health Organization, 1998, (unpublished document WHO/TB/98.239).

(4) WHO. Promotion of sanitation. Report of the Sanitation Working Group to the Water Supply and Sanitation Collaborative Council. Geneva, World Health Organization, November 1995 (unpublished document WHO/EOS/95.24).

(5) Mathur S, UNICEF, Indonesia, personal interview.

(6) Mr Temba, Ministry of Environmental Health, Zimbabwe, personal interview.

(7) Sanitation: The missing link to sustainable development. Report from the Eastern and Southern African Region Workshop on Sanitation, Harare, Zimbabwe, UNICEF 1994.

Mobilizing the media for sanitation promotion - WHO, Geneva, Switzerland

The media can be one of the most effective advocacy vehicles available. The objective is to get the media interested in sanitation and motivate journalists and reporters to write about it in newspapers and talk about it on radio and television.

Help to mobilize the media can be found among people and organizations that have had previous experience, such as multi- and bilateral organizations, NGOs, and external support agencies or from organizations which specialize in this function, such as public relations companies. You can, however, achieve much yourself by being systematic in your approach and following the practical steps outlined below. Because the media are organized in different ways in different countries, for example, in some countries media outlets are state run, while in others they are in the hands of the private sector, or it can be a combination of both. It is necessary to take this into account and tailor your approach to the circumstances of the media in your own country.


Develop a plan for mobilizing the media

Before you approach the media, you need to develop a plan outlining what you want to achieve and the actions you will need to take to be successful. This is often called a Media Strategy (see pg. 34 for an example). You will find, once you have read this article, and Advocacy for sanitation and Mobilizing partners for sanitation, writing such a plan will be quite straightforward.

Develop an information base

Good information is the basis of a successful relationship with the media. The media need facts from a credible source to use in their reports. One of the most important steps, before you even contact the media is to gather the data to make a case for sanitation. See “Developing an information base” in Advocacy for Sanitation. Do not underestimate the importance of having your facts well organized. The media will not take the time to research these things for themselves, and without facts they cannot make their reports or file their articles.

Choose only a few key messages

Many others are competing for the attention of the media. Your time may well be limited to a few seconds in front of a television camera, or a few minutes in a news conference. Therefore, it is necessary to select your messages carefully. Keeping to only one or two key points will enable you to repeat them more frequently which will help people remember them. Your key messages should communicate the one main point you want your audience to remember. More suggestions on how to develop effective messages are provide in Advocacy for sanitation under the heading “Building a persuasive case”.

Make sanitation news

Reporters and journalists are interested in “news”. This is what makes headlines and sells. You need to think of ways to present the problem of sanitation as news, make it interesting by releasing new information, or by putting it in the context of other issues which may be attracting media attention. For example, if education is receiving media attention, release facts and figures which show how sanitation improves child health and school attendance rates. Take advantage of media attention created by others by tailoring your own messages to be relevant to “the topic of the moment”. Remember that issues which are of local interest are more likely to be published so try to provide facts specific to your area and country.

Establish a media focal point

It is important to establish a point of responsibility for mobilizing the media. This can be one person or a group of persons in your organization, or a team created from a group of interested parties. Your focal point should reflect the local situation and the scale of your activities. Where possible, people that have worked successfully with the media in the past should be included.

Box 1. Focal point responsibilities

- developing a plan for mobilizing the media;
- implementing the plan (writing press releases, organizing news conferences);
- monitoring results;
- modifying the plan;
- organizing training for media spokespersons; and
- acting as a spokesperson.

Research the media

You need to familiarise yourself with the newspapers, magazines, television and radio outlets in your area and in your country and identify those which you think will be most interested in sanitation. Media personnel are more likely to pay attention to you and give you more time to present your case if you show you have done your homework and that you know something about the publications and programmes they work on. Developing a mutual respect for each others' work is an important aspect of building an effective media relationship.

Target the media

Once you have identified the media outlets you want to target, the next step is contacting them. First, you will need to find out the names of reporters or journalists specialising in health, environmental issues, government spending, or other issues which can be related to sanitation. Identifying a common area of interest is the first step towards establishing contact. You can make your contacts more successful by using the tips set out in Box 2.

Box 2. Tips for effective media contacts

· Do your homework.

Know the name of the person you want to speak to and know something about the publication or programme they work on.

· Plan ahead.

Think carefully about why you are calling, what you will say, and what you want to achieve from the contact.

· Practice.

· Be concise.

You only have one or two minutes to get your point across, and get the interest of the journalist.

· Be polite, professional and enthusiastic.

If they are not interested don't be discouraged. Ask what would be of interest to them.

· Contact the media well in advance of their print or broadcast deadline.

· Don't contact the media unless you have something to say that is of “news” value.

Preparing information for the media

Journalists work to tight deadlines. Therefore, information that is concise, clear and well presented is more likely to be used than material which requires extensive rewriting, researching, and confirmation. Specific guidance on how to prepare press releases and other key materials is provided later in the article, but the following general suggestions outlined in Box 3 should also be helpful.

Identify sanitation spokespersons

Reporters need to have access to people who will give interviews. They often need to interview people at short notice, so it is important to prepare well in advance to make sure the interview goes well and your point of view is put across effectively.

Select your spokespersons carefully. While some people make it look easy, don't be fooled. Their polished performance is usually a result of long hours of training, preparation and practice in front of friends, colleagues or the mirror at home. Most people are not naturals, and even if they are, they never neglect the golden rules of preparation and practice.

There are certain skills and techniques which can help people become more effective in interviews. It is advisable to organize this type of training for people selected as spokespersons, if they have not already had it. This is often called media training and courses are usually on a one-to-one basis. Participants are taught the basic techniques of effective interviewing and then practice these in simulated “live interviews” in front of a video camera. They can then see how they actually perform and where they need to improve. This type of training is most likely to be offered by public relations companies.

When spokespersons are first selected, they do not have to know about the subject, because preparing them and training them in effective interviewing techniques is part of the process of making a person an effective advocate.

Do not leave the result of an interview to chance. Carefully select your spokespersons (see Box 4), brief them well, and organize for training if it is needed.

Box 3. Tips for preparing information for the media

· Do prepare information specifically for use by the media. The media have specialised needs and you should tailor your information to meet these needs. This will always be better than pulling together more general information prepared for other purposes.

· Put yourself in the position of a journalist. Now prepare your information in a way that would help a journalist quickly put together a story to meet a tight deadline.

· Be concise. Rework your material by cutting and condensing it until there is no repetition or superfluous information. This saves a journalist time and makes your information more useable.

· Provide information in a summarised format, such as fact sheets, executive summaries of lengthy reports, and lists of commonly asked questions with answers.

· Make your point in an interesting way in the first few sentences to catch the attention of the media. This is sometimes called a “creative opening” and it means presenting your point in a different or unusual way to grab attention.

· Get straight to the point. Put the important information first and then provide any background detail necessary to support it. Don't do it the other way around.

· Use phrases that are easy to remember and make your point succinctly.

· Include direct quotes from influential people that express their belief and commitment to change.

· Provide sources for journalists to confirm statistics.

· Give your media contact a list of names and contact information of people available to give interviews.

Box 4. Tips for selecting spokespersons

Choose people who are:

- confident;

- influential;

- articulate;

- authoritative without being dictatorial;

- personable, that people can warm to easily and feel comfortable with;

- quick, organized thinkers, who can respond well to unexpected questions without taking much time to prepare;

- calm under pressure;

- enthusiastic about the subject; and

- already attracting media attention like film and sports stars, actors, academics or musicians.

Contacting the media1

1 Quoted from Owens B, Klandt K. TB Advocacy: a practical guide 1998. Geneva, World Health Organization 1998 (unpublished document WHO/TB/98.239). Chapter 3 pg 19-22, 26-29. The word sanitation has been substituted for the word TB.

Once you have done your preparation, you are ready to contact the media. Some of the main ways of contacting the media are outline below, with suggestions on how to do this effectively.

Press release

Journalists usually receive hundreds of press releases each day. For your release to get noticed, the headline and first paragraph must catch their attention. You should spend as much time getting the words just right in the headline and first paragraph as you do on preparing the rest of the release. (See Box 6 for a checklist on preparing effective news releases.)

Sending announcements or advisories

Advisories are used, along with phone calls, to alert journalists to a media event or news conference. An advisory should give all of the basic information on the purpose, date, time, location, and speakers at an event. A good advisory should also build some anticipation concerning the news which will be announced.

Placing feature stories

Feature stories are usually longer than news stories. They go into greater depth on how an issue affects people and may offer a number of different perspectives. In magazines, they can span several pages and be accompanied by pictures. On television, they can become hour-long programmes.

The best way to encourage a feature is to describe your idea in a two or three-page story proposal. You need to do a substantial amount of research yourself before handing the story over to the journalist to follow up. Your proposal should provide an outline of the story and list interesting people who could be interviewed. The newer, more unusual, significant or dramatic the story, the better. For example, a journalist will be more interested in an unreported outbreak of cholera, than a general story on diarrhoeal disease.

Writing for the media

Opinion piece

Most newspapers print opinion pieces called “opinion editorials” (op-eds) or guest columns. An op-ed is an expression of opinion rather than a factual statement of news. Although style varies according to different countries, an op-ed tends to be lively, provocative and sometimes controversial. It is a very effective way to register concern about sanitation to policy-makers and to inform communities about why they should care about controlling sanitation-related diseases.

Op-eds are usually around 1,000 words. It is best to call the newspaper first and request their guidelines for submitting an op-ed. If possible, speak to the appropriate editor to convince her or him of the importance of the issue.

Letter to the editor

Newspapers and magazines have a “letters page” which gives readers the opportunity to express their view or correct previously published information they feel to be inaccurate or misleading. Letters are widely read and provide a good opportunity to promote a cause and/or organization.

Letters should be short and concise. Those over 500 words are unlikely to be published. Short letters of no more than 100 words can be very effective. A letter should aim to make one main point and to end on a challenging note, with a call to action.

Make sure you refer to your organization. Letters can also be signed by a number of signatories, representing various organizations or interests, which may increase their impact. If it is responding to an article carried in a daily newspaper, it is important to fax or deliver it to the paper within a couple of days.

Planning media events

News conference

A news conference can be a very effective way to announce a news story to journalists. Speakers take the platform in a venue and make presentations after which journalists can ask questions. This is a tried and tested formula which, if you follow the rules (See Box 8), can make life easy for journalists and for yourself.

Be sure that your story warrants holding one, as news conferences can be quite expensive to organize and it can be disheartening if few people attend. In some cases, you may find you can achieve the same results by handling the story from your office. For this, you need to send your press release and briefing materials under embargo until the date of the launch to journalists, highlighting who is available for interview.

Press briefing

If journalists, who cover hundreds of stories and may know next to nothing about sanitation, are to produce informative accurate stories, they need to be properly briefed. Consider organizing an informal press briefing which also serves to build good relations with journalists.

For example, invite half a dozen selected journalists to attend a briefing at your offices in advance of a major event you are planning. Brief them on key developments and issues relating to sanitation and your organization's relevant work and policy. You may want to conduct this as a breakfast meeting and provide refreshments. It is a good idea to have clear briefing material, such as advocacy publications or fact sheets, to distribute.

If you attend an important national or international conference, you may wish to brief journalists in your community about important developments upon your return. Or, use an informal briefing to introduce a major new strategy or initiative in your organization.

Editorial meetings

In some countries, newspapers invite policy experts to give an “editorial briefing” at their offices. These provide an excellent opportunity to gain the editorial support of a newspaper which can be very influential in shaping political decisions.

Profile the kinds of editorials/columns that appear in the paper and the position they tend to take, particularly in relation to health care issues. Arrive armed with facts and figures that are relevant to the newspaper's audience. Make a persuasive argument to the editor that his/her readers should be concerned about lack of sanitation. Be ready to answer any questions the editor might have.

Photo opportunity

Television news and magazines need good pictures or visuals in order to report on a story. When you plan a media strategy, think about what images you need and how you will supply these.

You may want to pay for a photographer to take pictures and then distribute them to selected publications. You may also want to prepare a video news release (VNR) for broadcasters to use. Or, arrange a “photo opportunity” for photographers and television news people to take pictures themselves.

To announce the photo opportunity, send an advisory that gives the “Who, What, When and Where” of the event to media.

Box 5. Important international media

The following are a few of the most important media which have global influence. Sometimes your story will have regional or national but not international significance. But other times, it may be of international importance, and you should check to see if there are correspondents from these media located in your city you can contact.

- AP (Associated Press)
- Reuters
- AFP (Agence France Presse)
- International Herald Tribune
- New York Times
- The Washington Post
- The Economist
- FT (Financial Times)
- CNN (Cable News Network)
- BBC (British Broadcasting System)

Interviewing for the media

When an organization publicizes a story, it needs to have a number of spokespeople available to be interviewed. They need to be familiar with both their material and the basic rules of interviewing. It is very important to prepare. Find out about the show and if possible watch/listen to it. Find out who else is appearing with you.

Profile the audience and have in mind a typical viewer/listener. Ask whether the show is live or pre-recorded and if the audience will be calling in to ask questions. Anticipate the questions you may be asked and prepare a Question and Answer sheet. Practice. Practice. Practice.

Phone-in/discussion or talk show

Radio or television phone-ins, discussion and talk shows are a good way to put your point across live and unedited.

Talk show producers are always in search of new guests who can talk with authority on issues that concern their viewers and listeners. It is a good idea to research programmes and make contact suggesting yourself, your director or even a whole panel of speakers with different perspectives on the problems caused by lack of sanitation.

Contact phone-in programmes to establish when health issues are scheduled. Mobilize your supporters to phone in. When you call, strict first-come, first-served rotation applies, so hang on and you will be answered. Never read your contribution as it will sound stilted and people will stop listening. Aim to make two or three points succinctly and remember to mention your organization.

Access programmes

In some countries, broadcasters air what are known as access programmes. For example, in the UK, charities and NGOs can promote an issue or cause in a three-minute piece to camera known as a Public Service Announcement or Community Service Announcement, broadcast on regional television after the regional news. Contact your local TV station to see if they broadcast access programmes.

In some countries, TV and radio programmes are assigned a duty editor who logs calls from the public about specific programmes. Comments, passed on to the producer of the programme, are reportedly taken seriously. When a programme on sanitation is scheduled, mobilize your supporters to call and register their views.


When you have only a few seconds in front of a microphone or in a meeting, you need to use memorable phrases or soundbites that will stay with your audience long after you have left. The best soundbites get to the heart of the problem without lengthy qualified explanations. Broadcast producers can't resist them, and listeners and viewers remember them. The soundbite should capture and communicate the one key idea you want to leave with the audience, if they remember nothing else. Try to repeat the soundbite at least once during an interview with the media.

Box 6. Checklist for preparing an effective press release


· Make sure the headline and first paragraph are very interesting and newsworthy. The most important information should be in the first paragraph.

· Use the pyramid principle to order information, most important at the top, becoming more general for background.

· Aim to use a direct quote within the first three paragraphs of the press release. Use quotes to bring the issue to life and express strong opinions.

· Include the five Ws:

WHAT is happening?
WHEN is it happening?
WHERE is it happening?
WHO is saying it?
WHY is it important?

· Attach a fact sheet or background briefing material, rather than make the press release too long or cluttered.


· Use short sentences of 25 to 30 words.
· Use paragraphs containing only two or three sentences.
· Try to limit the release to one or two pages.
· Use a simple, punchy news style.
· Avoid jargon.
· Avoid lots of adjectives and adverbs.
· Use active rather than indirect verbs to tell the story with force and urgency.
· Proof-read the release carefully!


· Put the date and release details at the top of the page. State if it is EMBARGOED FOR RELEASE at the specific time and date, or is FOR IMMEDIATE RELEASE.

· At the end of the press release put END or -30 - or *** to indicate the final page of the release. Follow this with contact names and numbers for more information.

Box 7. Television interview tips

· Focus on getting one main message across in the interview. Come back to your main message again and again.

· Don't be afraid to turn around irrelevant questions and come back to your main point. Don't allow the interviewer to side-track you from your main message.

· Don't use jargon or highly technical medical language. Don't try to make too many complex points. Keep your answers simple.

· Be yourself. Rely on the strong points of your own character.

· Be enthusiastic about the subject. People will often remember the level of your passion for an issue more than what you specifically say.

· Look at the interviewer when talking with him or her. If there is an audience, look at them when appropriate.

· You don't have to know the answers to all questions.

· Don't allow yourself to become defensive or angry.

· Ask the producer what you should wear.

· Sit up straight and lean forward slightly.

Box 8. Checklist for an effective news conference


· A big, newsworthy story.
· New information relating to a big story being followed by the media.
· A statement on a controversial issue.
· Participation of high profile speakers or celebrities.
· Release of important new findings or research data.
· Launch of a major new initiative.
· Announcement of something of local importance.

Location and set-up

· A central well-known location, convenient for journalists, and appropriate to the event.
· Avoid large rooms which give the appearance that few people attended.
· Make sure the noise level of the room is low.
· Reserve space at the back of the room for television cameras, possibly on a raised platform.
· Reserve a quiet room for radio interviews following the news conference.
· Ensure light and sound systems are in working order.
· If possible, have fax, phone and e-mail capability available.
· Make sure there is a podium and a table long enough for all spokespeople to sit behind.
· Consider displaying large visuals, such as graphs, logos or charts.
· Prepare a “sign-in” sheet for journalists.
· Determine if you wish to serve coffee and tea, or light snacks, following the event.


· Hold the event in morning or early afternoon of a work day so reporters can meet deadlines.

· Check that you are not competing with other important news events on the same day.

· Start the event on time - avoid keeping journalists waiting.

· If you distribute material prior to a news event, use an embargo to prevent journalists from publishing before the event.

· Wait until the event to release information to create an element of suspense.

Possible materials

· Press release.
· List of news conference participants.
· Executive summary of report.
· Case studies and stories.
· Fact sheets.
· Biography and photos of speakers, and copies of speeches.
· Pictures (colour transparencies/black and white photographs).
· B-roll (broadcast quality video background footage).
· Consider putting all of the printed materials together into one “press kit.”

Inviting journalists

· Keep an up-to-date mailing list or database of journalists.

· Make sure you know who the health and social affairs correspondents are.

· Monitor which journalists are reporting on health.

· Focus on getting the most influential media to attend.

· Remember to invite international and foreign media.

· Get your event in journalists' diaries seven to 10 days before the event.

· Always make a follow-up call to check that the right journalist has received the information.

· Build interest and anticipation for the event without giving out the story.

· Consider providing general, background briefings to important journalists prior to the event, without disclosing to them your main news story.

· Consider offering “exclusive” angles on the story to key media.

Preparing speakers

· Select appropriate speakers.
· Select strong speakers who are charismatic, articulate and authoritative.
· Brief speakers carefully on the main message of the event.
· Prepare speakers in advance on how to answer difficult questions.
· Try to hold a meeting to brief all speakers before the event.
· Ideally, each speaker should present for only three of four minutes.
· Have each speaker make different points.
· Make sure that each makes one or two important points.
· Keep speeches short and simple aimed at a general audience and avoid technical jargon.
· Select a moderator who will manage questions from the floor after the presentation.
· Encourage lots of questions. Keep answers short.


· Within a few hours of the conclusion of the news conference, fax or deliver information to important journalists who were unable to attend.

· Make sure the switchboard of your organization is advised on where to direct follow-up calls from journalists.

· Gather news clippings of the coverage which results from the news conference and distribute this to important coalition partners and policy makers. A good source is the Internet.

Improving your performance

One of the most important things you can do to build your relationship and the continuity of contact with the media is to improve the way you work with them. By becoming better at what you do and understanding more about what the media can and can't do, you will build a greater mutual respect for each other. To improve the way you work, you need to evaluate your activities carefully. You need to work out what went well and why and what didn't go well and how you can overcome these problems. Investing time in evaluating activities and modifying your them accordingly will pay big dividends in your future relationships with the media.

Box 9. Example Media Strategy

This has been simplified to illustrate the sort of information which might be included in a media strategy. This is an example only, it is not exhaustive nor is it a template for what to include because you will need to create your own plan which reflects the local situation and your own priorities.


1. Put sanitation on the front page of two daily newspapers three times this year.

2. Have our sanitation spokespersons interviewed on radio once a month throughout this year

3. Have our sanitation spokesperson interviewed on television once this year.

Media targets


International Herald Tribune

National Newspapers




Local relevant magazines

Radio Stations:

BBC World Service

Voice of America

Local relevant radio stations



National public and private TV channels

Action plan




(write name
in this column)

1. Collection of key facts, statistics and research findings on sanitation.


2. Organization and preparation for Nov. Sanitation Conference


3. Preparation of media material including key messages, fact sheets, report summaries etc.


4. Development of sanitation logo and slogan, e.g. Sanitation. A right of every citizen.


5. Media training for sanitation spokespersons

May (1 week course)

6. Mobilization of partners and organization of joint activities to coincide with November National Sanitation Conference


e.g.-school childrens' artwork competitions

-street rally of supporters

-fun run with other events in support of sanitation

-ceremony to present a petition to politicians

-site visits

7. Press briefing


8. Press release(s) announcing


- National Sanitation Conference

- Joint activities to raise the profile of sanitation

9. Invite journalists to News Conference on last day of Sanitation Conference

10 days before Sanitation Conference

10. National Sanitation Conference

12-15 Nov

11. Joint Activities

12-15 Nov

12. Press release(s) to announce actions resulting from Conference.


Each of these activities will need a detailed plan of its own.

Monitoring and evaluation

· News clipping service to collect all articles published on sanitation
· Record of number and duration of radio and television interviews
· Record of actions taken by policy and decision-makers to advance sanitation.


Total: x dollars

Mobilizing partners for sanitation promotion - Sara Wood1 and Mayling Simpson-Hébert2

1 WHO Consultant, Geneva, Switzerland.
2 WHO, Geneva, Switzerland.

Your efforts to focus attention on sanitation can be multiplied by identifying other organizations and individuals to work in partnership with you. It is easy to ignore the voice of one organization, but much more difficult to ignore the voices of many thousand or perhaps millions of people. By involving others you will also have access to a much larger pool of ideas and resources for your activities. This means you can do more, and active partnerships attract higher levels of attention from both politicians and the media. Other organizations and groups work with different groups in society, for example, medical associations work with the medical community, business associations work with corporations and industry, local NGOs work with the community. By involving a variety of partners you can mobilize support from a broad cross section of society representing a wide diversity of interests.

Identifying partners

Mobilizing partners starts with identifying potential partners, then meeting with them and presenting a convincing case of why they should become involved. Some suggestions on how to make a presentation more effective are provided in Box 3 in Advocacy for sanitation. Advocacy is the key tool to use to convince groups to become partners. See “Building a persuasive case” in Advocacy for sanitation. Once you have the interest and commitment of a potential partner, you will need to work together to develop a programme of joint activities and establish how you can work together effectively.

Ideal partners are those that share a common interest, have previous experience in gaining support and initiating change, are influential in their own right, and already attract media attention.

The boxes which follow offers ideas for potential partners for sanitation promotion, tips for building successful partnerships, ideas for joint activities, principles for successful coalitions, tips for writing letters to government officials and three country examples.

Box 1. Potential partners for sanitation promotion


Government officials at national, district, municipal and local levels

· Prime Minister

· Ministers of relevant departments

· Mayors

· Councillors

· District and local government officials

External support agencies

· Multilateral organizations e.g. UNDP, WHO, UNICEF, UNCHS (United Nation's Centre for Human Settlements)

· Bilateral organizations e.g. Sida, DANIDA, SDC, USAID

International and national NGOs

· Foundations, e.g. Carter Institute

· Health organizations

· Women's organizations

· Development organizations

· Human rights organizations

· Children's organizations e.g. scouts and girl guides

· Water and sanitation development organizations

· Research organizations

Local nongovernmental organizations

· Community development groups

· women's groups,

· children's groups

· income generation committees

· village health committees

· cooperatives

· religious, social and traditional leaders

The private sector

· Multinational companies

· National and local businesses

The media

· Journalists interested in health, women's issues, development, government spending, environmental issues etc.

· editors

The medical community

· public and private sector health workers

· medical associations

· universities

· training institutions

The general public

· men
· women
· children


· powerful
· highly visible
· respected
· authoritative
· opinion leaders

· expertise

· outside the country political process

· relatively independent

· highly visible

· well respected

· difficult to ignore

· opinion leaders

· expertise

· independent from the political process

· action orientated

· flexible

· respected

· local knowledge

· local influence and respect

· influential
· independent
· opinion leaders
· respected
· international links
· expertise

· independent
· act quickly
· respected
· credible

· respected
· credible
· influential
· shared interests

· directly effected by inaction

· if united, the public is difficult to ignore

· if united, can influence policy

What they can do

· support sanitation policy development

· increase budget allocation for sanitation

· speak out and draw attention to sanitation

· lobby others

· influence others

· document and publicise results

· influence policy and decision-makers

· lobby government

· provide funding

· provide funding

· local knowledge and experience

· lobby others

· document and report results

· raise community awareness and support for sanitation

· influence the community

· participate in planning for change

· lobby local level government officials

· speak out and draw attention to sanitation

· initiate community-level action

· interest local media

· coordinate activities

· provide funding

· lobby for change

· provide specialist expertise, e.g. marketing, communications, technical, financial management etc.

· document and publicise results

· speak out and draw attention to sanitation

· grab national and international attention

· can be a vehicle for advocacy

· can make sanitation “news”

· influence politicians and decision-makers

· reach virtually every person in society

· create a sensation, or a controversy

· lobby for change

· influence politicians and decision-makers

· provide expertise

· demonstrate good practices

· document and publicise results

· undertake research and pilot projects

· participate in planning for change

· lobby politicians by writing letters, signing petitions

· hold mass demonstrations to show discontent

· attract media attention

Suggestions on how to mobilize

· use advocacy to draw attention to sanitation

· invite media attention

· work with partners on joint strategies to target this group

· use advocacy, but tailor the messages to the interests of this group

· organize meetings to bring different groups together

· sign joint declarations calling for action

· establish a coordinating committee

· develop joint activities

· identify those that share a common interest in sanitation

· use advocacy, but tailor the messages to be meaningful to the interests of this group

· initiate a dialogue

· set up a coordination mechanism

· agree a joint plan of action

· invite them to meetings and forums

· form a joint pressure group

· identify those that share a common interest in sanitation

· use advocacy, but tailor the messages to be meaningful to the interests of this group

· initiate a dialogue

· set up a coordination mechanism

· agree a joint plan of action

· invite hem to meetings and forums

· form a joint pressure group

· identify organizations that share an interest in advancing sanitation

· do personalized advocacy

· establish a coordination mechanism

· keep them informed

· develop joint activities

· develop a “good” information base of facts, figures and statistics

· identify the journalists with a special interest in sanitation and keep them informed

· provide journalist with newsworthy, timely information

· establish a media relations focal point in your organization

· organize important and influential people to act as spokespersons

· make an annual plan of events designed to attract media attention

· identify organizations with shared interests

· do personalized advocacy

· set up a coordinating mechanism

· keep the information flowing in both directions

· develop joint activities

· identify actions they can undertake

· seek their ideas

· advocacy through mass media

· organize community groups

· school and university activities

· awareness building at community festive gatherings

· request support from traditional and religious leaders

Box 2. Tips for building successful partnerships

· Look for groups that share a common interest.

· Do your homework. Find out about potential partners, and know something about their organization, what its goal are, how it is structured, who the key people are, and most importantly what they do.

· Be persistent. Building successful relationships with others takes careful planning, time and patience.

· Develop open and effective lines of communication so that everyone can be kept informed and up to date on activities.

· Share information, resources, ideas and expertise.

· Recognise that while there is common ground, there will also be areas of fundamental difference. Plan how you will deal with these situations.

· Be diplomatic.

· Consult your partners and ask their advice on relevant issues.

· Work in a participatory way and involve partners in planning and decision-making. This will increase their sense of ownership and responsibility for activities.

· Use a consensus approach to work with partners.

· Be enthusiastic.

· Show partners what they can do to make a difference. This is motivates action.

· Celebrate your joint successes.

· Evaluate your activities together and see how you can improve them in the future.

· Follow up and feedback results.

· Formally thank your partners for their efforts.

Box 3. Ideas for joint activities

· Letter writing campaigns to newspapers and government officials.
· Fund raising initiatives.
· Demonstrations/marches/fun runs etc.
· Events, sanitation days, clean up days etc.
· Advocacy workshops.
· News conferences.
· Joint statements calling for action.
· Sanitation awards.
· Internet websites.

Box 4. Principles for successful coalitions

· Choose unifying issues.
· Understand and respect institutional self-interest.
· Agree to disagree.
· Recognize that contributions from member organizations will vary.
· Structure decision-making carefully based on level of contribution.
· Clarify decision-making procedures.
· Help organizations to achieve their self-interest.
· Distribute credit fairly.

Adapted from: (1).

Box 5. Tips for writing letters to government officials

· Keep your letter concise and focus on a single issue.

· Make your argument in a well-reasoned way and support it with relevant data, statistics and powerful real-life stories.

· Be clear about what you want to happen.

· Ask for a specific action, a change in policy, an increase in funding, an appointment to present your case.

· Be positive and conciliatory in your first communication; avoid harsh criticism.

· Request information about the officials ability to respond; it may be that you need to be referred to somebody else.

· Request a direct response and follow up the letter with a telephone call.

Adapted from: (2).

Box 6. Mobilizing intersectoral partners in Nepal

Nepal has made impressive progress over the last five years in mobilizing partners for sanitation. They did it by:

· Creating awareness among politicians, planners, administrators, and media personnel, through meetings and brief orientation sessions, of the importance of sanitation and their responsibility for ensuring its integration into all development programmes.

· Raising awareness about the importance of different aspects of sanitation among the members of intra- and intersectoral coordination committees.

· Establishing a focal point for sanitation promotion in an appropriate government agency.

· Assigning the focal point clearly defined responsibility and authority as well as accountability.

· Organizing periodic meetings of water and sanitation coordination committees at all levels.

· Involving NGOs in the sanitation programme at every level.

· Involving as many women as possible in the sanitation programmes at every level.

· Including appropriate sanitation components in the curricula of schools, colleges, and training institutions of all development programmes.

· Emphasizing the integration of sanitation into all development programmes.

· Considering legislation on various sanitation issues.

Contributed by Dinesh C. Pyakural, Director General, Department of Water Supply and Sewerage, Ministry of Housing and Physical Planning, Nepal.

Box 7. Joining hands with churches for sanitation promotion in Angola

An effective partnership is taking place in two Angolan cities of Lobito and Benguela, with a total population of about one million. In 1997, 11 000 new latrines were built using the dome-shaped SanPlat, up from a little over 4000 the year before. The key to this sudden increase lies in the partnerships forged between the sanitation project and local churches, other NGOs and local leaders. Of all of these groups, the churches have played the most pivotal role. In 1998 they plan to build 40 000 more latrines.

The project actually began in 1990, but war and administrative problems caused the latrine building activities to gradually drop to zero by 1993. Subsidies for the slabs were increased to stimulate demand, but there was no enthusiasm and the ploy failed.

In 1995 the project decided to begin working with traditional leaders, something which had been impossible earlier because of the political situation in the country. At a meeting during that year, the traditional leaders suggested that the project approach the churches for assistance. “That is what we do when we have a problem,” they said.

The project called for a meeting with church leaders. This was something very new for government, as relations between the Marxist regime and the churches had been very tense. More than 30 church leaders attended the meeting where the situation was presented. The project asked for help and explained their difficulties. They made the point that the project and the churches actually had a common mission: to help people in need.

The project leaders talked about hygiene, diseases and death, about Christian values such as “love your neighbour” and being a “good Samaritan”, about Christians being the Light and the Salt, about Faith and Works. They distributed papers they had prepared that presented sanitation from a Christian perspective.

The churches are now involved in three things. First, they run two casting yards for making latrine slabs (out of a total of five), they do all of the community mobilization for sanitation and they do hygiene education for the project. Three messages with explanations are now advocated:

- Always use the latrine
- Wash your hands
- Be cautious with baby's faeces.

Why it worked

· The technology was simple, understandable, attractive and adaptable to felt needs. You can only mobilize a community for something they like.

· Only the slab was subsidized. The remainder of the materials and labour could be organized with no cash input. Most families are very poor and would have no cash to contribute.

· A partnership was forged among the project, traditional leaders, many churches and a few NGOs, all of whom had high credibility among the population. The project did not tell any of their partners how to mobilize the people or do the hygiene education. It was done their traditional way and it worked.

Contributed by Bjorn Brandberg, SBI Consulting, Eveni-Mbabane, Swaziland.

Box 8. Advocacy, social mobilization and communication for sanitation in Bangladesh

Bangladesh achieved major increases in drinking-water coverage in the 1980's but parallel improvements in the health of the country's population were not seen. Although safe water coverage had reached 80 per cent by the late 1980s, sanitation coverage remained a mere 8 per cent. This was because safe latrines, despite having been promoted in Bangladesh for nearly 30 years, remained unpopular with most of the population. A main factor was the high cost of the waterseal latrine being promoted. Also, latrines had been promoted on the basis of the health and germ theory, when in fact the attractions they would hold for the population related to privacy for women and prestige.

The programme. In 1990, with support from UNICEF, Bangladesh's Department of Public Health and Engineering started a social movement for change programme to encourage better hygiene practices and the buying of basic latrines. The programme focused on “users as customers”, “commercial producers as suppliers” and “an affordable product” (3), and from 1993 to 1995 took the form of a massive demand-creation effort - to the tune of US$ 3.7 million.

This involved advocacy to organize information into argument, which was then communicated through various interpersonal and media channels in order to gain political and social leadership acceptance, and to prepare communities for the programme. More specifically, advocacy:

- mobilized senior government staff, members of parliament, the media, NGOs and the community;

- persuaded politicians and senior government decision-makers that sanitation is a top priority in the drive against diarrhoea (which accounts for 300 000 child deaths each year in Bangladesh); and

- promoted the idea of “pathogen overload”, showing how every sector in society is vulnerable to waterborne disease.(4)

Social mobilization was next used to bring together intersectoral social “allies” to raise awareness of and demand for the programme, and to help ensure effective delivery of resources and services. These allies included:

- the leadership of a village-based organization, “Ansars”, with four million members, which trained its officers in sanitation;

- Islamic clergy who permitted a UNICEF communications officer to address 1.5 million people at a religious gathering and to distribute half a million leaflets on sanitation;

- the Prime Minister, who agreed to launch the programme logo at a national rally;

- organizers of a National Sanitation Week which was designed to promote the goal of a sanitary latrine for each household by the year 2000.

Wide-ranging programme communication efforts also contributed to this drive towards sanitation improvement. Such communication involves identifying, segmenting and targeting specific groups/audiences with particular strategies, messages or training programmes. In this case, the strategy included courtyard meetings which were used to explain the benefits of the programme to 25-30 families at a time. Concurrently, sanitation promotional materials, rather than simply repeating health messages, highlighted the privacy, convenience and prestige of latrines; in other words, they identified preferences and cultural values and ensured that the targeted messages reflected these.

Figure 1. The key elements of the strategy for sanitation in Bangladesh

Source: (5).

Importantly, a range of more affordable latrines were promoted. A more modest waterseal latrine was designed, less than half the price of the original and commercially produced by suppliers. A do-it-yourself latrine, which can be produced at little or no cost to the family, and with a life of about five years, was also approved.

The results of these activities have been impressive, as shown by a 1994 survey of 10 000 randomly selected families. Compared to 1985:

- use of sanitary latrines has increased from 4 to 35 per cent;
- use of tubewell water for drinking reached 92 per cent (up from 80 per cent);

- handwashing with soap or ash after defecating was up from 5 to 27 per cent.


(1) Organizing for Social Change. Washington, DC, Seven Locks Press, 1991.

(2) Owens B, Klandt K. TB Advocacy: a practical guide 1998. Geneva, World Health Organization, 1998. (unpublished document WHO/TB/98.239).

(3) Ikin D. A sanitation success story - the effect of demand creation in Bangladesh. Waterlines, July-September 1996, 30: 1-3.

(4) McIntyre P. Communication case studies for the water supply and sanitation sector. Water Supply and Sanitation Collaborative Council/IRC, The Hague, The Netherlands, 1993.

(5) McKee N. Social mobilization and social marketing in developing communities, lessons for communicators. Penang, Southbound, 1992.

Private-sector involvement in promoting sanitation - Sara Wood1

1 WHO Consultant, Geneva, Switzerland.

The rapidly developing trend of private-sector involvement in manufacturing and distribution of sanitation hardware bodes well for the sector. Private enterprise often brings with it competitive pricing and better service than that offered through public provision. In addition, the private sector's increasing interest in utility partnerships will bring new sources of finance and expertise to sanitation. These trends, which contribute significantly to sustainability in the sector, are being fostered worldwide.

This article looks at another opportunity for engaging the private sector in promoting sanitation. It shows how private industry, through its use of promotion programmes in the workplace, can be instrumental in motivating people to improve their sanitation and hygiene practices.

Is there evidence that private-sector promotion can work?

Only anecdotal evidence exists of the success of private-sector promotion of sanitation (see Box 1), but the success of this approach in other health-related initiatives has been well-documented. For example, the private sector supports healthier, more active life-styles by sponsoring sporting events, providing physical exercise facilities at workplaces, and manufacturing food products with less fat, fewer calories and greater amounts of fibre. Advertisements for healthy manufactured food products advocate that their purchase will lead to a better, healthier quality of life.

Sanitation needs innovative approaches and the private sector's participation in promoting sanitation presents an opportunity that should be seized.

What opportunities are there for the private sector to promote sanitation?

Various opportunities exist for the private sector to get involved in promoting sanitation, depending on the relevant company's type of business. Examples of private-sector promotion follow.

Company-based hygiene improvement programmes

Success in the food and beverage industry is directly linked to high food safety and hygiene standards. These companies have a vested interest in promoting improved hygiene behaviours and improving sanitation facilities in the workplace. They are likely to be very responsive to increasing their effectiveness in these areas because of the direct impact on their business objectives. Some multinational companies already support sanitation programmes in several countries, but this opportunity could be developed with a specially targeted programme.

Box 1. Private sector promotion of sanitation in Indonesia

In April 1997, Unilever, a multinational manufacturing company and Lintas an international advertising agency, combined forces to develop a television advertisement for a World Bank-supported hygiene and sanitation education programme. The Hygiene and Sanitation Education Programme is part of a wider Water Supply and Sanitation Project for Low-income Communities (WSSLIC).

WSSLIC is a project targeting poor communities without adequate water and sanitation facilities in six provinces of eastern Indonesia. In total the project is expected to reach over two million people in 1400 villages. The project is coordinated by the National Development Planning Board which brings together contributions from government ministries, nongovernmental organizations and private enterprise.

The objectives of the project are to:

- provide safe, adequate and easily accessible water supply and sanitation services;
- support hygiene and health education aimed at improving hygiene practices; and
- alleviate poverty.

Budget limitations for the hygiene and sanitation education component of the project, and the need to develop of a public service television advertisement, led to and alliance between the Regional Water and Sanitation Group for East Asia and Pacific (RWSGEAP) and the advertising agency Lintas. This collaboration resulted in the production and free airing of a television advertisement. The television advertisement targeted children with the message that they should wash their hands after defecation. The advertisement featured animated characters and special sound effects.

After the initial free playing of the advertisement on the national television network, Unilever funded the reproduction of the advertisement and the cost of advertising it on Indonesia's five private television channels. The logos of the contributing organizations appeared at the end of the advertisement.

The success of this collaboration has led project personnel at the World Bank to look for other private sector companies to involve in other aspects of WSSLIC.

Source: personal correspondence, Ratna I. Josodipoero, Regional Water and Sanitation Group for East Asia and Pacific (RWSGEAP),World Bank, Jakarta, email

Tourism is another industry that could benefit directly if sanitation is improved in the countries it promotes. Its support in promoting initiatives to improve sanitary conditions, by providing financial assistance for such public campaigns as national sanitation day, for example, could be explored further.

Example-setting by the private sector

Private-sector employers have the opportunity to set a good example and act as important influences for wide-scale acceptance of more effective methods of excreta disposal and the adoption of hygiene behaviours necessary for improved health.

This is especially pertinent to employers that provide housing for workers. These companies could take this opportunity to set an example for appropriate excreta disposal facilities, demonstrate alternative technologies, and introduce hygiene behaviour-change campaigns to encourage workers to adopt new practices.

Private-sector social responsibility

Private-sector employers have a social responsibility to their workers which they can exercise by introducing health-promoting activities in the workplace. This has been done with AIDS, where trucking companies have launched educational campaigns to encourage their drivers to use condoms. The companies in question have recognized that their workers, who travel extensively throughout the country, could pose a risk to themselves and the areas they visit. By supporting safe sex messages, companies are fulfilling their responsibility to their workers and the public.

The private sector should be encouraged to adopt such a role and to fulfil its responsibility as a corporate citizen by protecting and advancing the health of its employees. The benefits of increased employee loyalty, consumer preference, and a favourable public image are the likely outcomes of such employer-supported activities.

What are the advantages of the private sector undertaking a promotional role?

Public influence. The private sector, as individual companies and as a whole, can reach a vast number of workers daily and therefore has an unparalleled opportunity to influence positively the beliefs and opinions of these people towards sanitation. Furthermore, the high profile and respect that many private-sector organizations have in the community make them a powerful advocacy force.

Communication expertise. The private sector is also well-versed in the use of marketing and communication strategies, which they use to reach the public and influence their behaviour. These strategies could be employed to promote health by adopting new or improved behaviours.

Improved economic performance. Improved employee health as a result of private-sector promotion will lead to greater economic productivity. Cost savings on health services owing to lower rates of the diseases normally associated with poor sanitation will also have a positive economic impact. These results will not be achieved in the short term. Their achievement will result from a consistent long-term commitment to health and economic improvement.

New funding sources. Private-sector participation in promoting sanitation is a new opportunity to increase available funds for improving sanitation coverage. Government financial resources are shrinking and this situation is unlikely to improve in the short term. New avenues for funding are required and the private sector is an important and relatively under-utilized source.

How can the private sector be encouraged to get involved in promoting sanitation?

The private sector will promote sanitation if it is convinced that in doing so it will be advancing its own interests. Thus, the challenge for a sanitation programme manager lies in developing a strategy to convince prospective private-sector companies of the benefits of investing in sanitation promotional activities. The advantages have to be clearly demonstrated to show how they will positively affect the goals and objectives of the company from which support is being sought. Suggestions on a systematic approach that might be used are provided for your guidance. They are based on lessons learned in obtaining sponsorship funding in a commercial environment, but are relevant to this situation as it is the process that is important.

Steps in generating private-sector participation in sanitation promotion

· Identify prospective private-sector companies.
· Develop a proposal.
· Raise awareness.
· Demonstrate benefits of involvement.
· Develop the funding/sponsorship opportunity.
· Integrate with other activities in the development sector.
· Monitor and evaluate.

Social marketing for sanitation programmes - Sunil Mehra1

1 Senior Associate, Malaria Consortium, London School of Hygiene and Tropical Medicine.

Sanitation programmes face numerous challenges in their efforts to change sanitation practices and sustain improvements in sanitation behaviour. To address these, they must enhance the user's contribution in defining needs and how to meet them. The social marketing approach, with knowledge of consumer preferences at its core, is a promising means of addressing issues concerning the demand for sanitation products, provision of sanitation services, and changing sanitation behaviours. It could be used, for instance, to promote use of products such as improved water systems, and latrines, and household behaviours such as proper use and maintenance of latrines, handwashing, and covered storage of water, and proper waste disposal.

This article provides an overview of the social marketing concept so that sanitation planners, and programme managers can decide if they would like to apply it to their own activities.

What is social marketing?

Social marketing is a systematic strategy in which acceptable concepts, behaviours, or products, and how to promote, distribute and price them for the market, are defined (1). More specifically it applies commercial marketing techniques to social programmes in order to improve their effectiveness. It involves building up an understanding of the target group(s) (usually through research) to determine the most effective way to meet the group's needs as expressed by its members. The “Four Ps” which form the basis of commercial marketing - product, price, place and promotion - are used in social marketing campaigns.

Product in social marketing may be a physical product, such as a latrine, or a change in behaviour, such as handwashing after defaecation.

Price in social marketing may be a physical exchange of value, such as a commercial transaction, but it can also refer to the price involved in changing a behaviour. For example, there is a price in terms of time, if time is needed to carry additional water for handwashing rather than for other activities.

Place in social marketing means the distribution channels used to make the product, service, or concept available to the target group. If a physical product or service is being marketed, the place may mean the actual point of purchase or access. It if is a concept, the place would refer to the media through which the target group learns about that concept (2).

Promotion covers the broad range of channels through which the campaign messages are directed to the target group. Channels for promotion include mass media (television, radio, magazines and newspapers), and traditional methods such as plays, folk singers, and interpersonal communication.

To be successful, social marketing requires that the intended target groups, and groups that influence them, participate in formulating and testing products, programme strategies, activities, and specific messages and materials (1).

What does social marketing involve?

The key steps involved in adopting a marketing approach can be summarized as follows:

Problem identification. This needs to be defined in broad terms. Initially, the problem is defined in general terms only. This is because as more becomes known through research, the focus of the activity may shift.

Research. This is needed to identify the target group and its characteristics. Social marketing involves a number of different research stages and different research techniques may be used. For sanitation programmes, basic questions would include:

· How many households/neighbourhoods have adequate sanitation facilities or systems?
· What do people perceive as “good” and “bad” sanitation?
· Are the needs of women and men different?
· How much do people pay and how much would they be willing to pay for latrines?
· What are the perceptions of men and women about latrines, and are they different?
· What type of system do they prefer?
· What important characteristics do they prefer?

Research methods could include focus group discussions, in-depth interviews, observations of lifestyles and large-scale surveys.

Objective setting. This means development of measurable and time-bound objectives.

Target group segmentation. The data gathered during the research step is used to divide the target group into subsets with common characteristics.

Marketing plan development. The data gathered during the research is used to develop a plan detailing the activities that will be undertaken on each of the “Four Ps”, i.e. which products or behaviours will be communicated to the target group, what will be the pricing structure (if relevant), how the product, service, or concept will be made available to the target group, and, finally, how it will be promoted. Decisions will be based on the consumer preferences as identified through research.

Test marketing. Products, pricing, distribution strategies and promotional messages are tested among representatives of the selected target group(s) and modified and retested until they generate the desired result.

Launch. The social marketing campaign moves out of the test phase into the marketplace.

Monitoring and evaluation. This provides the information which can be used to modify any of the aspects of the campaign to make it more effective.

The steps in social marketing are not necessarily discrete stages with each needing to be completed before the next begins. Instead, several steps can be undertaken at the same time; for example, research results may be used simultaneously to develop programme objectives and to identify target groups.

How could sanitation programmes benefit from a social marketing approach?

Lessons (3) from past sanitation programmes and projects have shown that:

· Water and sanitation projects have often not taken adequate account of individual and community behaviour that affects people's use of the facilities provided. Expected health benefits were therefore not realized, despite the safe water provided to thousands of communities worldwide.

· Goals of sanitation projects have tended to focus on the number of latrines constructed or the number of people provided with access to latrines, and failed to consider promotion of the many behaviours - handwashing, safe excreta disposal, good personal and household hygiene, safe food handling, the avoidance of unsafe water sources, and protection of pumps and wells - that largely determine whether new facilities bring health benefits.

Sanitation programmes have been more concerned with the “supply” of sanitation products, and materials rather than with assessing the needs and preferences of intended beneficiaries. Yet responding to these needs and preferences could contribute to the design of appropriate and acceptable solutions to sanitation problems and help make improvements in sanitation sustainable. “Demand-led” sanitation places emphasis on what people want and how they can contribute to these efforts. Demand creation is also part of commercialized marketing, and may also have a role in sanitation programmes, provided the product in question is actually something consumers want and/or need.

To be successful, social programmes must meet the needs of the target group in a way that they prefer; this is often called consumer-orientation, an important facet of social marketing. Consumer orientation has been shown to be successful in a number of social programmes dealing with family planning, nutrition, immunization, oral rehydration, smoking, cancer detection, use of seat belts and prevention of heart disease and AIDS. It is a particularly valuable approach for solving problems that are related to behaviour, rather than technology (3).

Some recent accomplishments in social marketing include (4):

· The 30 per cent decline in infant mortality in Egypt due to promotion and marketing of oral rehydration salts.

· Improved use of contraception in Bangladesh. Around 44 per cent of men in Bangladesh talked to their wives about family planning within 12 months of a campaign launch and contraceptive prevalence increased by 10 per cent.

· Improved child nutrition in Indonesia. In this country, 85 per cent of women now feed their child a mixed food with green leaves, which has led to improved nutritional status of 40 per cent of Indonesia's children under two years of age.

· A decrease of almost 50 per cent in deaths due to diarrhoea in Honduras following a programme to educate mothers about the use of oral rehydration salts.

Applying social marketing in sanitation programmes

It is usually necessary for sanitation programmes to include those with proven experience in applying social marketing to development activities. And since social marketing activities involve a variety of different skills, it is likely that expertise from a number of different specialist areas will be needed. The following table provides some suggestions on where you may find expert help and the kind of expertise that might be offered.

Table 1. Sources of expert assistance on social marketing

Source of expert assistance

Type of expertise available

Private marketing companies experienced in social marketing agencies

· Practical experience in applying social marketing
· Project management
· Knowledge of specialized agencies such as research companies and advertising

Advertising agencies

· Developing communication messages including television, radio and press advertising
· Selecting the most effective way to reach the target group through mass media, traditional methods, interpersonal channels or a combination of these
· Buying media time and space, e.g. television advertising, newspaper space, etc.

Local media personnel from radio, television, newspapers or magazines

· Broadly, the same expertise as for advertising agencies but specialized to the particular medium they represent

Research institutions, organizations and private research companies

· Research (different organizations often specialize in one specific type of research, therefore, a number of research organizations may be involved if a variety of research techniques are used)


· Academic advice on marketing and social marketing
· Research skills and experience

Government departments or agencies

· Practical experience in applying social marketing in different situations
· Project management
· Various specialists, e.g. anthropologists, researchers, social scientists, marketers
· Advice on how to select appropriately experienced external specialists

Social development organizations

· Similar expertise to that available from government departments

Initial problems in applying a social marketing approach are likely to be poor understanding of the concept among the institutions and organizations responsible, and difficulties in bringing together experts and personnel from engineering, promotion, marketing, and health education. Social marketing experiences in other programmes show that one of the ways of overcoming these problems is to involve and inform all concerned from the start of the process (5).

Social marketing worksheet

The following worksheet is provided to help you understand the steps involved in adopting a social marketing approach in your programme. It may help you to identify whether use of social marketing would be appropriate, whether you would need to seek expert help, and what information you lack.

Try and fill in the last column of the worksheet below for your programme or project. Information on the target group(s)' preferences is required to define each of the “Four Ps” for social marketing to be successful.

Table 2. Worksheet 1: Applying the “Four Ps” to your sanitation programme

“Four Ps” of social marketing

Examples for sanitation

For your programme or project

Decide on what the product is, its form, format, presentation, in terms of packaging and characteristics

Products (tangible outputs): latrines
Practice or behaviour:
Using and cleaning latrines, washing hands after using the latrine
Clean environment, good sanitation for health/hygienic excreta management

Decide on what the consumer would be willing to pay, both regarding direct and indirect costs and perceptions of benefits: make the product worth getting

Cost of products (with or without subsidies)
Opportunity cost:
Time lost from other activities, missed opportunities, transport, loss in production or income
Psychological or physical:
Stress in changing behaviour, effort involved in maintaining latrine or obtaining additional water

Where will the product be available for the consumers, including where it will be displayed or demonstrated

Delivery of product:
Health centres, clinics, pharmacies, households, clubs, local businesses, schools

How the consumers will know the product exists, its benefits, costs, and where and how to get it

Delivery of message:
Television, radio, newspapers, posters, billboards, banners, folk singers or dramatists, public rallies, interpersonal/counselling

Source: Adapted from (2).

To find out more

This article provides an introduction to social marketing. Readers are encouraged to refer to the references overleaf for more information.


(1) Attawell K, ed. “Partnerships for change” and communication - guidelines for malaria control. Division of Control of Tropical Diseases, World Health Organization (1211 Geneva 27, Switzerland) and Malaria Consortium (London School of Hygiene & Tropical Medicine, Keppel Street, London WCIE 7HT, UK).

(2) McKee N. Social mobilization and social marketing in developing communities, lessons for communicators. South Bound, Penang, 1992.

(3) WASH. Lessons learned in water, sanitation and health: thirteen years of experiences in developing countries. WASH, Arlington, VA, 1993.

(4) Griffiths M. Social marketing: a key to successful public health programs. Paper presented at the Social Marketing for Public Health Conference, 5-7 March 1991.

(5) WASH. Social marketing and water supply and sanitation: an integrated approach, Arlington, VA, May 1988 (WASH Field Report No. 221).

Securing political will in Uganda - John Odolon1

1 Network for Water Supply and Sanitation (NETWAS), Entebbe, Uganda.

Securing political will in Uganda on sanitation has involved a long process stretching back more than twenty years. However in 1997 Uganda was one of the first countries in the world to issue a well-articulated national policy on sanitation at Parliament level. This article describes very briefly that process, provides a copy of the briefing presentation used at meetings along the way to win high level political support, and The Kampala Declaration, which states the policy.


The Government of Uganda, together with external support agencies such as UNICEF, has been supporting improved sanitation and hygiene behaviours for at least twenty years. Despite years of civil war (1979 to 1986) when security took centre stage in politics, efforts continued. The Ministry of Health, external support agencies and NGOs did some excellent work on sanitation promotion and developed effective educational materials and methodologies. These materials and methodologies were successfully used in creating awareness of the links between poor sanitation and hygiene and disease, and more importantly they promoted specific actions and practices that individuals, families, communities and others could take to address these problems. This work sowed the seeds of awareness for bigger changes when the time was ripe.

For example, in 1984 a committee was formed to revise the school curriculum so that it would more appropriately address sanitation, hygiene, and behavioural change. The committee was composed of ministries of health, education, water and natural resources, agriculture, local government, community development, finance and planning, as well as representation from parent-teachers associations, religious groups, NGOs, local institutions, donors and external support agencies. This two-and-a-half year effort resulted in wide acceptance and ownership of the curriculum. Over time, it created a greater awareness of the need to improve sanitation and hygiene from family level up to the President. An equally important part of this process was the physical demonstration and promotion of a range of technological options from simple upgrading of traditional latrines to higher levels of service such as the VIP latrine.

In late 1986 the HIV/AIDS epidemic was nationally recognized as a crisis. Issues of sexual behaviour, sanitation and hygiene were given more attention at all levels, particularly at the political level. All ministries associated with health, education and social development were mobilized to seriously address the problem. It was then that the need for safe sanitation and good hygiene practices were identified, politically, as critical to curbing the spread of diarrhoeal diseases from those affected by the HIV virus to the general population.

The only thing that was lacking by 1997 was a well-articulated policy on sanitation.

Building partnerships

The effort to make sanitation the centre of attention and obtain a national policy was a cooperative one involving the ministries of health, gender and community development, natural resources, finance and economic planning and information, and external support agencies such as UNICEF and WHO.

The first step involved putting together a committed team of experienced professionals at the Division of Environmental Health in the Ministry of Health. Those selected had to be suitably qualified and also have a high level of personal commitment to improving sanitation. The team's main purpose was to develop a strategic plan which would enable the problem of sanitation in the country to be defined clearly and articulated in the right political and other fora. The expected output was a clear focus on sanitation.

The team developed a sanitation strategic plan by first identifying the major environmental problems in the country. A workshop was held later with major stakeholders from government departments and other agencies to develop strategies for tackling these problems.

Advocacy and concept paper

An assessment of the status of sanitation in Uganda was undertaken and this provided important information for raising awareness and triggering discussion about sanitation among politicians, donors, administrators and NGOs. Discussion was generated formally through meetings, workshops, and national events and informally at social gatherings, sports events, and by using prominent private citizens such as retired professors and civil servants to initiate discussion.

A briefing presentation which follows and a concept paper entitled The promotion of sanitation in Uganda were important tools for securing political commitment. These documents were very effective because they quickly clarified the problem of sanitation for decision-makers and provided a plan of action for tackling these problems.

A national sanitation task force

Following this successful programme of advocacy, a national sanitation task force was established in July 1997. The secretariat is based in the Division of Environmental Health, but its composition is multidisciplinary. Membership includes representatives from government departments, NGOs, multi and bilateral organizations, support agencies and prominent private citizens. The task force developed further strategies for resource mobilization, information, education and communication. It developed a national Sanitation Resource Kit aimed at providing tools for the promotion of sanitation to various target groups including politicians, technical staff, community members and donors. They prepared a cabinet memo for the Ministry of Health for presentation to parliament in October 1997. The memo requested approval for the launch and implementation of an accelerated sanitation strategic plan.

The Kampala Declaration

The task force held Uganda's first ever National Sanitation Forum. All district authorities and other key stakeholders attended and together they signed a declaration of commitment, The Kampala Declaration which follows. The Declaration was signed by each person present.

Today Uganda's national sanitation programme is on firm ground and has full political backing.


Republic of Uganda

The National Challenge

The Poor State of Sanitation

Consequences of Poor Sanitation

What is the Ministry Doing Now #1

The Social Contract with the People

What is the Ministry Doing Now #2

What can be done about Sanitation?

Result - “Consensus on a holistic definition of Sanitation”

Result - “Basic Principles for Sector Policy and Strategy”

The Way Forward

Potential Components of National Sanitation Programme




We the District Authorities of Uganda together with the key stakeholders here assembled at the first ever National Sanitation Forum, on this day the 17th of October, 1997:

· Realising that poor sanitation is a major constraint to development in Uganda as manifested by:

- environmental degradation and pollution of otherwise protected water sources;

- high rate of morbidity and mortality in the country;

- lost productivity and high expenditure on curative health care cost;

- reduced learning capability of children through illness and early dropout of girls;

- high levels of stunting among children under 5 years;

- loss of community and national dignity and pride.

· Recognising that, sanitation is a way of life and constitutes the isolation of human excreta from the environment, maintenance of the safe water chain, the sustained practice of personal, domestic and public hygiene, safe disposal of solid and liquid wastes, and control of disease vectors and vermin, sanitation goes beyond the provision of physical devices and encompasses positive attitudes and behavioural changes by the people.

· Given the remarkable record of sanitation performance in the 1950s through the 1970s and whilst attributing part of the decline in the status of sanitation in the country to the decades of wars, economic collapse, institutional/social decay and poverty, the current sanitation situation, particularly the low coverage of latrines in Uganda, is unacceptable and is bound to get worse if concerted efforts are not taken.

· Acknowledging that the foundations for improvement of the sanitation situation rest with the collective wisdom of our leaders and the inherent desires of our people for a clean and healthy environment (as enshrined in the 1995 Constitution), hereby endorse the following guiding principle to halt the declining status of sanitation in Uganda and further commit ourselves to the 10-point Strategy for Action below as the basis for ensuring adequate sanitation for all by the year 2005. We the undersigned hold ourselves accountable for the success or failure of this endeavour.

Guiding Principles

· Basic Right: Sanitation is a basic right and a responsibility for every citizen of Uganda

· Partnership and Local Implementation: Community partnership with districts, lower local governments and administrative units and cultural and religious leaders should be the framework for delivery of better sanitation services

· Government Facilitation and Private Sector/Nongovernmental Organisations (NGO) Delivery: Government at all levels will create the enabling environment and facilitate the provision of services, but service delivery will be enhanced through the increased participation of the private and social intermediary sectors (NGOs).

· District Specific Solutions: Sanitation situations vary across the country. District specific solutions suitable for communities and households which can be sustained will dictate the course of actions.

10-Point Strategy for Action

1. Exemplary Leadership Commitment: We, the collective leadership of the districts, commit to set good examples at home, at work and in all public places for improved sanitation.

2. Full Community Mobilization: We shall mobilize and motivate the totality of the district and sub-county leadership (political, traditional, and administrative), households, communities and institutions (schools, health centres, industrial establishments, religious facilities) towards comprehensive promotion and provision of sanitation services for all households, institutions and public places in the district.

3. District and Sub-counties and Urban Authorities Focus: Sanitation begins at home. We shall facilitate the sub-counties and urban authorities to develop sanitation action plans with clear budget lines. These will be integrated into the District plans with explicit objectives of raising the profile of sanitation in our districts and committing resources to sanitation programmes beginning with the 1998/99 financial year. This approach will be the best way of responding to the peculiarities and needs of special geographical areas (security, pastoral communities, technical constraints, etc.) and large groups (disabled, elderly, etc). A task force shall be established immediately to initiate the process.

4. Coordination and Multi-sectoral Approach: Sanitation improvement shall be made an integral part of all social and economic developments in our districts. We shall endeavour to coordinate all of the sanitation activities taking place in our districts, provide linkages to all relevant sectors and establish the necessary framework for rational planning, monitoring and evaluation. A clear definition of the roles of all stakeholders would be defined through consultation to promote transparency, accountability and build collective vision.

5. Focus on Schools: Schools provide excellent opportunities to encourage positive life-long behavioural change. We shall ensure that every primary school and all other institutions of learning have adequate sanitation facilities (latrines, safe drinking water supplies and hand washing facilities) and with separate facilities for girls by the end of 1998. All primary schools shall be involved in School Health Promotion Programmes as dictated by the Universal Primary Education (UPE) programme. We further endorse the immediate re-introduction of school health inspections of pupils and premises in all sub-counties.

6. Fora at Districts: We shall organise and conduct sanitation campaigns in all sub-counties on a regular basis. This shall be crowned by an annual sanitation forum beginning 1998 on an agreed National Sanitation Day. This will ensure an annual mechanism for reporting of progress (based on agreed indicators) and refinement of the strategies. A massive public education campaign with special focus on rational approaches for overcoming inhibiting taboos and cultural practices will be mounted at all sub-counties. Monthly sanitation days shall be introduced at all districts and sub-county levels. We further endorse the re-introduction of inter-district, inter-community and inter-school competitions. Appropriate incentives for rewarding performance shall be instituted periodically.

7. Central Role of Women: We shall ensure that women, youth and persons with disabilities are adequately represented at all levels of the sanitation delivery system and are provided with opportunities for economic advancement and support to sanitation activities.

8. Private Sector/NGO Development and Service Delivery: We shall involve the private sector and NGOs in the development, production and dissemination of appropriate sanitation materials. Support to the local private sector and NGOs (including artisans and community-based groups) in skills development in sanitation service delivery inter alia communal latrines, production of sanitation facilities, sanplats, handwashing facilities and sanitation advocacy shall be facilitated. The appropriate enabling environment and incentive structures will be examined and applied to enhance their participation in sanitation services delivery. Different approaches for effective engagement of the private sector and NGOs should however be recognised.

9. Capacity Building at District Level: We shall ensure that we put in place a multi-sectoral cadre core at the district level to oversee implementation at the sub-county levels. Team work, motivation, balanced staff training and strengthening of the complementary institutions in the districts shall be given top priority.

10. Policies and Guidance: The four levels of government (national, district, sub-county and urban) should collectively develop a comprehensive sanitation policy, operational guidelines and pass necessary legislation to support sanitation improvements. Commitment to timely updating and enforcement of existing legislation should be one of the central pillars of the sanitation delivery at all levels.

Enabling Environment Support

We further declare our full commitment to the National Accelerated Sanitation Improvement Programme (NASIP). The programme will support overall capacity building and infrastructural improvements at all levels. We therefore call on the central government and partner donor agencies to assist in mobilizing the necessary resources in support of the programme. Direct and timely channelling of resources to the district and sub-county level will be called for. The re-orientation of available resources in lead agencies (Local Government, Health and Natural Resources) in favour of preventive health care and in particular sanitation should be the starting point. Although this programme is multi-sectoral and therefore the responsibility of all, the lead agency for environmental health at the national and district levels requires strengthening to transform it into a credible institutional mechanism for facilitating the implementation of the national programme.

Conclusion - Sanitation is a Responsibility for All

No family, community or institution can escape the negative impacts of an endemic poor sanitation situation. Only a comprehensive and multi-sectoral approach aimed at full sanitation coverage and backed by sustained positive attitudes and behavioural changes by all can make the difference. We therefore call on all leaders, citizens and institutions in Uganda to support the National Accelerated Sanitation Improvement Programme to ensure adequate sanitation for all by the year 2005.

Sanitation in Surat - Ashoke Chatterjee1

1 National Institute of Design, Ahmedabad, India.

When pneumonic plague hit the west Indian city of Surat (Gujarat State) in September 1994, its status as one of India's richest cities (diamond-cutting and textile manufacturing are centred here) was matched with that of India's filthiest, its notorious slums swollen with migrant workers. The city, the site of the first British trade post on the subcontinent (set up by Sir Thomas Roe in the 17th century, who described Surat as “a city much fairer than London”), had become renowned for its garbage heaps, open sewers and potholes.

In 1997 Surat (population 3.4 million) was ranked by India's heritage trust as the country's “second cleanest” city. Town-planners and administrators have been streaming in to learn from the mobilization campaign masterminded by Commissioner Mr S.R. Rao, a self-effacing administrator still getting used to his new status as a national celebrity. He attributes success “to the people of Surat, their representatives, the 15 000 employees of the Surat Municipal Corporation, the press and the judiciary”. In fact, it was mainly the personal example set by Mr. Rao, and his personal integrity and drive, that got people interested. He talked to authorities and leaders and citizen groups of all types to get public action. He also demonstrated that his Corporation could “deliver”, and demanded and got public action to supplement what government could do.

Sanitation campaign to clean up Surat

Sanitation has been a key focus in the “My Surat - Clean Surat” campaign which also targets 18 other action areas. Daily fieldwork is organized by city zones, each of them networked with a central control system through computer and radio links. Everyone, from commissioners to cleaners, is expected to be out on the job each day between 7:30 am and 12:30 pm.

A microplan for sanitation divides the city zones into sectors of 3500 m2, each with its own supervisory and task forces. Public latrines and urinals are cleaned each day, while every afternoon another group of cleaners moves out to follow up on the morning's activity. Special ward maps help these teams pinpoint critical locations. Defaulting citizens have to pay administrative charges for cleaning up after them, ranging from 50 to 5 000 rupees, depending on the mess.

At 3:00 each afternoon, Surat's 15 commissioners meet, armed with 9-page computerized reports for a “free and fair discussion and joint decision-making”. Sharing of experiences and random cross-checks are especially encouraged.

Over 50 “Pay and Use” toilets for men, women, and children operate through private initiative, and include the participation of the well-known Sulabh Corporation and Akhil Bharatiya Paryavaran Sansthan. Other private services include maintenance and construction contracts, at rates fixed for a 12-month period. Local doctors contribute their reports and monitoring assistance. Senior cleaners have been pulled out of retirement to strengthen the workforce with their experience.

The feedback system operating out of each ward office includes deadlines for responding to categorized complaints. This is 48 hours for cleanliness of public toilets and cesspool overflow, and 24 for solid waste disposal. Courier services help ensure that official responses reach citizens promptly. City media have been mobilized to keep a close tab on progress and to help educate the public regarding new patterns of behaviour. Eighty per cent of Surat's slums have now been provided with sanitation and other basic facilities. Indicators of profound attitudinal changes include recent interest in recycling human waste, and the level of community appreciation extended to sanitation staff. Performance awards are made on India's national days in recognition of efforts made on this dirtiest of clean-up jobs.

Surat's Medical Officer Dr. R. P. Sinha is also encouraged by the growing level of self-help among citizens, particularly in slum areas. Yet he believes the road ahead is a long one: “Awareness towards health practices is still required in the community. Time is the only solution.” Time, and will.

Lessons for success

People and politicians together

What is unique about the Surat story is that public support has made sanitation a political issue for the first time. Setting their personal example, the city's managers have motivated a system and a community which, until yesterday, were regarded as beyond hope. However, Mr Rao is the first to point out that Surat's success is not attributable to him. Surat demonstrates what people and the political system can do together if there is will on both sides. The will is there from decision-makers at every level of society, and it is they who are providing the muscle to keep things going. Mr. Rao is no longer in Surat, but so far systems are being maintained. Whether they will continue will depend once again on the will of those who succeed Mr Rao and other partners involved.

No extra money

The “Surat miracle” has been achieved within the constraints of existing administrative and financial procedures. All of the money required for this change came from funds available in the normal budget supplemented by funds raised by citizen groups brought together by Mr Rao and his team. No state or central funds were diverted to Mr Rao for sanitation. This means that from a financial point of view, the new sanitation effort is potentially sustainable for the long term.

Computerized management systems

Using good management systems to which computer technology can make important contributions, has been another key to success in Surat. They have put together a management kit, which includes computer systems for information storage, retrieval and use, so that their experience can be shared with others. Fifteen other Indian cities have drawn on this service from Surat so far.

Meeting the sanitation needs of the poor

Public “pay” toilets, 1600 of them, were constructed and more than 90% were sited inside slums. They are free to women and children, and males over 12 years pay 50 paise, a very small sum. So far people are demonstrating a willingness and ability to pay and this small payment has kept all of these units operating. Clearly this is a demonstration of sanitation demand!

The signal is out

The signal is out in India - if Surat can do it, what excuse does that leave other cities for not following suit? The last word comes from the President Prem Sharda of the southern Gujarat Chamber of Commerce and Industry: “Because of the changed image of our city, people elsewhere treat me with great respect when I tell them that I am from Surat.”


A requirement for the promotion of sanitation in any country is knowing how to do good and sustainable sanitation projects at community and municipal levels. If we cannot do good projects and programmes, we have nothing to promote.

The WSSCC Working Group on Promotion of Sanitation tried to identify the important elements for successful national sanitation programmes as well as the principles that underlie the more successful sanitation programmes and projects.

This part of the book contains what the Working Group believes to be the “best practices” that it could identify. The section is divided into three: Principles and guidelines, Empowerment and Checklists.

Principles and guidelines contains what we believe is “state-of-the-art” in the sector on how to do better programmes and presented in summary form for quick reference. They are presented in this form so that they may be converted by users into promotional materials for use at meetings, with the press and for other advocacy purposes. They can be used as tools for discussion-starters at workshops and seminars. They should never be regarded as ideal for every circumstance, complete or unchangeable.

The second section, Empowerment, provides ideas on how to engage communities and empower them to take ownership and responsibility for their sanitary conditions, a requirement for sustainability. It considers gender in planning, hygiene behaviour change, participatory approaches for working with communities, participatory monitoring and evaluation of projects and financing for low-income households.

The last section contains Checklists to assist field staff in applying much of what is discussed in the first two sections.

Important elements for a successful national sanitation programme - WSSCC Working Group on Promotion of Sanitation

National level

- political commitment from the top and at all levels;
- a clearly defined national policy; and
- supportive legislation and enforcement for sanitation facilities in public buildings.

Institutional level

- a set of agreed-upon principles to underpin the programme;
- an appropriate institutional framework to implement the policies;
- sufficient, independent funding to implement policies;
- a project-programme time-frame that allows time for sanitation change;
- on-going research; and
- broadly-skilled sector personnel.


- indicators of improvements and sustainability;

- a monitoring and evaluation plan (preferably participatory and at all levels);

- effective participatory methods for working with communities (including tools to apply a gender approach);

- effective communication and advocacy strategies;

- effective hygiene education;

- well-functioning sanitation technologies; and

- innovative financing arrangements, including credit schemes for the very poor (so that all households can pay).

Principles of better sanitation programmes - WSSCC Working Group on Promotion of Sanitation

This list of principles provides programme planners with a source of ideas and suggestions to help improve the quality of sanitation programmes and raise the professionalism of the sector. The list can also be used to evaluate existing programmes and determine how they might be improved. The principles have been used to develop the Checklist for planning better sanitation projects. (Numbering of the principles in no way implies priority).

1. Sanitation is the first barrier

From an epidemiological perspective, sanitation is the first barrier to many faecally-transmitted diseases, and its effectiveness improves when integrated with improved water supply and behaviour change. However, improvements in hygiene behaviours alone can result in disease reduction and can serve as a valid programme objective.

2. Promote behaviours and facilities together

Sanitation combines behaviours and facilities, which should be promoted together to maximize health and socioeconomic benefits.

3. Give sanitation its own priority

From an implementation perspective, sanitation should be treated as a priority issue in its own right and not simply as an add-on to more attractive water supply programmes. Sanitation requires its own resources and its own time-frame to achieve optimal results.

4. Generate political will

Political will at all levels is necessary for sanitation programmes to be effective. Communities are more motivated to change when they know political will to promote and support such change exists.

5. Use a “systems approach”

Communities are biocultural systems. In a sanitary environment, the key parts of that system - waste, the natural environment (with its unique physical, chemical, and biological processes), local cultural beliefs and practices, the sanitation technology, and the management practices applied to that technology - interact effectively.

6. Create demand

Sanitation programmes should be based on generating demand, with all of its implications for education and participation, rather than providing free or subsidized infrastructure.

7. Government role

Governments should be responsible for protecting public health. Government sanitation policy should create demand for services, facilitate and enhance partnership among the private sector, NGOs, community-based organizations, local authorities, and households, and remove obstacles in the path of achieving improved sanitation.

8. Be gender-sensitive

Sanitation programmes should equally address the needs, preferences, and behaviours of children, women, and men. Programmes should take a gender-sensitive approach but, learning from the mistakes of other sectors, guard against directing messages only to women or placing the burden of improved sanitation primarily upon women.

9. Build on existing practices

Sanitation improvements should be approached incrementally, based on local beliefs and practices and work towards small lasting improvements that are sustainable at each step, rather than wholesale introduction of new systems.

10. Empower people

User-ownership of sanitation decisions is vital to sustainability. Empowerment is often a necessary step towards achieving a sense of ownership and responsibility for sanitation improvements.

11. Use promotional methods

Proven methods of public health education and participation, especially social marketing, social mobilization, promotion through schools and children, exist and can be used to advance and sustain sanitation improvements.

12. Prioritize high-risk groups

Sanitation services should be prioritized for high-risk, under-served groups in countries where universal coverage seems unlikely in the foreseeable future. Hygiene promotion should be targeted at everyone.

13. Understand consumers

Latrines are consumer products and their design and promotion should follow good marketing principles, including a range of options, designs attractive to consumers (based on consumer preferences), affordable prices, and designs appropriate to local environmental conditions. Basic market research and participation in design will most likely be necessary to good programmes. Market forces are best understood by the private sector.

14. Continually promote

As in all other public health programmes aimed at preventing disease, promoting sanitation should be a continuous activity. This is necessary to sustain past achievements and to ensure that future generations do not become complacent as diseases decrease.

15. Take a learning approach

Continually monitor and evaluate and feed back the lessons learned into projects and programmes.

Principle cards - WSSCC Working Group on Promotion of Sanitation

The principle cards are meant to be a promotional tool. Photocopy them onto stiff brightly-coloured paper and cut them into squares. Make several sets.

In meetings where current sanitation strategies and programmes or projects are to be discussed, the cards can be used as discussion-starters. For example, you could divide the participants into smaller groups of 5 to 6 people, give a set of cards to the participants and ask them to sort these cards into cards they agree with and cards they do not agree with. Then have each group explain their reasoning to the larger group. Alternatively, each group could be asked to determine whether current sanitation projects and programmes apply these principles. If not, have them explain why not and discuss whether they should.

The cards can also be used to promote sanitation programme reform to individual decision-makers, on a one-on-one basis. Cards can be shown and discussed one at a time to promote the idea that all sanitation programmes should be based upon good principles.

Principles for
better sanitation

Working Group
on Promotion of Sanitation

Remember: sanitation
is the first barrier

From an epidemiological
perspective, sanitation is the first
barrier to many faecally-transmitted
diseases and its effectiveness improves
when integrated with improved water
supply and behaviour change.
However, improvements in hygiene
behaviours alone can result in disease
reduction and can serve as
a valid programme objective.

Promote behaviours and
facilities together

Sanitation comprises behaviours and
facilities, which should be promoted
together to maximize health and
socioeconomic benefits.

Give sanitation its
own priority

From an implementation
standpoint, sanitation should be
treated as a priority issue in its own
right and not simply as an add-on to
more attractive water supply
programmes. Sanitation requires its
own resources and its own time-frame
to achieve optimal results.

Generate political will

Political will at every level
is necessary for sanitation
programmes to be effective.
Communities are more motivated to
change when they know
political will exists.

Use a “systems approach”

At household level, good
sanitation is a “system”. It is a
harmonious resolution among four
factors: waste, the physical
environment, the local population's
cultural beliefs and attitudes,
and a technology.

Create demand

Sanitation programmes should be
based on generating demand, with
all of its implications for education
and participation, rather than providing
free or subsidized infrastructure.

Government role

Government sanitation policy should
facilitate and enhance partnership
among the private sector, NGOs,
community-based organizations
and local authorities in achieving
improved sanitation.

Be gender-sensitive

Sanitation programmes
should equally address the needs,
preferences, and behaviours of
children, women, and men.
Programmes should take a gender-
sensitive approach but, learning from
the mistakes of other sectors,
guard against directing messages only
to women or placing the burden of
improved sanitation primarily
upon women.

Build on existing practices

Sanitation improvements
should be approached incrementally,
based on local beliefs and practices
and work towards small lasting
improvements that are sustainable
at each step, rather than
wholesale introduction of
new systems.

Empower people

User-ownership of sanitation decisions
is vital to sustainability. Empowerment
is often a necessary step to achieving
a sense of ownership and
responsibility for sanitation

Use promotional methods

Proven methods of public
health education and participation,
especially social marketing, social
mobilization, and promotion
through schools and children, exist
and can be used to promote
and sustain sanitation

Prioritize high-risk groups

Sanitation services should
be prioritized for high-risk, under-
served groups in countries where
universal coverage seems unlikely in
the foreseeable future. Hygiene
promotion should be targeted
at all groups.

Understand consumers

Latrines are consumer products and
their design and promotion should
follow good marketing principles,
including a range of options,
designs attractive to consumers and
therefore based on consumer
preferences, affordable prices, and
designs appropriate to local
environmental conditions. Market
forces are best understood
by the private sector.

Continually promote

As in all other public health
programmes aimed at preventing
disease, promoting sanitation
should be a continuous activity. This
is necessary to sustain past achievements
and to ensure that future generations
do not become complacent
as diseases decrease.

Take a learning approach

Continually monitor and
evaluate and feed back the
lessons learned into projects
and programmes.

Features of better sanitation programmes - WSSCC Working Group on Promotion of Sanitation

The features of better sanitation programmes, below, represent some of the “best practices” identified by the Working Group on Promotion of Sanitation. While this list may not be complete, it was agreed by members of the Working Group that the better sanitation programmes have most of these features. These features reflect in practice many of the Principles of better sanitation programmes.

These features can be laid out in squares, and turned into cards, as done for the Principle cards, and used in the same way, to stimulate discussion and analysis of on-going sanitation programme practices in group meetings and with individual decision-makers.


· They take a learning approach. They show flexibility, change and innovate until they get it right. (Principle 15)

· They are focused on demand creation. (Principle 6)

· They combine social marketing and participatory approaches. (Principles 11 & 13)

· They create an environment in which private producers can thrive. (Principle 7)

· They have relaxed the definition of what constitutes “acceptable” latrines and obtained the highest political support for a less rigid range of good technologies. (Principles 5 & 7)

· They consider what people are already doing and help them to do it better. This includes building upon existing good technologies. (Principle 9)

· They offer a range of technical options affordable to most people without subsidy. (Principles 6 & 13)

· They introduce new latrine options through slightly wealthier, higher-status people in the community. This is because community members in most places expect wealthier and higher-status people to take risks and to be the first to try new things. (Principle 13)

· They let the community know that the sanitation programme has political support from the very top. This is because community members want to follow programmes that are endorsed from the top. (Principle 4)

· They involve schools, schoolchildren or community children. Many use schools as the entry point to the community. (Principle 11)

· They combine facilities with behaviour-change strategies. (Principle 2)

· They build on existing community organizations, rather than creating new ones. (Principle 9)

· They encourage community groups to formulate their own hygiene education programme, their own messages, and their own methods. (Principle 10)

· They use female and male extension workers. (Principle 8)

· They build capacity for community management of the project. (Principle 10)

· They involve a strong training and human resources development component at all levels. (Principle 10)

Principles of sanitation in emergency situations (1) - John Adams1

1 Oxfam Publishing, 274 Banbury Road, Oxford 0X2 7DZ, UK.

Principles for sanitation in emergency situations are very similar to Principles for better sanitation programmes. In a workshop held in Oxford (UK) in 1995, the participants considered the principles derived by the Working Group on Promotion of Sanitation and came up with a similar but adapted set for emergency situations. These are offered for consideration by those who deal with sanitation in emergency situations as a starting point. The Checklist for planning sanitation in emergency situations was created from this set of principles.

· Recognize sanitation as an equal priority: Sanitation is not “water supply and sanitation”. It is sanitation in its own right and should be treated as such. It should not be assigned greater or lesser emphasis than any other priority in an emergency situation.

· Accept that sanitation is the first barrier to faecally transmitted disease: The first barrier, we believe, is not medicine. The first barrier is sanitation, and that should be accepted as beyond dispute.

· Support human dignity in all interventions: Sanitation is not only about health. It is about improving the morale and dignity of the people for whom you are working. Dignity and morale are crucial to helping people to recover after a disaster.

· Recognize the political context: Refugee camps are very political environments, both internally and externally. When you are developing your programme you cannot ignore the fact that you are working in a highly political environment and you must allow for that fact in any decisions you make.

· Set sanitation objectives: Decide at the beginning what you are actually going to try to do, rather than just going and doing whatever you can. It is important to define objectives and then develop a programme to achieve them.

· Promote behaviours and facilities together: Promote behaviours and facilities together so that the two are linked. It is pointless to bring about behavioural changes if you do not have the facilities to make use of them. Conversely, there is no point in having facilities if people do not use them.

· Continually promote sanitation at all levels: Promotion of sanitation is not a one-off effort. It is a continuous process, at all levels: within the community that we are serving, but also at a managerial level within aid agencies, and with the management committees.

· Build on traditional practices: Always try to build on traditional practices. This might not always be feasible, but in general, if you can promote a practice that people have used historically, its acceptance is far more likely.

· Recognize gender and age needs: Recognize the needs of different age groups and genders. They make different demands and you should recognize that in what you provide.

· Encourage user participation: Encourage user participation from the very beginning. Remember that eventually we will all leave and someone has to take over. It is important that the users - while perhaps not a community at the beginning of an emergency - be involved in sanitation, and the sooner this occurs the better, even if only in a very minor way initially. Sow the seed for the future.

· Consider the needs of residents (local people) as well as affected populations: Consider the people who live around the camp, as well as those who live within it. Their needs are just as important. You must be sensitive to comparisons between what is provided in the camp and what local people have or do. Provision need not be the same, but you must be aware that normally there are other communities in the area, who were there before the camp was set up, and will be there long after it has gone; it is important that you bear their needs and their problems in mind in whatever you do.

· Recognize the environmental impact of sanitation: Recognize the environmental effects of sanitation and try to minimize negative impacts and maximize positive effects.


(1) Adams, J. ed. Sanitation in emergency situations, an Oxfam Working Paper, Oxfam Publishing, 274 Banbury Road, Oxford, 0X2 7DZ, UK. Reproduced with permission.

Guidelines on achieving water supply and sanitation in peri-urban areas - WSSCC Urbanization Working Group

The scale of urbanization

By the end of the century, 45% of the population of developing countries - some 2.25 billion people - will be living in cities. Water and sanitation utilities and municipal governments have to translate the quality of life expectations of these huge numbers of people into functioning infrastructure, public policy, legal measures and social and community services. In recent years, the view has gained currency that urban growth cannot be reversed but that its effects must be managed. This task is especially difficult in developing countries, where large numbers of city dwellers live below the poverty line in underserved, degraded and illegal settlements.

The peri-urban sector, which includes squatter settlements, overcrowded tenements and boarding houses in inner cities and illegal subdivisions, is often the dominant pattern of city living in developing countries. Rather than a deviation from the normal process of urbanization, or a transitory way of sheltering migrants, peri-urbanization must be acknowledged as a distinct process of producing cities, with its own features of constitution, growth and change over time.

Based on a comprehensive review of research work and experience gained in the sector, two key areas of concern emerged which are fundamental to the achievement of sustainable water supply and sanitation coverage to the poor in developing country cities:

- Lack of knowledge of the peri-urban sector, coupled with a failure to appreciate its importance, causes serious technological, economic and institutional mistakes; a better understanding of the peri-urban sector and availability of information on settlements to be served are crucial elements for the sustainable extension of service coverage.

- Lack of cost consciousness and of mechanisms for cost recovery and economic sustainability on the part of water and sanitation utilities has so far all but precluded their access to long-term capital markets, the only way to finance large-scale extension of coverage. It is crucial to enable sector institutions to review both capital and operating costs and to gain access to financial resources.

To address these two areas of concern, action should be taken on six inter-related strategic elements:

- security of tenure and other legal issues;
- people's participation;
- adequate cost recovery and resource mobilization;
- availability of technological options;
- institutional reform and capacity building; and
- water resources conservation and management.

Security of tenure

Basis for action

Full legal regularization of land tenure should not be considered a prerequisite for water and sanitation service provision. Local governments and utilities should work together to identify the minimum level of legal recognition of settlements that is necessary to guarantee security of tenure and to provide services. They should then gather data and information on peri-urban settlements in order to plan and design sustainable extension of service coverage.

Mutual recognition and the gradual upgrading of peri-urban settlements may then lead, in due course, to full tenure regularization. Indeed, tenure regularization can be seen as a step somewhere along the upgrading process which is based on mutual recognition.

Extension of basic services should be based on this mutual recognition between authorities and peri-urban settlement communities. Involvement of peri-urban communities, including their willingness to pay for services, and the commitment of local governments and WSS utilities to provide services to informal settlements should both be considered indispensable requirements.

Guidelines for immediate action

Give legal right to services. Governments should give utilities the legal right to provide WSS services to illegal settlements, by not subjecting this action to the unreasonable requirements of formal master plans.

Establish an office in local government to begin legalization process. WSS utilities should encourage and support the establishment, on the part of local governments, of a single authority or office with competence on land use and tenure regularization in informal settlements (permits, property titles, cadastral registers, etc), capable of speeding up the achievement of the minimum level of legal recognition necessary for provide services.

Employ paralegals to work at community level. ESAs and governments should employ trained intermediaries (e.g. paralegals or barefoot lawyers) to work as legal aids and advocates at community level. NGOs can also take the initiative in addressing legal issues at local level, by employing paralegals. NGOs may also be used as intermediaries by ESAs, governments and utilities.

Set up cadastral databases. Institutions with useful information on informal settlements - local governments, utilities, property registries - should set up and jointly manage “interactive” cadastral databases to facilitate evaluation of land regularization applications and to coordinate information management among different sectoral spheres of competence.

Disseminate computer applications for managing databases. Available computer applications for the acquisition, management and analysis of topographic, cadastral and socio-economic data on peri-urban settlements should be disseminated by ESAs, and subsequently by national sector agencies, to enable local governments, utilities and NGOs, to plan and implement upgrading initiatives.

Ensure women's access to security of tenure. Governments should ensure women's access to security of tenure, for instance by removing existing obstacles to their signing contracts or deeds together with their male partners - or without them in the case of women-headed households.

People's participation

Basis for action

Partnership is an essential feature of the provision of water and sanitation services. To guarantee adequate project design and efficient and effective management, the partnership needs to include all the agencies involved (government agencies, utilities, banks, NGOs, grassroots organizations and consumer groups). Governments, with the support of ESAs, should provide the legal, institutional and policy framework necessary to facilitate this partnership and remove obstacles preventing people's participation, especially those hampering the full involvement of women.

Organizing effective people's participation in the development and management of water and sanitation services requires specific skills and outreach services from government agencies, WSS utilities, NGOs and grassroots organizations. ESAs should provide opportunities for capacity building specifically aimed at enabling these organizations to implement participatory projects.

Guidelines for immediate action

Establish special units to work with communities. Local governments and WSS utilities should establish specialized units or cadres to deal with peri-urban communities and should implement awareness and information programmes to encourage positive attitudes towards people's participation.

Ensure women's participation in community-level planning. When formulating projects, particular attention should be paid to the instruments to be used - the loci of participation, the modalities of public meetings and consultations with community members, and the like - to ensure that women are involved and that their opinions are taken into account. Special patience and perseverance may be necessary to overcome women's resistance to participation, such as difficulties in expressing themselves before a male-dominated audience. The Primary Environmental Care (PEC) approach promoted by UNICEF may offer guidance on implementation of participatory processes in peri-urban settlements.

Assess potential local resources. To assess the potential of any particular project activity, the implementing agency needs to identify the local resources available, not only in relation to technical and financial inputs, but also in terms of human resources - i.e. individuals and groups whose opinions carry weight in peri-urban communities and whose actions can affect their development.

Revise regulations and requirements to facilitate community participation. ESAs need to revise regulations, conditions and programming requirements to facilitate people's participation in project planning and execution, since participatory approaches require flexibility in implementation and longer time frames.

Cost recovery and resource mobilization

Basis for action

Sound financial management of utilities is a prerequisite for gaining access to capital markets to finance new investments and to sustain WSS services. National governments, local authorities and WSS agencies need to change their policies on tariffs and cost-recovery in accordance with this principle.

It is necessary, however, to single out specific, demand-driven approaches to the question of cost recovery in the peri-urban sector, bearing in mind the prevailing social and economic situation and the specific mechanisms of the informal sector - income structures, employment levels, alternatives for savings and credit. In this context, development of methodologies to assess willingness and ability to pay of peri-urban communities is a crucial need.

Guidelines for immediate action

Adopt modern management practices. WSS utilities need to adopt modern management practices and information systems, including appropriate cost accounting, customer account management, and a consumer-oriented approach (collection of users' complaints, information, suggestions, etc), to improve their efficiency and create an atmosphere of trust for potential investors.

Full cost recovery can include cross subsidies. Although full cost recovery should be the basic principle for sound financial management, it does not preclude the application by WSS utilities of cross subsidies between projects, consumer groups, or others.

Subsidize sparingly. Transfer of resources from central governments should be necessary only in special circumstances. In those cases, it should be directed at subsidizing the demand rather than the supply, thus ensuring adequate targeting to the urban poor and sound financial management of the utility. Government subsidies need to be specific, transparent and temporary.

Training for making and recovering loans. ESAs should launch initiatives aimed at training NGOs, banks and WSS utilities to make and recover loans in peri-urban areas (e.g. revolving fund schemes to allow households to connect to WSS networks). ESAs and governments should be willing to test incremental or gradual credit schemes, as well as the performance of groups of inhabitants and grassroots organizations in repaying loans (“solidarity guarantees”).

Give women access to credit. Governments should remove the legal obstacles preventing women from gaining access to credit, giving them the same rights as men in the signature of loan contracts. Women's needs and opinions should be taken into consideration when devising repayment schedules and outreach mechanisms for credit schemes.

Pay attention to gender in willingness to pay studies. Recent research has shown that willingness to pay for improved water supplies is generally high. Nevertheless, willingness to pay needs to be assessed case by case and should form the basis of tariff systems and credit schemes. Both women and men should be consulted to gain an understanding of the actual behaviour of households and their real willingness and capacity to pay. The key role played by women in building families' willingness to pay needs to be recognized.

Appropriate technologies

Basis for action

Appropriate technology for peri-urban areas does not mean simply low-cost technology. It means technology which is tailored to the specific conditions - the geomorphological features of peri-urban sites, the dynamics of growth and change in informal settlements, the effective demand for particular levels of service, compatible operation and maintenance requirements and, not least, affordability.

Developing appropriate technological options and design solutions for the complex and difficult physical and socio-economic conditions in the majority of peri-urban areas demands a higher eve of engineering skills than is traditionally required for rural and formal urban WSS services.

Guidelines for immediate action

Assess technological options. ESAs and national sector agencies should help WSS utilities to develop guidelines for carrying out assessments of available technological options. It would be particularly useful to develop performance indicators linked to the various service levels, to help in the selection of those which best suit local circumstances and will ensure sustainability on the basis of efficiency in the use of inputs and in relation to evolving local realities.

Plan for both economic and residential water and sanitation uses. Planners of WSS projects need to take into consideration that peri-urban settlements are economically productive areas - not just residential areas.

Ask main users about design features. As the main criterion for technology choice, planners should endeavour to find out directly from the main users (normally women) what features the proposed service needs to have. They should pay special attention to the uses of water in household activities - usually carried out by women - such as laundry, food preparation, washing children, cleaning the house.

Rural options may not fit the peri-urban context. Extreme caution should be exercised when considering the transfer of technological options from the rural to the peri-urban context.

Overcome the rigid adherence to conventional standards. ESAs should assist national sector agencies in implementing training and awareness programmes to change the attitude of utility professionals towards the selection and application of appropriate technology options. It is necessary to overcome the rigid adherence to conventional standards that prevails in engineering culture and to encourage interdisciplinary work.

Site communal facilities carefully. ESAs, NGOs and WSS utilities should avoid building communal or public WSS services (e.g. water points, public toilets) on sites that are difficult to access, or too distant from households, or that do not preserve the right to privacy. Such features are particularly detrimental for women and children, who should be the most frequent users of these services.

Institutional reform and capacity building

Basis for action

The first target of institutional reform and capacity building should be to make sector institutions work by enhancing their financial and administrative efficiency. Beyond the need to improve the capacity of WSS utilities to perform their traditional duties, however, there is an important challenge to develop new capacities to provide services under the specific conditions of peri-urban areas.

Policy frameworks need to be developed at national level to address the roles, responsibilities and support needs of sector institutions in the delivery and management of WSS services in peri-urban areas. This does not only mean achieving the optimum performance of individual agencies in the provision of peri-urban services, but also promoting and supporting the establishment of partnerships among agencies.

Guidelines for immediate action

Attract and retain qualified personnel. Human resources development (HRD) programmes should first of all aim at enabling utilities and sector institutions to attract and retain sufficient numbers of suitably qualified personnel, including those equipped to deal effectively with peri-urban service provision. HRD programmes should include:

- adoption of competitive, market-based salary levels and benefits;

- establishment of adequate career structures, incentives and evaluation procedures;

- provision of training opportunities linked to career progression;

- retraining of available staff in customer relations and community liaison and development activities;

- special emphasis on enhancing capabilities in sanitation and sewerage development.

Involve the private sector. Involvement of the private sector should be encouraged by national governments and actively sought by utilities, which should explore possibilities for creating new roles for private companies in the provision of WSS services.

Establish working groups. ESAs and national sector agencies should actively encourage the establishment of inter-institutional and interdisciplinary working groups with spending and decision-making powers, as an innovative institutional arrangement to coordinate and promote upgrading of peri-urban areas and their integration into the city. In large cities or metropolitan areas, several such units could be created on a decentralized bases.

Involve NGOs as service providers where necessary. ESAs and national sector agencies should actively encourage WSS utilities and NGOs to develop mechanisms for NGOs to act as intermediaries or surrogate service providers to peri-urban communities when legal, administrative or other constraints prevent direct service provision by WSS utilities.

Assess roles, responsibilities and capabilities of WSS agencies. Local governments and WSS utilities, with the help of NGOs and citizens' groups should assess the existing roles, responsibilities and capabilities of agencies dealing with peri-urban WSS services in their locality, to help define possible institutional reforms.

Water resources conservation and management

Basis for action

Local governments, in partnership with other agencies, should be encouraged to develop an integrated approach to the delivery and management of environmental infrastructure - water supply, sanitation, solid waste disposal and drainage. In this context, extension of sanitation coverage to peri-urban areas needs to be recognized as a means of enhancing water resource protection.

Conservation and sustainable use of water resources require the development and implementation of a comprehensive framework of economic and regulatory instruments and incentives, as well as concurrent public information activities and enhancement of monitoring and surveillance capabilities.

Guidelines for immediate action

Apply incentives and instruments to protect water resources. Governments, with the help of ESAs, should explore practical ways of applying economic and regulatory incentives and instruments (e.g. the “polluter pays principle”) to protect water resources. In this context, monitoring and surveillance should be enhanced and undertaken systematically, to help prevent water pollution and improve water management.

Utilities should conserve water. WSS utilities should improve their own water conservation, though control of physical water losses, including leakage detection programmes, and improved measuring and charging mechanisms to reduce unaccounted-for water.

Explore ways of stimulating demand for sanitation. The fact that extension of sanitation services to peri-urban areas also protects water resources provides an added incentive for WSS utilities to explore ways of stimulating demand for sanitation and extend coverage, with the participation of the users.

Use incentives to encourage wastewater reuse. Governments should adopt economic and regulatory incentives to enhance water conservation and urban wastewater reuse, as ways of easing water shortage problems and to facilitate collection and treatment of wastewater.

Matters requiring further research and empirical testing. ESAs, national and local governments and sector agencies, utilities and NGOs are urged to design and implement applied research and information dissemination programmes in relation to the following:

1. Intermediate legal options for security of tenure in informal settlements.

2. Simplified institutional arrangements and bureaucratic procedures for cadastral registration and settlement regularization.

3. Rationalization of bureaucratic spheres of competence and procedures to grant legal title to tenure (or similar).

4. Policies and mechanisms to provide services to vulnerable groups (e.g. renters) and protect their interests when undertaking legal recognition and settlement upgrading, without blocking these processes.

5. Policy and legal instruments to facilitate service provision to settlements which, although they fall outside the territorial jurisdiction of local authorities, are part of the urban structure.

6. Effective ways of sharing responsibility for projects (financial resources, labour, management, etc.) and for the operation and maintenance of completed works among implementing agencies, WSS utilities and local communities (the desirable scope and level of community participation vary with the socio-cultural context).

7. Feasibility of implementation and functionality of existing tariff systems in relation to the goal of full cost recovery.

8. Comparative advantages of available mechanisms for equitable cost recovery (cross subsidies, single tariff with direct subsidies to poorest groups, and so on).

9. Practical mechanisms and institutional arrangements for breaking down large loans from financing organizations into the small loans needed for participatory approaches in peri-urban settlements.

10. Application of economic penalties and incentives, such as those based on the polluter pays principle, to environmental conservation and sustainable use of water resources.

11. Requirements and constraints relating to private sector involvement (e.g. guarantees offered by local and national governments, low revenues of WSS services, cost recovery frameworks, clear and stable rules, etc) and effectiveness of the various degrees of private sector involvement, including full privatization, in extending and improving services for the poor.

12. Technical solutions for adapting WSS systems to the shelter and infrastructure conditions of the peri-urban sector.

13. Patterns and requirements of household activities - food preparation, laundry, personal hygiene, house cleaning - in relation to water use, so that women's needs can be taken into consideration when formulating projects.

14. Guidelines for the practical application of participatory principles.

Principles of the strategic sanitation approach - Albert M. Wright1

1 Consultant, UNDP-World Bank Water and Sanitation Program.

Focus: the urban poor

Providing urban dwellers, particularly the poor, with adequate sanitation is one of the major challenges facing developing countries today - over half a billion urban dwellers are estimated to be without access to adequate services, and the urban environment is becoming increasingly degraded. The adverse consequences have been enormous in terms of health, availability and cost of water, economic development, and social cost. The problem has been worsening with time and growth of affected cities, reaching serious proportions in the megacities and large cities with populations over one million. The cost of addressing it and the cost of neglecting it are both increasing with time.

Traditional supply-driven approaches have proved ineffective in addressing the problem. But some recent innovative approaches, such as the condominial system in Brazil and the Orangi Pilot Project in Pakistan, have proved successful (see Low cost sewer-age). The Strategic Sanitation Approach (SSA) reflects those features of the innovative approaches which have helped to make them successful; it also reflects recent advances in technological knowledge and in concepts in the new institutional economics. It is an incentives-driven, demand-based approach to sanitation designed to overcome the barriers to the sustainable expansion of adequate sanitation to urban dwellers.

Barriers to urban sanitation

The search for barriers to urban sanitation started over 20 years ago. Initially, the high cost of conventional sewerage was thought to be the key constraint. A two-year World Bank research program to address this constraint was undertaken during 1976-78. It led to the identification of a range of lower-cost alternatives, including two on-site technologies, the VIP and the pour-flush latrine. Subsequent experience in Tanzania and other countries showed the need for sewerage systems intermediate in cost between conventional sewerage and low-cost on-site sanitation. The ensuring search led to the identification of a range of intermediate-cost sewerage systems, including simplified sewerage, solids-free sewerage, flat gradient sewerage, and the condominial sewerage system.

The availability of a wider range of technological options necessitated the development of criteria for choosing between the options. Failure of the supply-driven approaches, experience from successful approaches, as well as considerations of the principles of fiscal equivalence and of public finance led to the choice of a demand-based approach. This, in turn, created a need for methods for demand assessment at household, neighbourhood and local government levels.

In this way, a list of barriers to urban sanitation were identified, the key ones so far identified are:

- the high cost of sanitation investments;
- constrained financial resources;
- inappropriate technological practices;
- inadequate institutional arrangements;
- maintenance neglect;

Overcoming the barriers: The strategic sanitation approach

The Strategic Sanitation Approach is designed to address these barriers. Its key strategies are:

- demand orientation;
- unbundling;
- widening of technological choices;
- incentives-driven institutional arrangements;
- financing and cost-recovery arrangements;
- attention to operation and maintenance;

Demand orientation

Demand orientation entails responsiveness to what people want at a price. This implies ensuring that investments and operational choices are driven by what users and beneficiaries want and are willing to pay for. This strategy is designed to ensure that those who make investment choices incur an opportunity cost. Such an opportunity is a consequence of making choices under conditions of scarcity of resources. As a result of such scarcity, it is not possible for governments or individuals to have everything they would like to have. Hence choosing one thing generally involves giving up something else. What is given up in order to have something else is the opportunity cost of the choice that is made.

In a supply driven approach, those who make investment choices are not the ultimate beneficiaries or users of the installed sanitation facilities. Hence there is nothing that such people are forced to sacrifice or give up when they make one choice or another. In contrast, a demand-driven approach requires that the ultimate users and beneficiaries of investments, or those who will pay for such investments, are those who make the investment choices. The reason is that in making the investment choices, there is something important which they are forced to give up. The value of what is given up will vary with the cost of the option that is selected. It will be high for high-cost options, and low for lower-cost options. As a result, the choices they make tend to be realistic. Furthermore, the cost of their investment choices tends to approximate the value they attach to the choices.

For these reasons, the approach tends to induce commitment and a stake in the sustainability of the investment. This improves the prospects of proper care and maintenance of installed facilities and, hence, the sustainability of such facilities. Furthermore, it improves responsiveness to users, avoids a mismatch between supply and demand, and serves as a check on public accountability.

For investments to be sustainable, it is important that demand for them be expressed not only by the ultimate users, but also by the local governments in whose jurisdiction the investments are going to occur, and also by the communities or neighbourhoods where the beneficiary households would occur. If any one of these demands is not secured, the sustainability of the investment becomes uncertain.


Unbundling is the sub-division of sanitation systems into smaller packages or sub-systems. There are two types of unbundling, vertical and horizontal unbundling. The basis for vertical unbundling is the type of service to be rendered, together with its corresponding type and capacity of physical infrastructure. The total system is divided into sub-systems, each with a different type of physical infrastructure designed to serve a different function. Flow is sequential, from an upstream sub-system to a downstream sub-system. Thus we may have in-house sanitation facilities as one sub-system designed for household sanitation service; this would be followed by a feeder sub-system (consisting of secondary and tertiary sewerage systems) for collection of sewage from a community or neighbourhood and feeding it to trunk sewers (or to primary sewers). Finally, there would be trunk sewer sub-systems designed to receive sewage from feeder systems for bulk transport to treatment plants for final treatment and disposal. The upstream system consists of highly dispersed but small physical infrastructure. In contrast, downstream systems tend to be less dispersed but bigger in capacity and require bigger investments. These characteristics have implications for ownership, financing and management arrangements. Thus ownership of in-house sanitation facilities is private; its financing and management is also privatized. Ownership of feeder and trunk infrastructure may or may not be private, and its management and financing may be community-based, private, or public.

In horizontal unbundling sub-division is according to jurisdictional or drainage boundaries. Flow is not sequential, but in parallel, through different service areas. All types of services and technological types can occur in each horizontally unbundled service area. A service area may be self-contained, with final treatment taking place within the boundaries of the service area, it may limit itself to household and feeder sewerage services, and it may make use of a bulk transport sewer system that serves two or more service areas.

Unbundling facilitates the application of the demand-based approach; it makes it easier for beneficiaries to appreciate investment benefits, it helps define boundaries where costs and benefits occur, and facilitates assignment of responsibility for cost recovery. It has enormous implications for overall sanitation costs, investment and operational efficiencies, and the choice of proper management levels. It reduces the lumpiness of individual investment packages, improving affordability. Compared to centralized sewerage, it reduces the average diameters and depths of sewerage. This results in a reduction of overall investment costs - a cost reduction of 76 percent has been reported in the city of Juiz de Fora in Brazil. In flat terrain with high ground water tables, the reduction in average sewer depths lowers pumping costs during construction and also during operation and maintenance. Unbundling also allows greater flexibility in the implementation of projects; it improves the prospects of private sector participation, particularly of both formal and informal institutions. Moreover, it offers opportunity for competition between service providers working in different service areas. It also lends itself to decentralization and facilitates management at the lowest appropriate levels. A good example of both horizontal and vertical unbundling can be found in the Sanitation District of Los Angeles County. A recent report to the U.S. Congress (1997) indicates that about 25 percent of the U.S. population are served by decentralized wastewater systems. This implies an extensive use of horizontal unbundling in the United States of America.

Widening of technological options

The demand-based approach requires consideration of a range of sanitation technologies, ranging from low-cost on-site sanitation technologies, (where appropriate) to conventional sewerage. It also includes comparison of centralized and unbundled systems. Households, communities, and local governments are then provided with adequate information on the benefits and costs of each option to enable them to make informed choices between the options. It is important that only those options that are technically feasible for the given situation be included in the choice set.

The principle of widening technological options creates incentives for the development of alternative technologies. The availability of alternatives tends to reduce prices of existing options, enhances responsiveness to what users are willing to pay, improves access to service, and facilitates expansion of coverage. A number of technological alternatives are available for on-site sanitation and for intermediate cost sewerage. A number of treatment plants are also available. However, there is still need for more compact sewage treatment plants if the benefits of horizontal unbundling are to be fully captured. Other areas for further development of alternatives are technologies for recycling of sewage.

Incentives-driven institutional arrangements

Incentives are the reasons why individuals and organizations involved in the development, maintenance, and use of facilities do what they do. They are the factors or conditions that induce or motivate service providers or users to behave in one way or another. They are what people perceive as conditions satisfying their desires or creating net benefits for them. For some, incentives may take the form of rewards and penalties. For others they may be prestige, or an opportunity to work with others. Another form of incentive is the perception that the benefits obtained in an investment exceeds the cost of the resources devoted to the investment; alternatively, it may be the perception that the cost of not making the investment exceeds the cost of the resources invested. It is generally held that behaviour is driven by incentives, and that sustainability is driven by behaviour of those involved in the various stages of development - design, construction, operation, maintenance and use of physical infrastructure for services. Incentives are therefore of paramount importance in the sustainability of sanitation investments. It is through institutional design that incentive structures are defined.

Institutional design is concerned with the assignment of roles and responsibilities, assignment of authority for various activities (such as levying service charges and appointing service providers), definition of enforceable rules, and the definition of the enabling environment for the supply of services. The fundamental assumption in the Strategic Sanitation Approach is that all institutional arrangements give rise to some inherent incentives that affect behaviour of those involved in the development, maintenance, and use of sanitation facilities. These incentives may be consistent or inconsistent with the goals of sustainability of investments. The principal goal in the design of institutional arrangements is to ensure that inherent incentives are consistent with, and are conducive to, sustainability of investments. This requires that institutional arrangements be conducive to accountability, transparency, and lower costs. They should also be conducive to flexibility and reliability. They should also be such that, all things being equal, it is the beneficiaries of public investments that pay for the cost of such investments, and that what they pay reflects the extent to which they benefit from the investments. At the same time, adequate provision should be made for the indigent and for poverty alleviation.

Key measures that tend to induce improvements in transparency, accountability and performance of service providers include:

- user participation in all stages of project development and implementation;
- information to all stakeholders, including the public;
- management at the lowest appropriate level, and separation of powers (separation between supply and regulatory functions).

Other measures include:

- broadening of competition,
- applying commercial principles,
- involving non-formal institutions and the private sector,
- and using price as a signal for service costs.

The effective use of these measures requires feedback of experience and capacity building at all levels, including low-income communities.

Financing and cost-recovery arrangements

The objective of this measure is to identify funding sources for investments, and to assign responsibility for payment of the capital costs and the operation and maintenance costs. The goals are sustainable expansion of service, investment and operational efficiency, and reliability of service. In order to attain these goals, a number of principles need to be observed. Local demand should serve as the key criterion for devising technical solutions and for the allocation of financial resources. The financial gap between revenues and total system costs should be minimized; and cash flows should be sufficient to meet current financial obligations for operation and maintenance and for debt servicing, where appropriate. It is important that all (including the poor) pay a portion of the capital costs in cash, and that the amount paid should be sufficient to induce a stake in the sustainability of the investment. For the poor, in-kind contributions may be allowed to cover the balance of their contributions to capital costs.

Attention to operation and maintenance

Maintenance neglect has been one of the major constraints to the sustainable expansion of coverage. It results in premature deterioration of physical infrastructure, adversely affecting system performance and reliability. One of the consequences of poor system performance is failure to achieve expected benefits. Another is user dissatisfaction. This tends to lead to shortfalls in cost-recovery, lowering financial sustainability of investments, and sustainable expansion of coverage. For the poor, maintenance neglect is particularly devastating because it is easier for them to raise the lower amounts required for routine operation and maintenance than it is to raise the lumpy investments for periodic rehabilitation of damaged infrastructure. Besides, the rehabilitation takes up funds that could have been used for expansion of coverage. Thus maintenance neglect is a major constraint to the sustainable expansion of coverage. For this reason, it is important that in planning investments in sanitation, adequate and credible arrangements be made for undertaking and paying for routine operation and maintenance.

Further reading

Wright A. Toward a strategic sanitation approach: improving the sustainability of urban sanitation in developing countries. Internal working document. Washington, DC. UNDP-World Bank Water and Sanitation Program, 1997.

A gender perspective in sanitation projects - Angela Hayden1

1 Independent consultant, Geneva, Switzerland.

What are gender issues in sanitation?

Many sanitation projects have failed because latrines are not properly maintained or simply not used. Why?

Latrines might be sited far from dwellings and women may not like to be seen going to them. Perhaps children are afraid of falling down the hole. People may find the facilities dark and smelly, and would rather defecate in the open air. Men and women might not want to share facilities.

So what gives sanitation projects a chance to succeed?

A sanitation programme is implemented in a community with traditional patterns of living. The programme has to be built on existing practices. For that to happen, traditional patterns - and the motivations behind them - have to be understood. If changes to more healthy practices are to be made, the best people to promote those changes are the ones with a vested interest in seeing the results achieved.

What has all this to do with gender?

Suppose the men of a village construct latrines and are given training in how to maintain them, but then migrate for seasonal employment elsewhere, what happens?

If it is shown that improved sanitation facilities reduce the incidence of disease, women, who are usually the ones who care for sick members of the family, may be highly motivated to keep the facilities clean and functioning properly. But what if training courses are held far from the village and it is not acceptable for women to spend time away from their families to attend courses?

Questions and discussions of this kind are often called “gender issues”. The philosophical basis for considering gender issues is a quest for equity. In traditional societies, decisions are usually made by men. Often, women are expected to be subservient, even if they are able to exert indirect influence.

But sanitation is particularly concerned with gender issues because women are the ones responsible for water and sanitation. If their views and concerns are not expressed and integrated into the programme design, it is unlikely that the programme will earn their commitment. Failure is then almost certain. Evidence shows that when women truly incorporate behaviour change into the pattern of their daily lives, they pass these behaviour changes on to their children, thus increasing a sanitation programme's sustainability.

Focusing on gender means considering the different experiences of men and women, their potential and their limitations, the way they interact, how they share tasks, and how their activities are complementary. More importantly, paying attention to gender is ensuring that women as well as men participate in social and economic development.

Opportunities for men and women to participate in sanitation projects

Men and women should participate actively and equitably in:

- identifying local problems, priorities, and technologies;
- choosing acceptable and affordable sanitation facilities;
- designing and siting of facilities;
- constructing and maintaining facilities (physical or financial contribution);
- training in construction, use, and upkeep;
- educating their own children about proper use and upkeep;
- teaching schoolchildren about proper use and upkeep;
- managing sanitary conditions in the community;
- monitoring sanitary conditions in the community.

Experience shows that one of the main obstacles to the sustainability and success of sanitation projects is that women do not always participate. Women can take part in sanitation projects in many ways, depending on the need, culture and situation. Among these are:

- deciding how women can best be involved in project activities;

- selecting between available alternative sanitation options;

- participating in project indicator establishment and use through monitoring and evaluation activities;

- making detailed design decisions (about type of enclosure, building materials, doors, locks, lighting, siting, etc);

- promoting improvements at household level;

- doing latrine construction work (usually assisting men);

- manufacturing materials to be used in latrine construction (for example, bricks and tiles);

- working as interviewers to collect data;

- providing information as interviewees and focus group participants;

- using the latrines themselves on a regular basis;

- facilitating family use by making paper, soap, and water available;

- supervising children's use of latrines;

- teaching children and motivating other members of the family to use new or improved latrines with proper hygienic habits;

- educating and motivating other local people to use, care for, and maintain latrines properly and adopt proper hygiene habits;

- carrying water for pour-flush latrines and for general latrine cleaning;

- cleaning and general routine care;

- helping to assess the extent to which the project has succeeded.

Using the gender checklist for better projects

Sanitation projects are intended to benefit men, women, and children. If women as well as men are to be involved effectively in improving sanitation facilities, women and men must participate in all stages of the project: design, planning, management, implementation, operation and maintenance, monitoring, evaluation, and follow-up.

A gender checklist is included in the next section. This is intended to help ensure that men and women are involved in all aspects of the programme. Because women are often excluded from programmes, the checklist concentrates on ensuring their participation. Traditions and practices differ, so not all the items will be relevant in every case. Sometimes other factors will have to be taken into account, depending on local circumstances.

Use the checklist to jog your memory. Add or delete items if you want to. The checklist is intended to be of practical use to you in carrying out your work. It will probably have to be translated into the languages used by people working in sanitation programmes. It may be photocopied freely and handed out to anyone interested.

Make sure that the people using the checklist have the right skills, or try to provide appropriate training. If possible, find a specialist in gender issues to help you.

How can you find the answers to the questions in the gender checklist for planning projects?

Getting information about a community's sanitation behaviour and practices is best obtained via (in order of preference):

- participatory activities;
- focus group discussions; and
- interviews.

Here again, you will need people with special training to make certain that the participatory activities, focus groups or interviews produce valid and useful results. Ask a gender issues specialist to help you.

Participatory activities

These encourage individuals to participate in a group process. They are designed for planning at community level and encourage everyone to participate, irrespective of age, sex, social class or educational background. Participatory methods are particularly useful in encouraging the participation of women who, in some cultures, may be reluctant to express their views.

If possible, find someone who knows about participatory methods to help collect the information you need. Otherwise, you can find out about participatory methods by reading Tools for community participation: a manual for training trainers in participatory techniques by Lyra Srinivasan and Gender issues sourcebook for water and sanitation projects by Wendy Wakeman.

Focus groups

These are group discussions that gather together people from similar backgrounds or with similar experience to discuss specific topics. The group is guided by a moderator (or facilitator) who introduces the topics for discussion and helps to foster a lively and free discussion among the group members. An observer or note-taker records the main points mentioned in the discussion.

For focus groups to produce useful information, it is important to have a well-trained moderator and to select participants carefully. If you want to use focus groups as a way of gathering information, try to find an expert to help you.2

2 For more about focus groups, see The focus group manual by Susan Dawson, Lenore Manderson and Veronica L. Tallo, Methods for social research. In: Tropical diseases No. 1, social and economic research. UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, 1992 (unpublished document TDR/SER/MSR/92.1).


These are a good way of gathering information, so long as the people being interviewed feel free to express their true opinions and as long as they are selected at random. Many factors may inhibit women interviewees, making them reluctant to say what they really think. For example, a woman may feel uncomfortable if she has to answer questions in front of her husband or mother-in-law. Try to use trained interviewers (women's organizations may be of help here).

Some points to watch when interviewing women are:

· Employ women interviewers.

· Interview women in groups where possible, preferably where they gather for some other activity.

· Interview women separately from their husbands, if possible.

· Consider age, social class, and cultural match to make sure that the interviewer will be understood and trusted.

· Be aware that young wives may not be able to express themselves freely in the presence of their mothers-in-law, mothers, or any person with power over them.

· Make certain that you interview people from each of the groups within the community. Programme planners should find out from several different sources what groups exist in the community.

· Avoid recruiting interviewers from only the higher levels of society.

· Interviewers need to have some legitimacy, so consider training as an interviewer a respected person from within the community or from a similar background to the persons being interviewed.

· Appoint more than one interviewer, so that they can support each other, particularly when interviewing mixed groups.

References consulted

Hannan-Andersson C. Ways of involving women in water projects. Waterlines, July 1985, 4(1):28-31.

Perrett HE. Involving women in sanitation projects. Washington, DC, Technology Advisory Group (TAG), United Nations Development Programme (World Bank, Washington, DC), 1985 (TAG Discussion Paper No. 3).

Wakeman W. Gender issues sourcebook for water and sanitation projects. Washington, DC, UNDP-World Bank Water and Sanitation Program/PROWWESS (World Bank, Washington, DC), January 1995.

Wakeman W et al. Sourcebook for gender issues at the policy level in the water and sanitation sector. Washington, DC, UNDP-World Bank Water and Sanitation Program, Water Supply and Sanitation Collaborative Council, October 1996.

Hygiene behaviour-change: lessons from other sectors - Carol Jenkins1

1 International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka.

People everywhere are pleased to acquire convenient water supplies, but they are often indifferent to improved toilets and their use. This is because they do not believe or understand that their hygiene behaviour may be endangering their health. Consequently, they do not see the need to change what they are doing. When better toilets are installed, they do not understand why they should use them or keep them clean and working properly, thus failing to reduce their exposure to diseases and to reap full health benefits.

For this reason, improved sanitation does not simply entail installing better toilets. People must use them effectively to lower their vulnerability to disease. A major barrier to effective use is that many people do not believe or comprehend the correlation between their habits and many of the diseases they suffer. They continue to practice hygiene behaviours that, even in the presence of improved water and sanitation facilities, threaten their health.

For the health benefits from improved water supply and sanitation to come about, people must use facilities in ways that lower their exposure to organisms they cannot see and may barely believe in. Getting people to use these facilities effectively can only be achieved if sufficient resources are devoted to helping people discover for themselves the benefits of changing their hygiene behaviours. Since these behaviours are often steeped in tradition, ritual, and custom, the task of altering them may be much more difficult than that of simply providing sanitation facilities.

Changing poor hygiene behaviours is now recognized as the most effective intervention for reducing diarrhoeal diseases and many others. This must not be viewed as secondary to installing improved water and sanitation facilities, but rather as an integrated and high-priority component of every such programme.

The past few decades have been fruitful for those who work in the general field of health education. In the fields of nutrition, HIV/AIDS, vector-borne diseases, immunization and diarrhoea, and with other public health issues, lessons have been learned. In fact, what has been discovered underscores the inadequacy of the term “hygiene education” itself. Education alone is clearly not enough. Hygiene education should be reconceived and renamed “hygiene behaviour-change”. Although perfect recipes for behaviour-change programmes have not emerged, very clear lessons have been documented repeatedly that highlight several common elements required for successful health-related behaviour-change programmes. Some of the most important principles gleaned from these lessons are listed along with their correlates and illustrated.

Selected principles of health-related behaviour-change interventions

1. Adult human beings are not empty vessels waiting for information to direct their lives. They already have a complex system of concepts, attitudes, and values that inform their behaviour. Two examples of this principle follow.

Helminth infections. In the course of a school-based intervention to diminish the helminth load among Luo tribesmen in Kenya, investigators learned from children of a philosophy of worms that adults held, but would not divulge. Eventually, after living and working among the people in their communities, project personnel discovered that worms were considered essential to the functioning of the body. It was believed that disease was caused by an over-abundance of worms that had to be purged through the nose, or other body orifices. Traditional healers specialized in removing unnecessary extra worms, but the removal of all worms was considered to be very risky to human health.

Malaria. In numerous studies of people's perceptions of malaria in Africa and elsewhere, it has been found repeatedly that the convulsions and altered consciousness associated with high fevers are not perceived as a component of malaria, but as conditions caused by spiritual factors. This perception is maintained even though in almost all areas where malaria is highly endemic, people recognize the main features of the disease and have terminology to name them, and often a specific term for the disease.

Basic research is, therefore, required to understand a community's existing knowledge, beliefs, and actions. From this research, a few specific messages can be crafted, aimed at teaching new concepts. The following example illustrates how this was done for acute respiratory infections (ARI) in Honduras.

Formative research. Ethnographic and focus group research methods were used to develop an understanding of mothers' own diagnostic cues and terminology for ARI in their children. Health workers were trained to use new methods, including demonstrations, to convey a specific set of messages derived from the findings of this research to help mothers improve their understanding and ability to manage ARI in their children. Pre- and post-tests of mothers' knowledge showed that mothers' knowledge of ARI had increased markedly after the intervention, and that the new information had also spread to neighbours.

2. Levels of knowledge can be raised, but this may have little or no effect on behaviour, particularly preventive behaviour. Efforts to control tobacco use are a prime example, as are the following experiences from various AIDS interventions.

Sexual behaviour. This seems to be one of the most difficult forms of behaviour to modify. Typically, educational campaigns show an increase in knowledge about AIDS and sexually transmitted diseases (STDs), but a very slow increase, if any, in condom use as a means of prevention. In Ghana, after a campaign using TV, radio, comic books, badges and T-shirts, and school outreach, knowledge of the incubation period of HIV to AIDS rose from 9 per cent to 26 per cent, while condom use at last sex rose from only 14 per cent to 23 per cent. In the Rakai district of Uganda, where HIV prevalence among persons over 13 years old ranged, in 1992, from 12 per cent in rural areas to 33 per cent in the trading centres, surveys showed very little misconception about the modes of transmission of HIV, but preventive attitudes and behaviours were highly resistant to change. Even where, as in Cote d'Ivoire, over a third of the men understood that condoms are protective, less than 10 per cent reported regularly using them. In country after country, AIDS workers have found that learning about modes of HIV transmission and about methods of prevention is simply not enough to make any significant impact on the epidemic.

New information is integrated into socially meaningful but not necessarily scientifically valid contexts. Again, AIDS experiences illustrate this point.

In biomedical terms, HIV is a virus, transmitted by the exchange of blood or sexual fluids, that gradually weakens the immune system, leading to the syndrome known as AIDS. It is a slow virus, and people look and feel healthy for a long period during which they can transmit it. To many people in Africa, AIDS is a disease of foreigners, of tourism, and loose Western morality, transmitted through sex with unclean people or, increasingly, with people from known areas of high prevalence. Invariably, and in every country, people think AIDS is a disease of “the other”, which is synonymous with a disease of immorality. Thousands of men and women reconstruct the messages of safer sex according to their own needs, e.g. it is safe if you wash well after sex, or if you complete the sex act quickly, or if you have “negotiated” a trusting relationship, or if you know your sexual partner fairly well. In other areas, although basic knowledge of AIDS is high, the apparent inconsistency of the spread of infection reinforces ideas that only persons with susceptible blood or those attacked by witches will acquire the disease. Sadly, as the disease spreads, none of these concepts or precautions is sufficient to prevent transmission. These concepts and many others are widely accepted as true because they make social sense, not because they fit the known scientific facts about HIV.

3. Action is determined not only by knowledge, but also by situational and structural factors. In other words, programmes aimed at modifying (health) behaviour must take into account not only pre-existing knowledge systems, but also possible limitations to behaviour change imposed by, for example, a poor economic situation or lack of infrastructure. The following two examples drawn from different countries underscore this principle.

Papua New Guinea. In a community-based treated bednet project, village women sewed bednets from rolls of netting, treated them, and sold them to members of surrounding communities. Evaluation surveys conducted in these communities showed the greatest constraint on buying these nets was lack of cash. When garden crops were ready for marketing, bednet sales increased. Persons with year-round cash incomes were the most frequent buyers.

The Gambia. The introduction of home-based rehydration solutions for use among children with diarrhoea was a successful project. Evaluation studies showed that 85 per cent of mothers knew something about preparing it and 61 per cent reported having used it during the last bout of diarrhoea. When the data from the evaluation study were analysed according to whether the mother came from a developed community (having a paved road, health centre, school and foreign-aid project) or an undeveloped one, it was found that in the undeveloped areas only 58 per cent had used the solution compared to 80 per cent in the more developed areas, even though knowledge of the solution was equal in both types of area. This finding supports the idea that community-level structural factors also condition the move from knowledge to behaviour.

Facilitating behavioural change means lifting situational and structural constraints. This is demonstrated by the all-condom policy in brothels in Thailand.

Lifting constraints. Brothel workers were unable to refuse customers who would not use condoms because brothel owners take a percentage of money paid for sexual services. Despite prostitution being technically illegal in Thailand, meetings were held between police, local government officials, and brothel owners. An all-condom policy was introduced to all sex establishments simultaneously in the area and those who did not comply were threatened with fines and possible closure. They were also informed as to how they would be monitored. Within a short period of time after the policy's introduction, the number of condoms used by sex workers increased nearly fourfold and the incidence of STDs decreased dramatically.

4. Individuals act, but their actions take place within social contexts in which other people's evaluations of them matter. The following example from Ecuador illustrates this principle.

Immunization. During the mid-1980s, a large-scale mass mobilization for immunization took place in Ecuador. Promotion was continuous and mass vaccination days were implemented. Evaluation showed that immunization coverage had doubled in an equitable manner, reaching poor and inaccessible populations. The probability that a mother would vaccinate her child was linked more strongly to the behaviour of her peers than to any other variable - including her level of education, wealth or knowledge about vaccination.

Changing people's behaviour over the long run means changing community norms. This is shown in the following example from Thailand.

HIV prevention. In an HIV-prevention project among male sex workers in Thailand, an experiment was designed for bars, dividing them into two groups - intervention bars and control bars. In both groups, condoms and lubrication were distributed free. In the intervention bars, educational materials were provided and special workshops conducted. In the control bars, information brochures only were distributed. In the evaluation, positive attitudes towards condoms and actual condom use increased more in the control than the intervention bars. Why? From in-depth discussions with bar workers and owners, it was discovered that bar owners in the control group had actively reinforced condom use by pushing the workers to carry condoms, reminding their customers to “play it safe” and allowing the workers to refuse customers who would not use condoms. These innovations had not been part of the intervention strategy in the experimental bars and occurred less often. In the small sub-culture of bar workers, owners are important people and occupy roles similar to elders in family-based communities. Their acceptance and promotion of condom use provided an important boost towards safer sex practice.

5. Sustained behavioural change may require continuing input of new ideas and support. This principle is supported by the experiences described below.

Aid agencies. For many years, international aid agencies have been funding various interventions of one- to three-year programmes. Very few have extended their funding beyond that, although assessments of these programmes, even by their own personnel, recommend longer-term funding. “Short-lived campaigns are ultimately ineffective and can be harmful”, states one evaluation document. Many programmes advocate institutionalizing their activities, in the hope that this will lead to sustainability

AIDS interventions. In this field, awareness has risen rapidly that continuing evaluation and refinement of communications for behaviour change are essential. Any type of behaviour-change programme will require continuing input and support because, as time passes, motivation for the newly adopted behaviour often declines, the costs of making the change begins to outweigh the perceived benefits, and environmental factors may shift, making the altered behaviour unrewarding. There must be a continuing process of evaluation in which change agents, targeted community members, programme managers, and funding agencies participate. A reminder from those in social marketing: Soft drink companies never stop advertising.

Practical steps in promoting hygiene behaviour change

Hygiene behaviour change requires using the above principles, applied to the specific issues concerning sanitation in the target community. How can this be done? Read through the following steps, considering the type of personnel needed to carry out this programme. If there are experienced development agents in the area, these agents may have the skills in basic research, and in facilitating community discussions and decision-making. If these do not exist, they may have to be introduced from outside the area. If visual media or other types of media are to be produced, specialists may have to be employed. After reading these steps, make a list of the personnel available and required for your hygiene behaviour-change project. Ultimately, however, the people themselves must perceive a problem or need, decide on a solution, and change their practices.

Understand what people do now and why

Some type of research is required to understand the community's existing systems of beliefs, values, and practices. This can be conducted in a variety of ways, with questionnaire surveys (quantitative methods), observations, open-ended interviews, and group discussions (all qualitative methods). Utilizing methods that bring community members into the research process is always best. Wherever possible, local persons should be hired as research assistants. An outsider may be necessary as a consultant to design and organize the work and to analyse and write a report. Reports should also be produced in such a way as to be presentable to the community members. The research should answer basic questions, such as:

· What do the people believe causes diarrhoeal diseases? What are the terms used to describe these?

· How do they think such diseases are transmitted?

· How and where do people (adult men, adult women, children, and babies) now defecate?

· What are the existing hygiene practices (e.g. handwashing, personal bathing, and anal cleansing)? What proportion of people do what?

· How are babies cleaned after defecation? What happens to their faeces? Are these considered dangerous?

· Are human faeces present in the environment (e.g. near houses, in fields, or around the toilet)?

· In the local belief system, are human faeces linked in any way to the development of disease?

· What are the best ways to spread information in the community?

Develop the behaviour-change project jointly with the community

Collaborating with community members, via a series of brainstorming sessions should help determine how exposure to disease could be reduced through improved sanitation. New concepts of disease causation may have to be presented for consideration. Possible behaviour changes must be seen as beneficial in some way, and not necessarily simply in terms of improving health. Since behaviour changes incrementally, it is important to allow people themselves to decide what can be done in the first instance. They should assess the following:

· Are existing toilet facilities conducive to improved sanitation behaviour?

· How might they be altered?

· What are the differences in facilities and usage for men and for women?

· If the risks are strictly behavioural, what are they?

· Would handwashing alone, several times a day with an agent (soap, mud, etc.) be an acceptable behavioural goal?

· What would be needed to facilitate such a change?

Take a gender-sensitive approach

In every discussion, be certain to have men and women, boys and girls, present and contributing. Do not let local health workers or teachers dominate the discussion. If some groups, e.g. youngsters, have trouble speaking up in front of adults, suggest they stage a play to express their opinions. Raise issues related to gender for people's consideration.

Address the real perceived needs of the people

Develop a list of the needs as perceived by the people in order for change to come about. These might be structural, financial, social, or educational.

Make use of all available resources

Decide which of these needs can be met with available resources and which ones are essential, but require resources not yet available. Consider all options. Work with what is available and consider ways to acquire new resources. Maintain a few basic environmental health principles, e.g. if new sanitation methods are adopted, they must not contribute to further environmental pollution.

Make educational messages simple and accessible

Decide on a few important messages for an educational campaign and the channels for spreading these messages that best fit the community. Use as many affordable channels as can be included. To decide which ones to use, you need information on:

· How many households have radios or TV?
· What proportion of men and women are literate? In what language?
· Where do people congregate?
· Are there organizations, e.g. women's groups, youth clubs, in the community?
· Who could act as change agents? Educated youngsters? Respected elders?

Listen to the people

Let community members explain how best to deal with what appear to be cultural or simply local constraints, e.g. the inability of women to go alone to a toilet house.

Transfer skills by doing, not just talking

Carry out the campaign using local, trained change agents, and other information channels as appropriate. Include, wherever appropriate, the learning of new skills by demonstrating and doing them. Develop media with local people's help and test before using them.

Evaluate your work

Conduct a qualitative evaluation shortly after starting the campaign to identify unforeseen problems and make adjustments. Later, conduct a more thorough quantitative evaluation of the number of people exposed to new information, improvements in knowledge, and reported behaviour changes. If at all possible, conduct discreet observations (or let local children do this) to confirm reported behaviour changes.

Keep the community involved

Feed the results back to the community. Reward it for whatever positive changes have taken place with a celebration or other appropriate event. Find local helpers to keep up the good work. If needed, move into a second phase to incorporate additional changes.

Creating successful projects

Information on methodologies for achieving successful hygiene behaviour-change programmes, such as participatory approaches and child-to-adult approaches, are available from a number of publications documenting experience in several countries (1, 2).

To assist programme planners, a Checklist for planning hygiene behaviour-change in sanitation projects has been included in this book.


(1) Boot MT and Cairncross A. Actions speak: the study of hygiene behaviour in water and sanitation projects. The Hague, The Netherlands, IRC, 1993.

(2) Simpson-Hrt M, Sawyer R, Clarke L. The PHAST initiative: participatory hygiene and sanitation transformation: a new approach to working with communities. Geneva, World Health Organization, 1996 (unpublished document WHO/EOS/96.11).

Background Reading

Academy for Educational Development and the Annenberg School for Communication. Results and realities: a decade of experience in communication for child survival. A summary report of the Communication for Child Survival or HEALTHCOM Project. Washington, DC, USAID, Bureau of Research and Development, Office of Health, 1992.

Bateman OM. Sanitation and family education (SAFE) pilot project. Report on the baseline survey. Bangladesh, CARE, 1993.

Caprara A et al. The perception of AIDS in the B and Baoulf the Ivory Coast. Social Science and Medicine, 1993, 36:1229-1235.

CARE (Bangladesh). Don't just say it, do it! Issues for consideration when planning for behavior change in hygiene education programs. Bangladesh, CARE, 1995.

Hornik R. The knowledge-behavior gap in public information campaigns: a development communication view. In: Salmon C, ed. Information campaigns: balancing social values and social change. Sage Annual Review of Communication Research, Vol. 18. Newbury Park, USA. p. 113-138, 1989.

Konde-Lule J, Musagara M, Musgrave S. Focus group interviews about AIDS in Rakai District of Uganda. Social Science and Medicine, 1993, 37:679-684.

Mercer M, Mariel C, Scott S. Lessons and legacies. The final report of a grants program for HIV/AIDS prevention in Africa. Baltimore, Md, The Johns Hopkins University, School of Hygiene and Public Health, Institute for International Programs, 1993.

Nzioka C. Lay perceptions of risk of HIV infections and the social construction of safer sex: some experiences from Kenya. AIDS care, 1996, 8(5):565-580.

Simpson-Hrt M, Yacoob M. Guidelines for designing a hygiene education program in water supply and sanitation for regional/district level personnel. WASH Field Report No. 218. Washington, DC, USAID, Bureau for Science and Technology, Office of Health, 1987.

Sittitrai W, Phanuphak P, Roddy R. Male bar workers in Bangkok: an intervention trial. Thai Red Cross Society, Bangkok, 1994, (Research Report No. 10).

Smith W et al. A world against AIDS. Communication for behavior change. Washington, DC, Academy for Educational Development, 1993.

van Wijk C, Murre T. Motivating better hygiene: report for public health mechanisms of change. UNICEF, The Hague, The Netherlands, IRC, 1995.

Zeitlyn S. Sanitation and family education (SAFE) pilot project. Report on the qualitative assessments. Bangladesh, CARE, 1994.

Participatory approaches to community empowerment - John Odolon1

1 Network for Water and Sanitation (NETWAS), Entebbe, Uganda.

Failure of traditional sanitation programmes

Water is perceived as a community need, but sanitation is seen as a household problem, requiring individual attention. People are happy to talk about water but not about sanitation. In the past, water and sanitation programmes have found it easier to rally support by emphasizing the need for water. The sanitation aspects of programmes are often neglected or unsuccessful.

There is clearly a need for programmes to deal specifically with sanitation. What type of programmes should they be? Traditional approaches to promoting sanitation have failed. One notable example is the use of the law to solve sanitation problems. This approach has only served to alienate communities from sanitation benefits.

Educational methods for passing on information on sanitation, using the classroom, are essentially teacher-centred, leaving community members only on the receiving end and with little chance to put forward their own suggestions of how things might work better. Many extension workers still use this approach, albeit with poor results. “Education” and “communication” are not synonymous - effective communication is a two-way process of exchange.

Home-improvement campaigns through competitions were popular until recently. In this approach, the standard of cleanliness was raised and the number of clean homes increased, but the effect was very short-lived, since the campaigns' objective was simply to win a prestigious position. Once the campaign was over, the standards of hygiene and sanitation dropped, and the effort was not sustained.

In all the above cases, there was little community member involvement in deciding what approach would bring the best possible results and in following the progress of sanitation interventions. This realization has led to the adoption of approaches that recognize and allow the optimal use of valuable community attributes, namely, self-esteem, associative strengths, responsibility for decisions made and actions taken, resourcefulness, and the capacity for being action-oriented.

Programmes have sometimes wrongly assumed that communities would make monumental changes in their way of life as a result of programme inputs. Experience has shown that it is important to recognize the advantages of making small incremental changes, and building on successes that have been achieved through participatory effort.

Benefits of participatory approaches

Where participatory approaches have been used, beneficiaries have expressed a feeling of empowerment - they have moved from just being recipients of services to becoming decision-makers, helping to chart out the course of development in their localities, and sharing the responsibilities associated with implementing interventions.

Participatory approaches in sanitation allow community members to see where they are in terms of the facilities available (technological options) for excreta disposal. Community members are also able to identify the next (better) stage they wish to reach. They are able to discuss openly what hinders them from attaining that stage and to suggest how obstacles can be overcome.

Bringing to light the needs of often marginalized community groups, such as women and children, is not easy if there is no avenue or forum that will cater to the special needs of these groups. Decisions affecting them are often made to their disadvantage. Participatory approaches that are sensitive to factors such as gender, educational status, and income allow disadvantaged groups to contribute. Because of the investigative nature of participatory approaches, community members acquire much useful data from around them and new information is brought in by extension workers. This helps to expand the knowledge base at the community level. The participatory tools and techniques encourage creativity which facilitates the acquisition of necessary skills for implementing interventions. Examples of skill areas include construction, proper use of handwashing facilities, and communication of health messages to other community members.

Desirable hygiene behaviour, the objective of hygiene and sanitation programmes, can seldom be enforced. It can be achieved far more successfully by using participatory approaches. People will wash hands after using the latrine or after handling children's faeces if they have participated in identifying the potential hazards associated with human excreta and understood the unhealthy behaviours that cause contact with it.

Costs of using participatory approaches are comparatively low, since the resources used are largely available within the community. No complicated equipment need be bought and illiteracy is not a hindrance.

Although participatory approaches have been considered time-consuming, the overall benefits and savings to sanitation programmes have been tremendous, making the time a good investment.

Since participatory approaches place people first, they should result, if conducted well, in self-determination and acceptance of responsibility for sanitation improvements.

What are participatory approaches?

Participatory approaches empower communities by bringing about awareness and understanding, as well as a sense of ownership, leading to sustainable change.

The keyword in participatory approaches is “participation” - getting community partners in development programmes to take active roles in identified activities, such as decision-making for planning and implementation.

The following assumptions are commonly made about participation, the focus in each case being the enhancement of the people's capacity to handle development issues.

· Labour contributions increase people's identification with the system being built - people will take pride and maintain the system since they have contributed physical effort.

· People are willing to part with resources as an investment in maintaining the facilities - communities will value the facilities as their own and therefore contribute to their maintenance.

· There is a need to establish a local infrastructure to manage and sustain facilities, with special focus on local leadership, formation and use of committees, and training of local artisans for maintenance work, with the roles and responsibilities of each outlined in a formal agreement or contract.

Projects based on the above assumptions are not necessarily successful, however. From lessons learned, the following additional assumption has gained momentum:

· A broad cross-section of the community needs to be involved in the decision-making process from the outset. At the same time, participatory community education must be undertaken. Women's involvement in both is a key factor.

Participatory approaches aim to achieve the following:

- local support for programmes, including the involvement of local leadership;
- voluntary generation of ideas and interventions by community members;
- ownership of programmes by community members;
- participation in decision-making by disadvantaged groups in society, particularly women;
- community organizational structures for the management of interventions;
- integration of activities - hardware and software;
- an educational process to generate and sustain participation;
- the removal of obstacles to collaboration: attitudes, beliefs, and behaviours; and
- the training of local community animators.

The unique difference between participatory and other approaches is that participatory approaches are non-directive. When participatory approaches are applied to hygiene behaviour change and sanitation, the following aspects are emphasized especially:

- guiding community members to make their own decisions;
- enabling communities to seek and generate their own information for decision-making;
- promoting self-direction and self-reliance, through a shared sense of ownership;
- helping communities to monitor and review their own progress;
- enhancing community resourcefulness;
- letting the community decide the time-frame and pace of activities; and
- overcoming uncertainty through experience and success gained over time - learning by doing.

Factors that contribute to successful application of participatory approaches

Full community participation can be realized using participatory approaches. The following factors contribute to their success.

· Advocacy is necessary to create an enabling institutional environment (e.g. an umbrella government department) with the requisite support structures.

· Policy-makers have to be involved as they decide on the strategies for programme implementation; their involvement will help secure their support for the use of participatory approaches.

· Participatory approaches have to be institutionalized in key government ministries, such as health, gender, local government, and water.

· The use of participatory approaches in sanitation programmes needs to be effectively promoted to ensure their acceptance by decision-makers.

· It is advisable to start with a small pilot project and use it as evidence of how effective the approach can be, to convince others in senior positions that they should expand the programme.

· Social aspects, including gender and educational status, have to be considered.

· The availability of resources needs to be ensured, including funds, persons trained in the use of the approaches, participatory tools, and other support materials.

· Providing back-up support for those involved in the programme is good for building up confidence and making them more familiar with the approach.

· A realistic time-frame is needed to build up capacity to adapt and use the approach.

· It is important to establish, from the outset, a monitoring and evaluation mechanism to ensure the correct direction.

Examples of participatory approaches

Many types of participatory approach have evolved over time. Each is designed to enhance participation through meaningful decision-making, planning, implementation, and monitoring and evaluation of activities. Participatory approaches are sensitive to existing situations. They draw answers out of communities, rather than attempting to impose preconceived solutions.

Three examples of participatory approaches are described below.

PHAST - Participatory Hygiene and Sanitation Transformation (1)

This innovative approach to promoting hygiene, sanitation, and community management of water and sanitation facilities is adapted from the SARAR (see below) methodology of participatory learning, which builds on people's innate ability to address and resolve their own problems. PHAST aims to empower communities to manage their water and to control sanitation-related diseases by promoting health awareness and understanding which, in turn, lead to environmental and behavioural improvements. This approach is being jointly developed and promoted by WHO, UNDP-World Bank and UNICEF. It has been piloted in Botswana, Kenya, Uganda, and Zimbabwe.


SARAR,2 the participatory methodology on which PHAST is based, has proven effective in enabling people to identify their problems, plan for change, and implement and monitor that change. SARAR is based on the idea of participatory development. It assumes the following.

· Personal involvement in decision-making is the root of real long-term commitment to change.

· People closest to the problem are the best ones to find the solution.

· Self-esteem is a prerequisite to decision-making and follow-through.

· Sustainable learning takes place best in a group context, which contributes to a normative shift.

· Learning should be fun.

2 SARAR stands for Self-esteem, Associative strengths. Resourcefulness, Action-planning and Responsibility.

SARAR3 was developed during the 1970s and 1980s by Dr Lyra Srinivasan and colleagues for a variety of development purposes. The major work describing the methodology for the water and sanitation sector is entitled Tools for community participation: a manual for training trainers in participatory techniques (2).

3 This approach has been used by the Promotion of the Role of Women in Water and Environmental Sanitation Services (PROWWESS) programme run by the UNDP-World Bank Water and Sanitation Program,

PRA - Participatory Rural Appraisal (3)

PRA is a participatory methodology that seeks to establish rapport with community-level beneficiaries. By so doing, the approach brings community members together, catalyses ideas, enquires, allows for choice, adaptation and improvements in implementing interventions, and enables participants to watch, learn, and listen.

It is a semi-structured, multidisciplinary approach, using various tools, that can be adapted to different situations. It is based on an earlier approach known as Rapid Rural Appraisal (RRA), which was mainly used to obtain information quickly, with little community involvement, so as to build up a profile of communities.

Information on participatory approaches can also be found in the following articles: Promoting sanitation through community participation in Bolivia, and Strengthening a rural sanitation programme using participatory methods in Uganda.


(1) Simpson-Hrt M, Sawyer R, Clarke L. The PHAST initiative: participatory hygiene and sanitation transformation, a new approach to working with communities. Geneva, World Health Organization, 1996 (unpublished document WHO/EOS/96.11).

(2) Srinivasan L. Tools for community participation: a manual for training trainers in participatory techniques. New York, UNDP, 1990, (PROWWESS/UNDP Technical Series Involving Women in Water and Sanitation).

(3) SDC. Participatory rural appraisal (PRA): working instruments for planning, evaluation, monitoring and transference into action (PEMT). Berne, Swiss Directorate for Development Cooperation and Humanitarian Aid, 1993.

Background reading

Srinivasan L. Option for educators: a monograph for decision makers on alternative participatory strategies. New York, PACT Communications Development Service Inc., 1992. (PACT can be contacted at: 777 UN Plaza, New York, NY 10017, USA.)

Pretty JN et al. A trainer's guide for participatory learning and action. London, International Institute for Environment and Development (IIED), 1995 (Participatory Methodology Series).

Other documents consulted

Cairncross S. Sanitation and water supply: practical lessons from the decade. UNDP/World Bank Water and Sanitation Program, Washington, DC, World Bank, 1992 (Water and Sanitation Discussion Paper Series DP Number 9).

LaFond A. A conceptual framework for sanitation and hygiene behaviour programming. Working paper, Arlington, VA, USAID Environmental Health Project, April 1995.

Sustainability of water and sanitation systems. Conference proceedings, 21st WEDC Conference, Kampala, Uganda, Loughborough University, UK, 1995.

The IDWSSD and women's involvement. Geneva, World Health Organization, July 1990.

UNDP/World Bank Water and Sanitation Program. Annual report, Washington, DC, World Bank, July 1994-June 1995.

Wakeman W, et al. Sourcebook for the gender issues at the policy level in the water and sanitation sector. Washington, DC, UNDP/World Bank Water and Sanitation Program, Water Supply and Sanitation Collaborative Council, 1996.

Working with communities. Nairobi, UNICEF Eastern Africa Regional Office (Community Development Workers Training Series Number 2).

Participatory monitoring and evaluation of sanitation projects - Jennifer Rietbergen-McCracken1, Sara Wood2 and Mayling Simpson-Hébert3

1 Independent consultant, Geneva, Switzerland.

2 WHO Consultant, Geneva, Switzerland.

3 WHO, Geneva, Switzerland.

This article introduces participatory approaches to the monitoring and evaluation of sanitation projects, drawing on the rapidly expanding literature available on this subject. It offers practical guidance on how to integrate participatory monitoring and evaluation (PME) into ongoing sanitation programmes and presents examples of innovative PME efforts in the sanitation sector. You are encouraged to take those elements of the PME approaches described here which fit your particular sanitation project, and to decide how best you could incorporate these components into project design and management. The list of references at the end of the article includes a number of manuals which can help you learn about different participatory techniques for monitoring and evaluation (m&e) purposes. You will also find some information on participatory methods in Participatory approaches to community empowerment and A gender perspective in sanitation projects.

Participatory monitoring and evaluation can be defined as:

“a process of collaborative problem-solving through the generation and use of knowledge. It is a process that leads to corrective action by involving all levels of stakeholders in shared decision making” (1).

Monitoring generally refers to the routine checking of progress throughout the life of a project, while evaluation usually means occasional assessments at important stages of the project, such as expansion into new areas, or completion. However, the distinction between these two components is less evident in PME since PME is often a regular procedure undertaken throughout project implementation.

New approaches to monitoring and evaluation in the sanitation sector (2)

For many years the monitoring and evaluation of sanitation projects focused on purely numerical targets, such as the number of facilities installed, or public health impacts, which are notoriously difficult to attribute directly to sanitation interventions. These early assessments were therefore very limited in scope and the results often inconclusive. More recently, attention has turned towards the need to ensure that sanitation efforts are sustainable - not only in terms of maintaining the installed facilities but also ensuring that their users are empowered with the necessary information and sense of ownership to effectively use and manage those facilities. This new emphasis has meant that m&e efforts have changed to incorporate more participatory methods (with local communities playing a larger role in the design and management of sanitation projects), and to use indicators of behavioural change as surrogates for health impact indicators. Indicators of users' behavioural change (such as taking water from a tap rather than the stream, washing hands after defecation, reporting breakdowns to the local technician, etc.) are fairly easy to observe and can help evaluators assess whether the preconditions for health improvements are being met.

Why monitor and evaluate sanitation projects?

A process of monitoring and evaluation (m&e) can strengthen sanitation projects by (3):

- revising and fine-tuning the initial design of the programme to take into account new priorities and opportunities;

- recognizing and reinforcing successful activities to encourage those responsible and keep up momentum;

- ensuring that the programme remains tuned to community needs, and

- informing decision-makers about realities at the local level to help them modify policies where needed.

Different approaches to monitoring and evaluation

In conventional projects, detailed blueprint plans are produced at the beginning of the project and then used to implement project activities within the specified time-frame. Evaluations are usually conducted by outside experts at various stages during implementation and upon completion. The data needed for evaluation is also collected by outside experts and tends to be highly scientific, systematic and quantifiable. It is unlikely to be made publicly available, and would not be widely understood if it was.

Blueprints cannot be drawn up for participatory projects, however, since in these projects the community designs and develops its own plan - which reflects its individual needs and priorities - over a period of time. Accordingly, no two plans will ever be completely the same. (The differences between conventional evaluation and participatory evaluation are summarized in Table 1.) Moreover, a different style of monitoring and evaluation needs to be adopted in order to be consistent with and provide support for people's involvement (see Box 1).

Table 1. Comparing conventional and participatory approaches to evaluation

Conventional evaluation

Participatory evaluation


External experts

Community members, project staff, facilitator


Predetermined indicators of success, principally cost and production outputs

People identify their own indicators of success, which may include production outputs


Focus on “scientific objectivity”; distancing of evaluators from other participants; uniform, complex procedures; delayed and limited access to results

Self-evaluation, simple methods adapted to local culture; open immediate sharing of results through local involvement in evaluation processes


Usually upon completion; sometimes also mid-term

Merging of monitoring and evaluation; hence frequent small evaluations


Accountability, usually summative, to determine if funding continues

To empower local people to initiate and control corrective action

Source: (1).

Box 1. Avoiding inappropriate blueprints

Decision criteria adopted by engineers are all too often based on previous similar projects, rather than developed for specific project conditions. To avoid this problem, a water and sanitation project in Ethiopia started with a participatory evaluation of hygiene practices, and in-depth evaluation of the ability of the local population to pay for water used. The end result was a project which met the individual needs of the different communities being served by providing each with the appropriate amount of water at required locations, using a realistic combination of house connections, yard connections, and public fountains. The evaluation also revealed problems that the project needed to address. For instance, the evaluation team noted that a public water standpost attendant in one town was very arrogant towards water users and neglecting his duties, in effect reducing water availability by about 25 per cent.

Source: (4).

Participatory approaches

Clearly, participatory approaches to monitoring and evaluation involve a wide range of stakeholders (i.e. those with a potential interest in the project), among them at least some of the following groups:

- community members - including those not involved in the project as well as active users of the project services;

- project staff working at all levels;

- staff of other similar projects and programmes in the area;

- high-level supporters and policy-makers who may be interested in the results of the PME work, and

- outside evaluation facilitators whose role is to help guide the process and bring an element of objectivity.

The PME approaches described in this article focus particularly on the first group - community members - since it is this group which is most often excluded from conventional evaluations, and which has a major contribution to make (see Box 2).

Box 2. Rural women responsible for monitoring

As part of a participatory monitoring and evaluation system for a rural water supply and sanitation project in Nepal, facilitators asked women in communities to list indicators of good sanitation practices in the home. The women created a “healthy home” profile which listed good sanitation practices to look for, and then visited each other's houses to check whether these practices were in fact followed. The women clearly enjoyed this activity and the technique proved to be both a valuable motivational tool and a monitoring aid, and was even used by women in several communities where the project was not operating.

Source: (5).

Of course, some sanitation projects may benefit from application of both types of m&e, or a combination of the two: occasional conventional, outsider-led evaluations (for example, when there is a need for specialist expertise), and regular participatory assessments to provide continuous feedback. Participatory assessments can take the form of:

- review workshops which bring project staff of all levels and community representatives together to discuss the performance of the project and to seek ways of improving it;

- field-based participatory assessments which involve community members and other stakeholders directly performing their own analyses of the project, assisted by trained teams of facilitators; the results of these assessments may be presented as “evidence” to review workshops;

- self-evaluations which are a particular type of assessment whereby community members rate themselves and consider the impact of the project on their own lives; again these analyses are facilitated by trained teams.

In any type of PME activity, the local people and other stakeholders are given an active role in the process. They are not just consulted as potential sources of information but given the primary responsibility of collecting and analysing the information that they have decided is important.

A participatory approach to m&e is particularly relevant (6):

- if the project concerns “social development”;
- if objectives are continually evolving;
- if one of the main aims is to enable groups to develop organizational capacity;
- if the active participation of different groups is essential for the success of the work.

Since sanitation projects - perhaps more so than any other type of project - have exactly these kinds of characteristics, PME activities should be regarded as critical to their success.

Benefits of participatory monitoring and evaluation

By actively involving local people in monitoring and evaluation, participatory approaches not only enhance the quality of the work but also bring important benefits to local people themselves, since they get a chance to learn more about the project, analyse their own performance as well as that of other stakeholders, and to suggest improvements in project design or policies. Additionally, since their investigative and analytical skills will become strengthened during the process of PME work, they will be better able to take a more active role in the future management of the project. The benefits of using participatory approaches in monitoring and evaluation can be summarized as (6):

- increased relevance: community involvement helps ensure that evaluation focuses on issues of real concern and takes into account the different perspectives of those familiar with the day-to-day aspects of the project;

- improved access: the results of participatory evaluations are more readily available and understandable to local people, and therefore more open to scrutiny by those who will be affected by the project;

- heightened sense of ownership: people will be more committed to follow-up action if they have participated in the m&e work;

- increased sustainability: all of the benefits listed will increase the sustainability of a project as a whole since the different stakeholders have worked together in reviewing the project and recommending ways of improving it.

Box 3 describes how some of these benefits were realized in a participatory assessment in an urban sanitation project. The benefits of participatory approaches to m&e greatly outweigh their limitations (or “costs”) which may include (6):

- a slower process, because of the need to bring the different stakeholder groups together and to provide them with basic training in PME techniques;

- less objectivity, as local people are personally involved in the project and may find it difficult to take a neutral stance;

- limited capacity to use specialized analytical techniques such as cost-benefit analysis.

The latter two limitations can be addressed by combining PME with more conventional evaluations involving outside experts. The time costs can be seen as a long-term investment and must be budgeted for in the planning of a PME activity.

Box 3. Community members rethink an unsuccessful project, India

In Hodal, Haryana, in India, an urban sanitation project was failing to generate any demand for pour-flush latrines. The project team could not understand why the “beneficiaries” even went so far as to destroy demonstration latrines. A participatory assessment was initiated in eight wards to try and uncover the problem. Community members were asked to identify local sanitation problems as they saw them. They listed nearly twenty problems, including a leaking water tower that had been built by corrupt contractors and which was now flooding the streets. An artist drew pictures of all the problems listed by the community, and in subsequent sessions facilitators asked local people to sort the cards into three different piles according to who was responsible for solving these problems: households, local government, or both together.

This assessment evoked a strong response. At first, some participants said officials from the state government should do everything because they had all of the control. But during continuing debate, many people stated that most of the problems were a joint responsibility. Amidst a great deal of anguish it emerged that the community was angry that the project had been planned without its input, and pointed in particular to the picture of the water tower built by the corrupt contractor. Now they felt forced to build latrines in their households using government contractors over whom they had no control. By the end of the community discussion sessions, people had started providing ideas on how they could carry out the project, identifying the alternatives of hiring their own contractors or doing the work themselves.

The three-week participatory assessment became the basis for systematic action planning in the community, which led to a new project strategy. The project was renamed the People's Latrine Program of Hodal and the state government agreed to let the community try its own approach. Over 500 applications for loans for the latrines were received during the first three weeks following the assessment.

Source: (7).

Prerequisites for successful participatory monitoring and evaluation

It is not worth undertaking PME unless some basic conditions are met to ensure that the results will be translated into improvements in the projects and policies involved. In the absence of at least a willingness to create these conditions, PME can actually do more harm than good, by raising the expectations of local people who take part in the m&e work and making it more difficult to enlist their support for any future participatory activities. You might like to ask yourself the questions in Box 4 to see whether your project is “ready” for PME.

Box 4. Is your project ready for PME?

The following questions can help you assess whether your project is ready to use participatory approaches in its m&e work.

· Does the project currently operate in a participatory manner? Are local people actively involved in planning the sanitation activities? Are communities given responsibility for deciding how the project is managed at the local level?

· Is there already a commitment to local capacity-building within the project? Are local staff and community members given the chance to learn new skills?

· Is there any flexibility built into the yearly planning and budgeting process? If new ideas for improving sanitation emerge from participatory m&e work with communities, would it be possible to react quickly to support implementation of them?

· Would it be possible to set aside sufficient time, and human and financial resources to undertake PME?

· Do communication channels exist to enable information about the project to flow from local level staff and communities to senior managers and policy-makers? Are there any opportunities for local people - ordinary men and women as well as leaders - to provide feedback on the performance of the project?

· Are the project managers open-minded when provided with feedback from the field? Would they be likely to take seriously the results of PME work? Are the project engineers willing to discuss technical details and other issues with local people?

These questions are best answered by bringing project staff of all levels together at informal discussion workshops. A wealth of simple techniques is available to help staff examine these institutional questions in a non-threatening manner and to help sensitize staff to the need for participatory approaches. See, for example, Srinivasan (8).

This is not to say that the project needs to be a perfectly functioning participatory operation. Indeed, PME has been used effectively to create the initial momentum for reorienting previously top-down projects towards more participatory approaches (see Box 5). Moreover, senior managers who have been very sceptical of local people's ability to analyse and plan development activities often become the strongest advocates for participatory work when provided with the results of community-led assessments. However, it should be stressed that participatory approaches to monitoring and evaluation are much more likely to succeed when incorporated into project design from the beginning. Conversely, PME efforts undertaken at an advanced stage of a conventional project require a great deal of energy and perseverance.

Box 5. Participatory workshop helps reorient a water supply project in Kenya

A rural water supply project in Kenya was suffering from a rush to install the infrastructure among communities before they had been prepared adequately for their role in its operation and maintenance, and organization of its use. To address this problem a participatory workshop was held to bring together senior planners and extension workers. A facilitator divided the participants into mixed groups and assisted them in a card-sorting exercise which consisted of creating an ideal sequence of activities for a hypothetical project, including integration of the “hardware” and “software” activities (i.e. the activities related to building infrastructure and the activities related to people). As the exercise progressed, and the planners realized the importance of community mobilization and capacity building, their attitudes changed visibly. This was reflected in a subsequent reorientation of the project with more resources going to community preparation. In the reoriented project the arrival of the drilling rigs in the villages was dependent on a signal from the extension workers that the communities were organized and ready.

Source: (7).

What to evaluate in sanitation projects

Deciding the exact topics to investigate in any PME activity is best done in collaboration with local people and other stakeholder groups, to ensure their agreement on the scope of the evaluation. Here are some good rules of thumb to follow in deciding what to measure (9):

- measure progress towards meeting objectives - if it was worth setting an objective, make sure you can measure how well that objective has been accomplished;

- measure only those things that will give needed information - don't waste time collecting statistics which will serve no useful purpose;

- concentrate on those indicators that have the most potential to help redirect activities - i.e. what information will be most useful in making decisions concerning the project;

- use proxy indicators where direct measurement of important factors seems impossible or prohibitively costly - i.e. measure something that seems close to the information sought (see Box 6), and,

- balance the need to know with the ability to find out - attempt to measure only what is feasible with the skills and resources available.

To be both feasible and meaningful, evaluations of sanitation interventions must go beyond measuring the achievement of immediate objectives (such as counting the number of facilities installed), but stop short of trying to assess achievement of long-term objectives (i.e. trying to prove ultimate health impacts, as mentioned above). So intermediate goals need to be identified - the evaluation then focuses on the extent to which these have been achieved. The most important intermediate goal of any sanitation project is to achieve sustainable results. In brief, sustainability requires both equitable and effective use of sanitation facilities to generate lasting benefits for the communities involved, and environmental protection to avoid depletion or degradation of resources. So sanitation projects need to evaluate three broad aspects:

Box 6. Local people select water quality indicators

Village women and men in Indonesia identified the following indicators to help them in measuring water quality. All these indicators are valuable for measuring water quality, although they will not provide any information on the bacteriological quality of the water.

· Does the source look clean? Are there any animals in it?
· Are insects breeding in it?
· Are there any leaves or sticks in it?
· Is there other rubbish in it?
· Is there human or animal waste nearby?
· Does it have any colour?
· Does it smell bad?

· Does it taste bad?

Source: (1).

Equity: Everyone in the community should have access to the water and sanitation arrangements. No individual or group should be left out, since this will put at risk not only those who are excluded but the rest of the community as well.

Effective use: Facilities must be used effectively if disease is to be prevented. Therefore, practices and attitudes should be oriented towards optimal, hygienic and consistent use of water and sanitation facilities. Health education is crucial to achieving effective use since it raises people's awareness about health and encourages lasting changes in behaviour.

Protection of the environment: The project should be assessed not only on its present environmental impacts but also on its likely future environmental impacts. Otherwise, decisions taken now may prove inappropriate later, for example, in times of drought, or when the population increases.

A sanitation project will be much more equitable, effective and sustainable if it operates in a participatory manner, and gives responsibility to communities for planning and implementation of activities. To fully assess project performance, therefore, a PME exercise must evaluate the extent to which the project has been participatory. Here again, local people can suggest indicators to use and various techniques exist which can be employed to help community members analyse the participatory aspects of projects.

In deciding what to measure, it needs to be borne in mind that different stakeholders will have different priorities and different opinions about how to assess a project and whether or not it has been successful (see Box 7). PME activities often reveal important information about what different groups value most.

Key steps in participatory monitoring and evaluation

Participatory monitoring and evaluation is best thought of not as a linear, but as an iterative and continuous process. Participatory assessments, self-evaluations and analyses lead to the planning and implementation of corrective actions, which in turn undergo participatory assessments. The key steps in a typical PME process are listed in Box 8.

Box 7. Differing views of success

Different people will have different views concerning whether or not a project can be considered successful and therefore different ideas of what indicators should be used in a PME activity. For example, in latrine projects, the project staff usually focus on the total number of household latrines built, while at the community level this is often of little concern. In one urban sanitation project in Nepal, women stated that the key indicator of success should not be the number of individual cubicle toilets constructed in different locations, but rather the total number of women who could simultaneously use one public facility. For the women, latrine use also represented their only opportunity to sit and talk together; thus a communal toilet was more desirable than individual toilets offering privacy.

Source: (1).

Box 8. What is involved in participatory monitoring and evaluation?

The key steps to remember in undertaking PME work include:

1. Prepare in advance

- involve all major stakeholder groups in the initial decision to undertake PME;

- determine the budget and time available;

- identify a lead facilitator to coordinate the work;

- bring together a cross-section of stakeholders, including community representatives and project staff, to agree on the objectives of the m&e exercise, the questions to address and the indicators and methods to use;

- request the lead facilitator to select and train the local facilitators in the PME methods to be used.

2. Undertake the data gathering and analysis

- the local facilitators assist communities to carry out the evaluation work - the lead facilitator supervises and supports their work;

- leave time for several rounds of field visits and in-the-field analysis by the facilitator team.

3. Plan for action

- hold one or more meetings - again including a cross-section of stakeholders - to further discuss and analyse the PME results and plan for corrective action.

4. Disseminate the results

- give feedback presentations in the field for interested community members;
- hold informal review meetings with project staff;
- organize a final workshop for senior managers and policy makers;
- remember, PME is an ongoing process, so regular assessment and feedback mechanisms need to be set up.

N.B. Please note that this checklist is not exhaustive and each project will require its own sequence of PME activities.

Source: (7).

Planning a participatory monitoring and evaluation system

Setting up and managing a PME system involves putting in place the appropriate institutional arrangements, communication channels, staff incentives and resources to support the participatory work (see section above on prerequisites for successful PME). Many projects have found it useful to establish a committee of representatives of the different stakeholder groups to oversee all the PME activities. The kinds of questions commonly asked during planning of PME exercises include (10):

Who should be responsible for the PME work?

Most PME activities include a lead facilitator to coordinate the work. This lead facilitator is usually responsible for helping select and train a team of local facilitators which in turn helps facilitate evaluation work with the various stakeholder groups. The local facilitator team should include a cross-section of community members and local project staff. For major evaluations, one or two outside experts may also be required to investigate particular aspects of the project (such as financial management or technical issues).

What background should the PME facilitators have?

The lead facilitator usually has a background in social sciences and is typically a researcher or development practitioner. He or she should have expertise and practical experience in participatory methods for use in m&e work. The educational level of the local facilitators is rarely important, although the team should include at least some literate people to assist in report writing. Visual techniques can be used for data gathering and analysis in situations where a large number of the participants are illiterate. More importantly, the facilitators should be willing to adopt a participatory, non-hierarchical approach for the m&e work. (Some community leaders and project staff may find this difficult, however.) The local facilitator team should also be gender-balanced to ensure that the views of both women and men are heard.

What role should the PME facilitators play?

The PME facilitators should act as catalysts for the evaluation work, helping communities and other stakeholders to undertake the assessments and self-evaluations. The facilitators should guide and observe the m&e process without letting their own opinions or specialist expertise get in the way. The main objective of participatory work of this kind is to elicit the different viewpoints and priorities of the local people, not to achieve the most technically-accurate analysis possible.

How much will the PME work cost?

The cost of a PME exercise will obviously vary from project to project but base costs generally include the professional fees of the lead facilitator, payment for the team of facilitators, travel, and materials. Budgeting of field costs should take into account the need for preparatory team-building and training work. It is also wise to allow for more than one trip to the field since some gaps and discrepancies in the information collected during the first round of community visits may need to be addressed in a follow-up visit.

How long will it take?

The duration of PME work depends on the size and complexity of the project, the level and availability of local expertise, and the number of stakeholders involved. It also depends on how the m&e has been organized. If undertaken as distinct events at various stages of the project, each exercise may require about six to eight weeks of the facilitators' time - for preparation, training, fieldwork and report writing. But if carried out largely by community members as an integral part of the project's day-to-day activities, the PME work will not require that large blocks of time be set aside.

What kinds of output should be produced?

The results of the PME work should be presented in such a way as to ensure that all the different stakeholder groups have access to them, and the chance to comment on them. Thus a single version of the written report may not suffice. Other options include:

- a set of photographs or a video showing the PME process and some of the findings (e.g. the level of attendance observed at a health education meeting, or the state of sanitation facilities);

- some of the outputs from the visual techniques used in the PME work (such as maps made by community members to show the number, location, and relative popularity of the different sanitation facilities in the area);

- oral presentations to each stakeholder group, by members of the evaluation facilitators' team;

- simple information sheets, newsletters, radio reports or other mass media communication methods.


1) Narayan D. Participatory evaluation: tools for managing change in water and sanitation. Washington, DC, World Bank, 1993 (World Bank Technical Paper No. 207).

2) Workshop on goals and indicators for monitoring and evaluation for water supply and sanitation, Geneva. Washington DC, UNDP-World Bank Water and Sanitation Program, 1990.

3) Bateman MO et al. Report on the monitoring and improvement system. Sanitation and family education. (SAFE) Pilot project, Bangladesh, CARE, 1995.

4) Almedom AM, Blumenthal U, Manderson L. Hygiene evaluation procedures: approaches and methods for assessing water - and sanitation - related hygiene practices. International Nutrition Foundation for Developing Countries, 1997.

5) Buzzard S. The rural water supply and sanitation field testing project, Nepal: a case study of participatory monitoring and evaluation. Paper presented at a conference entitled, “The World Bank and Participation”, The World Bank, Washington, DC, September 1994.

6) Gosling L, Edwards M. Assessment, monitoring, review and evaluation toolkits. London, Save the Children, 1993.

7) Rietbergen-McCracken J, Narayan D (compiled by). Participatory tools and techniques; a resource kit for participation and social assessment. Washington, DC, World Bank, 1997.

8) Srinivasan L. Tools for community participation: A manual for training trainers in participatory techniques. New York, UNDP, 1990, (PROWWESS/UNDP Technical Series Involving Women in Water and Sanitation).

9) Rugh J. Self-evaluation: ideas for participatory evaluation of rural community development projects. Oklahoma City, World Neighbors, 1986.

10) Mebrahtu E. Participatory monitoring and evaluation: an introductory pack. Institute of Development Studies, Sussex, UK 1997.

How to find out more

Narayan D. Participatory evaluation: tools for managing change in water and sanitation. Washington, DC, World Bank. 1993 (World Bank Technical Paper No. 207).

An excellent guide to using participatory techniques for monitoring and evaluating water and sanitation projects. The book also contains sets of indicators and suggests which techniques can be used for each indicator. Available from:

The World Bank Bookstore
The World Bank
1818 H Street, NW
Washington, DC 20433

Almedom AM, Blumenthal U, Manderson L. Hygiene evaluation procedures: approaches and methods for assessing water- and sanitation-related hygiene practices. International Nutrition Foundation for Developing Countries, 1997.

A handbook full of practical advice on how to do a participatory evaluation of hygiene practices. Examples are provided to show how the different techniques were used in various projects. Available from:

Intermediate Technology Publications
103-105 Southampton Row
London WC13 4HH

Mebrahtu E. Participatory monitoring and evaluation: an introductory pack. Institute of Development Studies, Sussex. UK, 1997.

A very useful briefing pack containing 19 articles on PME covering a wide range of sectors and topics, plus an annotated bibliography of PME (focusing particularly on Participatory Rural Appraisal material), and a listing of other PME bibliographies. Available from:

Institute of Development Studies
at the University of Sussex
Sussex BN1 9RE

Other useful sources of information on PME, apart from those listed in the references and footnotes of this article, include:

Who are the question-makers? Participatory evaluation handbook. New York, UNDP, 1997.

Available from:

Sharon Capeling Alakija
Director, OESP
1 United Nations Plaza
Room DC 1-2164
New York City, NY 10017

Feuerstein M-T. Partners in evaluation: evaluating development and community programmes with participants. London, Macmillan Publishers, 1986.

Available from:

Box 49
St. Albans
Herts AL1 4AX

FAO. Participatory monitoring and evaluation: handbook for training field workers. Bangkok, FAO Regional Office for Asia and the Pacific, 1988.

Available from:

FAO Regional Office for Asia and the Pacific
39 Phra Atit Road
Bangkok 10200

Financing low-income household sanitation facilities through household credit - Robert Varley1

1 Research Triangle Institute, USA.

Household on-site sanitation benefits not only the individual household, but also the wider community. This is because it both prevents disease and protects valuable water resources. This translates into economic benefits. But even so, shortage of donor and government funds often dictates that sanitation programme costs must be recovered. This article focuses on promotion of household on-site sanitation and how to pay for it once demand has been created.

There are no simple solutions to financing sanitation in low-income communities. Promoting water supply is easy because water is a necessity and can also be a source of income if used for productive pursuits such as contract washing of clothes, and vegetable gardening (where safe). Promoting sanitation is much harder since its value is not immediately obvious. Most literature on water supply and sanitation finance focuses on water supply, with little on how to finance sanitation for individual households. Some examples of successful sanitation financing exist, but these cannot be applied universally. However, lessons learned suggest that with imagination, flexibility, common sense and financial discipline, problems concerning how to finance sanitation can be solved.

Elements of household credit financing

Supply-led2 approaches to sanitation can improve sanitation coverage. Indeed, they can be reassuring since almost any coverage goal can be formulated and the financial problem reduced to raising a sum of money to pay for that level of coverage (usually calculated by multiplying the beneficiary population by the uniform cost per person.) Such approaches assume that a population's needs justify the proposed programme; resources are then committed to supplying low-cost facilities to meet them. Cost recovery is thus not a major objective and eligibility to receive the facility is usually based solely on need. Even if a loan-based scheme is operated, the agreement with the beneficiaries focuses on getting them to receive the benefit, rather than on their understanding and accepting their obligations as borrowers.

2 A supply-led strategy is one that focuses on provision of a product or service to intended beneficiaries.

Cost recovery in sanitation projects is possible, though, and credit is just one of the tools that can be used to attain such a goal. Moreover, it is flexible and can be combined with subsidies or grants, and the beneficiary's own contribution. Credit programmes are best used as part of a demand-led strategy.3 And if significant demand for sanitation does not exist, then it must be created. This can be done not only by stressing perceived private benefits, but also by creating environmental health awareness and encouraging pressure on non-complying neighbours to enforce sanitary practices. Additionally, if credit services are to work well, the availability of credit must work to enhance that demand. Success is measured by sustained cost-recovery which shows that something has been delivered which people are willing to pay for. However, demand-led strategies involve considerable uncertainty, since the eventual outcomes (including level of demand) are not known in advance. Current preferences, and the extent to which behaviour, attitudes and tastes can be altered in favour of sanitation, are further areas of uncertainty. Planning is therefore difficult.

3 A demand-led sanitation strategy works by making potential beneficiaries aware of their need for a product or service, or by enabling potential beneficiaries to express already felt demand for a product or service (1).

But we can at least be precise in our use of terms. For instance, we should avoid using the term “ability to pay”. When it is said that people are not able to pay for something, what is really meant is that they are poor and should not have to pay. “Willingness to pay” (WTP) is preferable as a criterion because if people are willing to pay for something then we know they are able to in the usual sense of the word (2). If people are unwilling to pay because they are very poor, then a subsidy should be considered if an additional economic benefit, such as protection of community health, would accrue.

WTP as an eligibility criterion is essential if cost recovery is the objective. If materials for building a pit latrine are given free to poor households (because they are not willing to pay for them at all), they will perhaps sell them and use the money for something they are willing to pay for. Helping a consumer to become “able to pay” will not be an effective strategy if he or she is not willing to use the increased “ability to pay” (created via subsidy and gifts) for the purpose intended. In providing loans, the sponsor should be satisfied that the borrowers are creditworthy, i.e that they:

- have the capacity to pay back the loan, and,
- intend to pay back the loans.

Credit is not meant to be a quick fix for success. Offering credit tied to household sanitation investments is simply one possible means of encouraging people to spend some of their limited income on sanitation. Credit facilities extend the options available to households who would otherwise have had to save for the facility, if not continue to do without it. Their impact can be enhanced by ensuring that a wide range of sanitation options is available from private suppliers (or the sponsor if the sponsor is also the supplier). This is because preferences in low-income communities are often highly varied; some households choose the cheapest pit latrines while others want and are willing to pay for full toilets with running water and storage. Tailored options can also be considered. They are most efficiently supplied by a competitive private sector, with the sponsor using credit as the major, but not only way of creating new demand.

Credit mechanisms - as well as making sanitation improvements easier to finance - can actually lower the cost of the investment. If the client can pay for the sanitation hardware in a lump sum, contractors are likely to offer a lower price. Materials to be provided by the households themselves can also be bought at a discount if purchased in bulk. In the absence of credit, households may pay more for materials if they are only able to purchase many small lots of materials until they have enough to complete the work.

Informal microfinance4 - rotating savings and credit associations

4 Microfinance usually involves the lending of small loans for small projects, using simplified criteria. In other words, they are loans which large institutions are reluctant to make, generally because such loans are not cost-effective from their point of view.

Rotating savings and credit associations (ROSCAs) are an established feature of urban and rural societies in many parts of the world, and can be part of a programme's financing strategy. In a ROSCA, a fixed number of participants meets regularly (12 participants could meet monthly, for example) and each contributes a fixed sum to a pot of money. Each month ownership of the pot goes to a different individual, according to some criterion (e.g. a lottery), with everyone receiving the pot once. In this way, a larger sum of money is saved than could be saved by a single individual. Used to finance numerous ends, this system is generally cheap to operate since it does not require rigorous accounting and is self-controlling. And because of group pressure, defaults on obligations are rarely seen.

In Thailand, household rainwater collection systems have been financed by ROSCAs, with each participant household contributing once a month to a pot, the contents of which is used (along with voluntary labour) to construct another system each month (2). In rural communities, where voluntary off-season labour is available and social cohesion common, ROSCAs can be a useful financing strategy within the context of an environmental health campaign. ROSCAs are also popular in urban areas even though other means of saving are often already available. In some urban areas, for instance in Nigeria, ROSCAs have even been used to raise funds to send back to the village from which members originated. So ROSCAs not only help rural people to save, but can also help urban dwellers to retain their social links with rural communities. The principal intervention required by a ROSCA, which is in fact an opportunity, is that of using the monthly event to promote sanitation and find ways to direct the saved funds to making sanitation improvements.

Formal microfinance institutions

If programme sponsors want to achieve scale and efficiency, they will probably want to make use of the extensive body of knowledge in the field of practical microfinance: namely, what works and what doesn't. There is no single formula but there are simple principles that must be learned and applied if sanitation programme costs are to be recovered, A cardinal rule for all “bankers” is that the person approving the credit should be held accountable for the quality of the loans (i.e. the successful repayment of the loan, on time). If instead, separate organizations are responsible for making loan decisions and collecting repayments, lender incentives to collect and borrower incentives to repay tend to weaken. This was illustrated by the high loan arrears experienced by an otherwise successful sanitation programme in Lesotho: the financing of pit latrines was made the sole responsibility of a state bank and the promotion programme and latrine construction made the responsibilities of the sanitation authority (2).

In some countries, effective microfinance services are already available, although they often finance only a limited number of activities (i.e. they are “targeted”); usually those considered to be “productive”. But if efficient micro-credit services which are not targeted (the so-called minimalist approach) are available, a sanitation programme need not get involved in the difficult business of lending at all. In such cases, the sanitation programme can concentrate on demand creation through public health promotion, lowering costs by sponsoring research in low-cost technologies and creation of competition among and/or regulation of private contractors (e.g. bonding of contractors).

Household credit financing schemes for sanitation: general lessons learned

Use existing informal financial institutions

If household sanitation is to be financed by loans it may be cheaper for the relevant programme to arrange a system whereby borrowers use existing informal financial intermediaries rather than for it to develop new collection systems. A World Bank-supported programme for shared sanitation facilities in Kumasi, Ghana might have been even more successful if the organizers had used traditional intermediaries such as the “susu” to collect fees. The susu are informal bankers, who make regular visits to houses and markets to collect savings from their clients and provide short-term loans to traders. Susu collectors may deposit surplus funds in commercial banks and are even able to access credit. It is a stable system, with minimal risk and that is why it thrives. Usually local residents of good character, susu collectors are reputed to have detailed knowledge of clients' household financial status. However, a proposal to use them in the World Bank programme was rejected in favour of the “greater security” and effectiveness of using government employees as collectors (2).

Integrate sanitation with other development activities

Public health arguments are rarely strong enough to generate the necessary time, money, and commitment needed for sanitation. When sanitation is combined with other community development activities, however, the costs of establishing meaningful participation and community governance can be shared. Moreover, money alone is a weak substitute for contributions such as participation and leadership. If given blindly, it can encourage corruption, creating more problems than it solves (1, 4).

Adopt a realistic time-scale

“There is always time to do it twice but there is never time to do it right” is a useful reminder of the input required to ensure the success of a sanitation programme. Any credit scheme will eventually fail if the desire to expand coverage as fast as possible is not matched by an equal commitment to recover the loans and relend the money to new borrowers. This is not a steady process and requires an upfront investment in learning. Time spent on getting the financial arrangments right in the first place will be more than adequately rewarded when growth in coverage picks up, and the programme is able to rely much more on the reliability of its systems, and much less on the dedication of core staff.

Consider an incremental approach to lending

Credit relationships, and indeed all relationships with financial institutions (including savings services), are most effective when they are long-term, and involve repeated transactions. Credit should not be treated as a one-off transaction targeted at a single outcome. Part of the effectiveness of using an informal intermediary, such as the susu, lies in the relationship that develops between credit supplier and user. This relationship is based on information, trust, and confidence, all of which increase with time, and all of which contribute to social cohesion and development. The experience of the Cooperative Housing Foundation (CHF) in Honduras is just one example. Small loans for on-site water supply and sanitation facilities were made and once successfully paid off, larger loans for more extensive housing improvement were offered. This incremental approach allows the borrower to gradually increase debt burden and the lender to assess credit-worthiness or debt capacity (2).

Consider cross-subsidization from water services

There is widespread agreement that, for the poor, the price of water is very high - either in terms of time spent collecting water or payment to vendors. Programmes which can exploit the demand for water, while still lowering cost to those presently served by vendors, can free up resources for pursuing other programme goals such as improving sanitation coverage.

Use staff with banking and credit experience

In all credit projects, the initial emphasis should be on recruiting staff who are experienced in finance, rather than retraining people with limited financial backgrounds. In the pioneering work done by CHF in Honduras, staff stumbled on the importance of cash-flow management and created a spreadsheet to help them perform this function. This worked, but an accountant would have been able to show how the same cash-flow information could have been derived from conventional balance sheets and income statements. Additionally, balance sheets and income statements can be checked and understood by formal sector accountants, and so can be valuable materials for a community organization or NGO wanting to demonstrate its credit-worthiness to a potential lender or investor.

Guarantee quality and protect the rights of the poor

One of the most valuable services that a sponsoring agency of a household financing scheme can provide is to increase the negotiating power of poor households when dealing with contractors. Additionally, a sponsoring agency can reduce contract performance risk for poor households - for example, if on-site sanitation is to be financed by a housing improvement loan, the payment to the contractor can be made conditional upon inspection and approval of the contractor's work by the loan officer. The scheme can also make a point of using approved contractors only, who must redo work if it is found to be unsatisfactory.

Some useful financial principles

Use financial and accounting terminology

When discussing financing options and raising funds from donors or charitable private investors it is best to use conventional terminology because it is commonly and widely understood.

Financial information systems should be simple and easy to understand

The experience of large organizations can be called upon to ensure that the simple, easily understood financial information systems run by a sanitation programme work smoothly. One of the main problems for small programmes is how to achieve economies of scale.

Do not offer artificially low interest rates

If subsidies are to be provided they should be based on the purchase price of the facility, not the interest rate, which should reflect the full costs of the lender. The field of microfinance is riddled with examples of how well-meaning attempts to subsidize interest rates have made the intended beneficiaries worse off and bankrupted the lender. Granting a loan at substantially below-the-market rate (i.e. in the poor community) creates a disincentive to repay - even good borrowers will prefer to pay the interest only and not repay the principal. Besides, low-interest loans generate fierce competition among would-be borrowers and they may not be won by the poorest. On the other hand, if the poor are willing to pay high interest rates in order to be able to borrow, then these same high interest rates will attract people who want to lend.

Use subsidies and grants prudently

Subsidies and grants should be used to complement consumer demand, not to replace it. As mentioned above, the interest rate should not be subsidized at all. But if subsidies are to be provided, beneficiaries should be aware of the real costs involved and their own obligations (for example, regarding use or maintenance of the associated service or facility). Subsidies have sometimes led to poor programme performance because they have sent the wrong signals to participants and stakeholders. For example, in the Lesotho programme referred to earlier, a participant cautions that “the user should finance, using appropriate credit mechanisms and employing trained local builders. Once subsidies are offered, it is very difficult to discontinue them. They inherently contradict a sustainability policy” (3).

When using a household credit mechanism, understand the trade-off between minimizing costs and targeting the poorest customers

By having one interest rate for all loan sizes, the larger loans can be made to subsidize the smaller. (Administrative costs as a proportion of loan size are higher for smaller loans than for larger loans.) This serves to increase the poor's access to borrowing. At the same time, targeting of loans should not be too restrictive. For instance, if the community's wealthier sections are denied access to microfinancing services, opportunities to cross-subsidize the poor may be lost. Moreover, the better off tend to be looked upon as role models, and as poorer households become less poor over time, they will tend to emulate the facilities available in the trend-setting wealthier homes.

Allowing for risk and default

“There are three types of default: wilful default, resulting from dishonesty; default owing to misfortune; and default caused by foolishness. The misfortunes and foolishness of our clients (the borrowers) should be dealt with patiently. But try to eliminate or pursue the dishonest defaulters by consulting loyal clients about selection and mobilizing them for recovering defaults” (4). A zero default rate on loans may seem desirable, but is not necessarily good banking practice. Some risks, such as those associated with misfortune, are best allowed for in the interest rate charged. Rather than avoiding all risk, a competent financial intermediary makes an allowance for it in the interest rate charged to the customer. For example, loans to single females may represent a lower risk than loans to single males, which would justify a rate differential. The likelihood of default is also determined, in part, by the degree of social stigma attached to default. Generally, this will be greatest where social cohesion is strongest.

Avoid strict targeting of credit for narrowly defined purposes

Ensuring that a loan given for one purpose (e.g. sanitation) actually results in increased expenditure for that purpose is difficult and expensive. The largest and most successful microfinance product in the world - the small KUPEDES loan of the Bank Rakyat Indonesia (BRI) - tends to be used for many purposes, although ostensibly it is aimed at helping microentrepreneurs. For example, KUPEDES has frequently been used to finance housing improvements and sanitation (2).

Interestingly too, the BRI has decided that repayment, particularly for second and subsequent loans, is of more concern than close customer monitoring. Contrary to what might be supposed, close customer monitoring to establish whether lenders are about to default (or are spending their loan on the entrepreneurial activities) is a low-return activity. BRI already know from previous loan(s) that that particular customer is creditworthy.


The main strategy for improving sanitation in poor rural and peri-urban communities is community mobilization and a sustained campaign to promote awareness of the consequences of poor sanitation. In other words, neither money poured into credit schemes nor outright grants will succeed in increasing sanitation coverage unless perceptions and behaviour relating to sanitation are changed. However, a household credit approach can enhance efforts to improve sanitation by helping households to cover hardware costs.

The main factors affecting the viability of a credit scheme will be the size of the loans and the administrative costs of disbursement and collection. The lower the cost of the facility, the less viable a credit scheme - the smaller the loan, the higher the fixed costs of lending as a percentage of loan size.

It is also worth considering making a sanitation loan package part of a range of credit products, to allow subsidization from more profitable loan activities (such as lending to microentrepreneurs or for water supply). For instance, sanitation credit usually achieves more when made an integral part of a wider programme which targets housing improvement, than when operated as a stand-alone programme.


(1) Varley RCG, Yacoob M, Smith S. Beyond participation: locally based demand for environmental health in peri-urban areas. Virginia, USA, Environmental Health Project, December 1996 (Environmental Health Project Applied Study No. 6). (The Environmental Health Project can be contacted at: 1611 North Kent Street, Suite 300, Arlington, VA 22209, USA.)

(2) Varley RCG. Financial services and environmental health: household credit for water and sanitation. Prepared for the Bureau for Global Programs, Field Support and Research, Office of Health and Nutrition, US Agency for International Development, January 1995 (Environmental Health Project Applied Study No. 2). (See above for contact address.)

(3) Blackett, IC. Low cost urban sanitation in Lesotho, March 1991. Published in March 1994 as Water and Sanitation Discussion Paper Series Number 10. Washington, DC, The World Bank.

(4) Khan AH. The Orangi Pilot Project, reminiscences and reflections. Karachi, Oxford University Press, 1997.

Further reading

Evans P. Paying the piper. An overview of community financing of water and sanitation. The Hague, The Netherlands, IRC (Occasional Paper 18).

Johnson S, Rogaly T. Microfinance and poverty reduction. Oxfam Publishing, Oxford, UK.

LaFond A. A review of sanitation programme evaluations in developing countries. Environmental Health Project and United Nations Children's Fund, Virginia, USA, February, 1995 (Environmental Health Project Activity Report No. 5). (The Environmental Health Project can be contacted at: 1611 North Kent Street, Suite 300, Arlington, VA 22209, USA.)

Renz L et al. Programme-related investments: a guide to funders and trends. New York, The Foundation Center, 1995.

Sara J et al. Rural water supply and sanitation in Bolivia, UNDP-World Bank Water and Sanitation Program, May 1996. Washington, DC, UNDP-World Bank Water Sanitation Program, May 1996.

Varley RCG. Child survival and environmental health interventions: a cost-effectiveness analysis. November 1996 (Environmental Health Project Applied Study No. 4). (See above for contact address.)

Further information on a wide range of sanitation topics and related publications (including some on finance issues) can also be found on the Internet at the following address: and

Checklist for planning better sanitation projects - WSSCC Working Group on Promotion of Sanitation

This checklist has been drawn from the Principles of better sanitation programmes and Features of better sanitation programmes.

If you are interested to know how closely a planned project follows the “principles” and “features”, you may wish to try this checklist. If your answer to these questions is consistently “yes”, you have followed the “best practices”.

If any answers are “no” you might examine whether changing this feature would improve the project.

Project formulation

· Are communities being selected for sanitation change because of their keen desire for improvement



or because it is at high risk for sanitation-related diseases?



· Is the project planned in a way that changes can be made as lessons are learned?



· Is the sanitation project accepted as a priority in its own right, rather than viewed as an add-on to a water programme?



· Does the sanitation project have its own budget and own time-frame



separate from any water supply project that may be taking place concurrently?



· Is the project assessing how the community's improved sanitation system will be a successful part of its larger ecosystem, cultural beliefs and practices?



· Does the project have a component either to create demand for sanitation or to encourage the expression of demand that is already there?



· Is the project assessing whether the principles of social marketing can or should be applied to the project to understand consumer preferences in the design of facilities? (See Social marketing for sanitation programmes.)



· Is the project learning about and considering the cultural beliefs and practices of the community in designing the hygiene behaviour-change component?



· Is the project involving the community in collecting information on the current sanitation situation for use in developing the project?



Project management

· Is the community involved in setting the project's objectives?



· Is a realistic time-frame being allowed for the project?



· Is the project identifying what additional support from other sectors might be needed to make the project successful?



· Is the project developing a plan for how the sanitation project will be managed? Does this include:

defining roles and responsibilities?



setting out supervisory structures?



developing reporting systems?



coordinating activities?



outlining communication systems?



Community participation

· Is the project considering how (whether) the essential elements of social mobilization can or should be applied?



· Is the project assessing how (whether) participatory approaches can or should be applied to encourage better dialogue with the community and to involve it actively in decision-making? (See Participatory approaches to community empowerment.)



· Is the project creating an environment in which the community feels a sense of responsibility and ownership for the project?



· Is the project trying to use existing community organizations rather than creating new ones?



· Is the project consulting with people trained and experienced in methodologies for achieving effective community participation?



· Is the project creating an environment in which private producers can be involved in providing the hardware for the project and can thrive economically in doing so?



Gender sensitivity

· Is the project employing a gender specialist and using the gender checklist? (See A gender perspective in sanitation projects and the associated gender checklist.)



· Is the project using both male and female personnel to reach out to the community and households?



Hygiene behaviour change

· Do the project personnel recognize that hygiene behaviours are as important as facilities for improving community and household sanitation?



· Is the project identifying behaviour changes that need to occur in the community and households to get the benefits of facilities?



· Does the project have a strategy for bringing about behaviour changes? (The Checklist for planning hygiene behaviour-change in sanitation projects is a useful source of further information on this subject.)



· Are hygiene behaviours and facilities being promoted together, in a complementary way, in the project?



· Is the project trying to involve community groups in formulating their own hygiene education programmes and own messages and methods rather than having these designed from outside the community?



Selecting technologies

· Is the project using information collected about what people in the community are doing now for sanitation, and trying to build, step by step, upon these traditions to improve sanitary conditions?



· Are the project personnel keeping an open mind about what kind of sanitation technologies might be possible for the community?



· Is the community being advised about a range of technical options from which it can choose?



· Are these options affordable to the great majority of households, without subsidy?



· Do community members have opportunities to assess for themselves various sanitation technology options, and to



participate in a meaningful way in their selection?



· Do community members have opportunities to suggest adaptations to the various sanitation technology options presented, so that they can be made more appropriate to the local situation?



· Are some household financing schemes being offered to the community to help them pay for facilities?




· Is the project trying to win the support of slightly wealthier and higher status people first before approaching the poorer households or groups?



· Does the project have political support from the highest possible level within this social context?



· Is the project letting the people in the community know that this sanitation project is supported by higher-level political figures?



· Does the project include and involve schools



schoolchildren or



other community children?



· Is the project planning for the promotion of sanitation and hygiene behaviours to be a continuous activity rather than a one-off effort with a limited time-frame?




· Is the project building capacity for the community to take over the operation and maintenance of any new facilities?



· Is the project offering additional training to its personnel to help them accomplish the above?




· Is the project planning to provide the necessary support to the community until it is able to sustain the project on its own?




· Is the project involving the community in developing a monitoring system that it can use to measure progress and as a basis for continued improvement? (See Participatory monitoring and evaluation of sanitation projects.)



Checklist for planning sanitation in emergency situations - Mayling Simpson-Hebert1

1 WHO, Geneva, Switzerland.

This checklist is intended to help plan for sanitation in emergency situations. In preparing this checklist, certain assumptions have been made. These are:

· The emergency situation to which this article refers is one in which people have been displaced and who are now living temporarily in camps or shelters until they can return to their homes.

· The sanitation facilities will be set up quickly and are not intended to be permanent or used in the long term.

The checklist has been derived from Principles for sanitation in emergency situations, an output of a workshop on sanitation in emergency situations (1).

“Sanitation” is taken here to mean interventions to reduce people's exposure to disease by providing a clean environment in which to live. This includes disposing of human excreta, refuse, and wastewater; control of disease vectors; and providing washing facilities.

As you plan your sanitation programme in an emergency situation, check the following to see if you have done them. If your answer to these questions is consistently “yes”, you have followed the “best practices” identified by the workshop participants. If your answer is “no”, you might examine whether changing this practice would improve your programme.


· Is the sanitation programme seen as a priority in its own right (needing its own resources and time-frame) and not as an add-on to the provision of water?



· Do programme staff recognize that providing sanitation in emergency situations is the first barrier to disease transmission (both faecally-transmitted and vector-borne diseases) and equally if not more important than providing medical services for the population?



· Do programme staff recognize that providing sanitation to the population will improve the dignity and morale of the displaced people?



· Do programme staff recognize the political context of refugee camps and that sanitation decisions must be made within it?



· In all decision-making, is there an effort to involve representatives of the population in the emergency situation from the beginning?



· Is the programme sensitive to what will be provided inside the camp or temporary locations as compared to the sanitation needs of the local population living nearby?



· Are programme staff, in consultation with community representatives, defining sanitation priorities and establishing sanitation objectives (global and specific) before beginning any sanitation work?



· Is an effort being made to understand the population's traditional sanitation practices and beliefs and to build on them whenever possible?



· Is an effort being made to understand the differing needs of women, men, and children in planning the sanitation programme?



· Are hygiene behaviours and facilities being planned and promoted together?



· Is there a plan to promote sanitation, continually, at all levels, rather than viewing it as a one-time effort?



· Is there a plan for the users to become involved in maintaining the sanitary services after the initial period?



· Is the programme considering the environmental effects of sanitation on the larger environment and attempting to minimize their potential negative impact?




(1) Derived from Sanitation in emergency situations. Proceedings of an international workshop held in Oxford, December 1995. An Oxfam Working Paper. Available from Oxfam, 274 Banbury Road, Oxford OX2 7DZ, UK.

Checklist for planning hygiene behaviour-change in sanitation projects - Mayling Simpson-Hebert1 and Sara Wood2

1 WHO, Geneva, Switzerland.
2 WHO Consultant, Geneva, Switzerland.

A hygiene behaviour-change programme can help individuals, families, and communities to become aware of the links between behaviours and disease. It involves encouraging and helping people change behaviours, to achieve the greatest reduction in disease possible. This requires community participation in deciding which behaviours it wants to work on changing and which sanitation options are most appropriate to its needs.

In many settings, ideal sanitation facilities are not within the community's reach. But communities and individuals can still adopt improved hygiene behaviours that will lead to better health. It is also recognized that even when good facilities are available, they will not necessarily translate into major health improvements, unless they are accompanied by changes in hygiene behaviours. Therefore, with or without improved water supply and sanitation facilities, improved hygiene behaviours can improve health.

This checklist is intended to help sanitation project personnel plan better sanitation projects. It should be used to check whether all important elements of planning are in place.

As you plan the hygiene behaviour-change component of your sanitation programme, check the following to see if you have done them. If your answer to these questions is consistently “yes”, you have followed the “best practices” identified by the Working Group. If the answer is “no” you might consider whether collecting such information would improve your project.

Collection of basic information

Helpful hint: Data collection should be a joint activity between the programme and the community. (References are included at the end of the checklist, should you wish to find out more about different data collection methods, and when to apply them.) Some of the information needed may already exist in previous surveys or in the records or files of other agencies operating in the area. It may save much time to check what information is already available. You then need only collect what is missing or update information that is out of date.

Have you collected the following basic information about the community? Please note: this is not a survey form.


information collected

population size



household sizes



proportion of households headed by women



ethnic groups or economic groups and their sizes



high-risk groups



Health determinants

major health problems in the community



relative importance of water/sanitation-related diseases



seasonal variations in diseases



Current and traditional hygiene practices

where men defecate



where women defecate



where children defecate



where babies faeces are disposed of



where sick people defecate - particularly those with diarrhoea



anal cleansing practices



handwashing practices after defecation



handwashing practices after handling babies' faeces



handwashing practices before feeding children and eating



important beliefs and taboos related to location and sharing of latrines



latrine emptying and excreta reuse practices, if any



food handling and preparation practices and possible sources of contamination



water handling practices and possible sources of contamination



bathing habits (men, women, children, and babies)



face-washing practices (men, women, children, and babies)



places where flies breed



other important personal and domestic practices in this society



all of the above, differentiated by age, economic class, and ethnic group if potentially useful




availability of water, distance, amounts, and quality



availability of services, such as schools and health clinics



Social structures

· Has the programme identified: the formal power structures, e.g. for election of politicians and officials?



informal structures, such as community leaders, opinion leaders, and elders?



characteristics that tend to make people's opinions carry weight (such as money, children, age, education, cattle, spouses, and gender)?



persons having the most influence over community health decisions?



how and by whom household decisions are made, specifically decisions on health and hygiene-related matters?



the status of women? Are they able to participate actively and equitably in community matters?



· What structures already exist in the community that could be used to support the intervention? How representative are they by gender, social status, etc.? How effective have they been in the past?



Planning community participation in the hygiene behaviour-change programme

· Has the programme planned how the community will participate in planning, developing and implementing the hygiene behaviour-change programme?



· Has the programme determined which methodology/methodologies would be most appropriate to use for the hygiene behaviour-change programme?



Determining key hygiene behaviours for the programme

· Has the programme determined, from collecting basic information, which behaviours are harmful to health and which are good healthful practices?



· Has the programme determined the underlying reasons for poor hygiene behaviours?



· Are poor hygiene behaviours due to socioeconomic factors, religious or cultural beliefs, availability of water or latrines or both, educational factors, social norms or social pressures, or decision-making at the household level?



· Has the programme considered, along with the above, whether new sanitation facilities will require entirely new behaviours for this society?



· Has the programme determined, from the above, the key hygiene behaviours on which the hygiene education programme needs to focus?



· Has the programme determined who and how many people in the community already practice the key hygiene behaviours?



· Has the programme prioritized, from considering the above, the key behaviours to be promoted?



Helpful hint: The programme should select those hygiene behaviours, which if altered, will have the greatest effect in reducing the transmission of disease.

· Has the programme identified what the community considers to be its needs and priorities for hygiene behaviour-change?



Helpful hint: Hygiene behaviours that the community sees a need for and which do not conflict with traditions are a good place to concentrate initial efforts. Success here will help when it is time to tackle hygiene behaviours that the community does not see as important or that conflict with cultural traditions. These require more effort to change. Experience acquired in the former situation will help when addressing more complex situations.

Determining the monitoring and evaluation requirements of the intervention

Has the programme determined the following aspects of the monitoring and evaluation activity?

· Whose responsibility will it be?



· How frequently will it be done?



· Which indicators will be used to measure progress?



· How will the results be reported to the community?



Planning the hygiene behaviour-change intervention

· Has the programme identified, from collecting basic information, the desired outcome and set measurable objectives for the intervention?



· Has the programme identified the target audience for the hygiene behaviour-change intervention?



· Has the programme analysed the target audience to determine if it needs to be segmented further into groups that share similar beliefs and perceptions?



· Has the programme identified how each change should be promoted?



· Has the programme encouraged community representatives to participate in creating the hygiene education intervention?



· Has the programme identified who should implement the hygiene behaviour-change programme?



· Do those chosen have the necessary skills, experience, and training to undertake the task of implementing the programme?



· Has the programme considered the need for both male and female extension workers?



· Has the programme considered working through schools and with children as change agents?



· Has the programme identified, contacted, and integrated its activities with other sectors that should be involved in the hygiene behaviour-change programme? Other relevant sectors could be water supply, housing, primary health care, environmental health services, schools, and home economists.



Planning the hygiene behaviour-change messages

· Are the messages based on an understanding of factors that influence the community's behaviour, including what it believes and understands?



· Are the messages easy to understand? Have the messages been pretested with a group of people who have the same characteristics as the target audience?



· Are the messages persuasive enough to make people change? Do they provide an incentive for change that makes sense in the context of the community in which they will appear?



· Does the behaviour-change programme message meet a need that the target audience has said is important for it to satisfy?



· Have behaviour trials been carried out to check whether people can do what is being asked of them?



Determining the potential for different communication methods

· Has the programme collected the following information on the potential for different communication methods?



- literacy levels of men, women, and children;



- existing formal channels of communication (health centres, schools, public meetings, churches, mosques, temples);



- existing informal channels of communication;



- mass media access in the area (radio, TV, video, newspapers, magazines, etc.); and



- ongoing health education activities.



· Has the programme analysed what health information is already being conveyed through existing communication channels?



· Do the new messages agree with or contradict the messages of this intervention?



· Has the programme worked out how to overcome the problem of contradictory messages if it exists?



Managing the hygiene behaviour-change intervention

· Has the programme developed a plan for managing the intervention?



· Has the programme worked out the full cost of the intervention, including the cost of personnel, facilities, equipment, supplies, transport, travel and an allowance for contingencies, such as cost increases and any unforeseen costs?



· Has the programme worked out how the cost of the intervention will be funded?



· Has the programme obtained the necessary funds to implement the intervention?



· Has the programme worked out how the funds will be managed, including book-keeping, payment of bills, and a system of regular audits to check for any irregularities?



· Has the programme considered running a training workshop at the intervention's outset to brief those involved, provide necessary training, and present the opportunity for any confusion or misunderstandings to be resolved?



Helpful hint: A management plan could include the following:

- the responsibilities (job specifications) of all those involved;
- to whom they are responsible;
- how often they are expected to report their results;
- the form of report that is expected (written or verbal);
- how all the activities of individuals involved will be coordinated;
- frequency of meetings (weekly, monthly, quarterly, etc.);
- the support that will be provided to project members; and
- how information will be communicated efficiently to those involved in the project.

More information about planning a hygiene education programme can be found in the further reading listed below.

Further reading

Almedom AM, Blumenthal U, Manderson L. Hygiene evaluation procedures: approaches and methods for assessing water- and sanitation-related hygiene practices. International Nutrition Foundation for Developing Countries, 1997.

Boot MT. Making the links: guidelines for hygiene education in community water supply and sanitation. The Hague, The Netherlands, IRC, 1990 (Occasional Paper No. 5).

Boot MT. Just stir gently: the way to mix hygiene education with water supply and sanitation. The Hague, The Netherlands, IRC, 1991, Technical Paper Series No. 29.

Boot MT, Cairncross A. Actions speak: the study of hygiene behaviour in water and sanitation projects. The Hague, The Netherlands, IRC, 1993.

GTZ. Community participation and hygiene education in water supply and sanitation. Federal Republic of Germany, Technical Cooperation, 1989.

Wood S, Sawyer R, Simpson-Hrt M. PHAST step-by-step guide: a participatory approach for the control of diarrhoeal disease. Geneva, World Health Organization (unpublished document WHO/EOS/98.3).

Gender checklist for planning sanitation projects - Angela Hayden1

1 Independent consultant, Geneva, Switzerland.

This checklist has been developed as a starting point for gathering data on gender issues in sanitation projects. The answers to these questions will show you where there are obstacles to be avoided or overcome, and where there are opportunities for making the sanitation project more successful.

Try to make certain that the people using the checklist have been trained in gender issues or are at least aware of what an appropriate gender approach is. If you feel those using the checklists lack experience in gender issues, try to organize training. If possible, find a gender specialist to help you. Gender specialists can be sought in government departments, universities and training institutions.

Basic Questions

The basic questions to answer at each stage of the sanitation project are:

· How can men participate?
· How can women participate?
· How can women and men together participate?
· What skills and capacities do they need?
· How can men benefit?
· How can women benefit?
· How can women and men benefit together?

Institutional background

· Are gender specialists included in the project staff?



If not, arrange training to sensitize staff to gender issues.

· Is there an official government policy on gender issues?



If there is, find out about it and see how it can be used to enhance the sanitation programme.

· Is there a government agency or ministry specifically concerned with gender issues?



If so, write down its name and make contact.


· Can the local government agency responsible for sanitation offer training or experience in gender issues?



If it can, see whether sanitation project staff can benefit from such training or experience.

· Are there organizations, particularly women's organizations, involved in sanitation or related activities?



If there are, write down their names and contact them to see whether they can be of help.




· Can lessons be learned from the experience of the ministry, local government agency or voluntary organizations (especially women's organizations)?



Review that experience and see if you can pick up any useful tips.

· Are voluntary organizations (particularly women's organizations) capable of providing training?



If so, find out who they can train and what sort of training they can provide.

· Do women, men or both play an active role in any community organizations or committees concerned with sanitation?

Try to find out if they attend meetings and if they speak at meetings.


Project area sanitation facilities

· Where do men defecate?


· Where do women defecate?


· Where do children defecate?


· Are there any toilets?




· If there are toilets, do men use them?



Do women use them?



Do children use them?



If men, women or children do not use them, try to find out why.


· Were the toilets constructed by men, women or both?




· Are the toilets maintained by men, women, both or no one?




· Would men, women or children prefer different sanitary facilities?



If yes, what type of toilets would they choose?


· Would men, women or children like to change the location of the toilets?



If yes, where would they like the toilets to be?

Cultural and religious factors

· In this culture, is it acceptable for men and women to share toilets?



· Is it acceptable for women to be seen walking to use toilets?



· Are the above attitudes changing?



· Have people seen or heard about more modern facilities and are their expectations changing?



Social and economic conditions

· Who is available to construct and maintain sanitary facilities (taking migratory patterns into account)?





· Are there large numbers of female-headed households?



If so, can the women who are heads of households get involved in constructing or maintaining the toilets, or in promoting their use?

· Are there significant economic differences among the target population?



If there are big differences, how can you make sure that all the different groups get involved in the sanitation programme?



· Can women make decisions in the household or in the community?



If so, how can their decision-making power be helpful in the sanitation project? If not, how can they become involved?



Current gender roles

· Whose role (men's, women's, or both) would it be to:

pay for a latrine?




construct a latrine?




maintain a latrine?




clean a latrine?




train children to use a latrine and wash their hands?




· Could any of the above gender roles be changed?

Women's potential for participation

· Are women interested and do they have the means and opportunity to express their interest?

If women are uninterested, consider ways to link their concerns with sanitation.

If women lack the means and opportunity to express their interest, participatory methods can be used. These are designed to overcome these kinds of difficulties. More information on participatory approaches can be found in Participatory approaches to community empowerment.

· Are women able and willing to contribute labour or materials (in line with their traditional roles)?

If they can, try to ensure that the sanitation project is designed to make use of their potential.

· If women have the time, skills, or willingness do they contribute to:










hygiene education?



monitoring and evaluation, including establishing project indicators?



Does this vary by season?



If they lack skills, can training be provided?



· Have women a special interest in sanitation projects, for example because of using humus for gardening?



Make a list of any particular interests and explore how these interests could motivate women to participate in the sanitation project.

· Are women aware of the health benefits of improved sanitation and hygiene practices?



If not, what sorts of activities or materials would be best for increasing their awareness? How could the group work together to identify what their health education needs are?



Men's potential for participation

· Can men contribute labour or materials (do they go away from the home for long periods to work)?



Make sure that the sanitation project takes account of their availability.

· Do men have the time or skills to enable them to contribute to:












hygiene education?



monitoring and evaluation, including establishing project indicators for measuring gender sensitivity?



If they lack skills, can training be provided?



· How can men be motivated to participate in the sanitation project?

Perhaps community leaders can set an example.


· Are men aware of the health benefits of improved sanitation and hygiene practices?



If not, what sorts of activities or materials would be best for increasing their awareness?



· How can men be sensitized to what women perceive as the sanitation priorities?



References consulted

Hannan-Andersson C. Ways of involving women in water projects. Waterlines, July 1985, 4(1):28-31.

Perrett HE. Involving women in sanitation projects. Washington, DC, Technology Advisory Group (TAG), United Nations Development Programme (World Bank, Washington, DC), 1985 (TAG Discussion Paper No. 3).

Wakeman W. Gender issues sourcebook for water and sanitation projects. Washington, DC, UNDP/World Bank Water and Sanitation Program/PROWWESS (World Bank, Washington, DC), January 1995.

Wakeman W et al. Sourcebook for gender issues at the policy level in the water and sanitation sector. Washington, DC, UNDP/World Bank Water and Sanitation Program, Water Supply and Sanitation Collaborative Council, October 1996.


An important and key requirement for the promotion of sanitation is innovation. This field has lacked innovation, both in promotional techniques and in sanitation technologies. Innovation and the exchange of information about these innovations is greatly needed.

Permanent mechanisms for the exchange of information on innovations need to be established, such as Internet conferencing and websites, professional meetings and associations and a professional scientific journal devoted to sanitation. Some of these mechanisms are beginning to appear.

Contained here are articles on innovative approaches showing success. This part is divided into three sections: Child-centred approaches, Participatory approaches, and Innovative technologies.

The group of articles on Innovative technologies are included here to familiarize readers with some new (and old) rather unconventional ideas being tried on large and small scales. This section does not address most of the classical sanitation technologies which have been endorsed by different sector organizations over the past decades, for that would be a separate and very large task. Here we are promoting the idea that innovation on all fronts and the sharing of information on these will move sanitation forward. These efforts, however small scale and outside walls of conventional thinking, should be supported because they may offer us alternatives for the future. Technologies of the future should recycle nutrients and prevent water pollution and further water scarcity. Without application of these key principles, we will create increasingly worse environments and greater sanitation problems. The articles should be regarded as promising steps and not necessarily as an endorsement by the World Health Organization or the WSSCC.

Promoting sanitation through children - Angela Hayden1

1 Independent consultant, Geneva, Switzerland.

Changing sanitation habits, challenging long-held beliefs or mentioning the unmentionable, calls for promoters who have energy, enthusiasm, commitment and time, and who are open-minded and willing to try something new. These are typical characteristics of children and adolescents.

Children's willingness to change sanitation habits and generate demand for better sanitation systems can provide a basis for successful health education programmes. It has also been recognized that older children often care for younger children and can influence them in changing their habits and beliefs. This has recently led to development of a child-to-child approach to transmitting improved hygiene practices.

This article explores how communities can be motivated to improve their sanitation and hygiene situation and practices through children. The approach seems to offer considerable promise for the sector since it taps an abundant and widespread resource. While not many such experiences have been documented, the case studies that follow from India, the United Republic of Tanzania and South Africa indicate a need to share this promising development as a priority.

What are the advantages of child-centred approaches?


Involving children offer obvious hope for sustainability because as children grow into adults, they will continue to implement improved sanitation practices and will influence their own children and communities to do so.

Another aspect of sustainability is the sheer mass of children potentially ready to carry out a sanitation initiative. In many developing countries, half the population is under 15 years old.

Community involvement

Involving children almost inevitably involves their parents and teachers. Children are present in every community, within every group, and even if their status is low, their energy and enthusiasm are hard to ignore.


Changing entrenched beliefs and practices is one of the greatest obstacles sanitation programmes face. Young minds are more open to new ideas. In areas where discussing sanitation is taboo, working through children may be the only way of introducing a community to improved sanitation practices.

How could child-centred approaches be implemented?

The following aspects of implemention of child-centred approaches require consideration, along with the necessity of obtaining policy commitment and specifying the results expected from programmes undertaken by children.


Appropriate training is needed for:

- facilitators;
- child promoters; and
- teachers and supervisors.

Training should ensure that improved sanitation and hygiene practices are learned, assimilated, and accepted.


A one-off activity is unlikely to have lasting results. The successful case studies include long-term follow-up, in one instance through training, in the other through repeated house visits. It therefore seems important to ensure that activities are repeated or reinforced over a long period so that changes to sanitation and hygiene practices become firmly established.


Activities should be evaluated periodically, perhaps once a year, for two reasons:

- to make certain that objectives are being attained and, if not, to adjust the project so that it eventually achieves the desired results; and

- to encourage children and adults in the community to continue their efforts by showing that those efforts are helping to improve sanitation, hygiene, and health.


As the case studies demonstrate, sanitation and hygiene promotion can have wider implications in empowering children and communities. Children become leaders and the organizational structures of communities are strengthened.


While promoting appropriate sanitation and hygiene practices, the project itself should embody other development ideals. For example, the project should actively promote gender equity and environmental protection. It must not only build local capacity, but should recognize and reward achievements. In the examples, the project provided prizes, such as school-bags and teaching materials.

Checklist for planners wanting to use a child-centred approach

· Read the case studies which follow and, if necessary, contact the authors for further information.

· Consider how children could be instrumental in improving community sanitation and hygiene, taking into account their social status.

· Contact groups of teachers or parents to test their reaction to possible projects.

· Use other articles to help in designing and implementing your project, in particular, the articles on Participatory approaches to community empowerment, and Social marketing for sanitation programmes, as well as the more practically-based articles such as the Checklist for planning better sanitation projects, the Checklist for planning hygiene behaviour-change in sanitation projects, and the Gender checklist for planning sanitation projects.

The Bal Sevak programme in India - Nandita Kapadia-Kundu and Ashok Dyalchand1

1 Institute of Health Management, Pune, India.

Young community agents of change

Schoolchildren are a valuable community-based resource and can participate actively in improving sanitation systems. This case-study illustrates a number of mechanisms through which children can be mobilized to promote sanitation. It demonstrates the impact that Bal Sevaks (children who serve their communities) have had on handwashing after defecation in a rural area of Maharashtra, India. It describes a process of empowering children, and the community-wide effects of their activities. (See also Promoting sanitation through children.)

Project description

The villages of the drought-prone Marathwada area of Maharashtra, India, present a sanitation scenario similar to that of much of the rest of rural India - scant sanitation facilities, deeply-ingrained, inadequate hygiene habits and a low demand for improved sanitation systems. Furthermore, cultural inhibitions prevent village workers from addressing issues such as defecation hygiene because villagers are embarrassed to talk about defecation.

In 1990, the Institute of Health Management, Pachod (IHMP), a grass-roots NGO, faced an unusual dilemma. Although over 75 per cent of the village households where it was working had soap, less than 25 per cent washed their hands with it after defecation. In addition, the Institute's health workers expressed extreme reluctance to address the culturally sensitive defecation issue. This situation required an alternative approach, so the Institute embarked on a child-to-community programme. Children, called “Bal Sevaks” (children who serve their communities) were mobilized to change defecation hygiene behaviours in adults. Bal Sevaks work in pairs; each pair is responsible for 30 households.

The project's objectives were:

- to generate a demand for sanitation facilities in 186 villages in Maharashtra;

- to change hygiene-related defecation behaviours, specifically to increase handwashing with soap or ash after defecation, in these villages in Maharashtra;

- to develop leadership potential in children by establishing children's groups; and

- to encourage community initiatives for environmental cleanliness and sanitation.

Although the programme began with hygiene education, it now addresses sanitation demand, and maintenance and sustained use of latrines, leadership development among children, cleanliness and beautification of the environment.

The Institute's programme covers a total population of 150 000. The Bal Sevak Programme includes four primary activities:

- house-to-house visits by children;

- establishment of children's groups (Bal Sanghatans),

- Bal Shakti, a newsletter for rural children; and

- community organization involving environmental initiatives.

Children participate in the programme as volunteers. As an incentive for their participation, Bal Sevaks are provided with school books.

Home visits by Bal Sevaks

Since Bal Sevaks tackle the difficult challenge of habit-related behaviour change, they employ an intensive, interpersonal, persuasive strategy. A Bal Sevaks pair visits each household twice a month. The younger child (8-10 years old) holds posters as the older child (10-14 years old) speaks. The children focus on a specific number of behaviours as new topics are addressed. The Bal Sevaks also monitor the programme at a household level.

Bal Sevak house visit.

The Bal Sangathans simulate village councils, by which children prepare themselves for future leadership roles.

Monthly in-service meetings are held for the children. The school-teacher supervises the Bal Sevaks at the village level.

Children's groups (Bal Sangathans)

Children are organized into groups called “Bal Sangathans” that are formulated along the lines of village councils. The village council is the primary body involved in implementing village-level development programmes. Bal Sangathans have been formed in 25 villages. The children elect leaders who are then trained by the IHMP. The Sangathans meet regularly to plan specific village-level activities. By simulating village councils, children prepare themselves for future leadership roles.

Some of the activities and programmes that the Sangathans have undertaken include fund-raising at the village level for a children's park, voluntary labour for cleaning defecation sites and handpump surroundings, and children's parades for disseminating sanitation and health messages. The formation of local street theatre troupes, which began as a spontaneous initiative by one of the village Sangathans, is now being replicated in other programme villages.

Bal Shakti: children's newsletter on sanitation

Since the Bal Sevak Programme was expanded from 25 to 186 villages, a mechanism was required to keep children and school-teachers updated on programme issues and activities. The IHMP decided to produce a monthly newsletter for children that provides them with reading material outside of their school curriculum. A 1995 survey indicated that 98 per cent of 300 rural school children in the Bal Sevak villages had no access to reading material other than their school books.

Two workshops were held in 1995 with village school-teachers and children to finalize the content, format, and frequency of the newsletter. The children named the newsletter “Bal Shakti” (Bal means child; Shakti means power) and recommended that it be published monthly. An 11-member advisory committee was formed, comprised of village school-teachers, children, and the IHMP representatives.

The newsletter focuses on different aspects of health and sanitation. It is distributed to the 186 villages with one copy for every three households. Recent issues have included articles on selection and training of Bal Sevaks, gender issues, how to conduct a promotional sanitation campaign, and personal hygiene behaviours. The newsletter includes activity sheets.



Organizing the community for environmental initiatives

Intervention with children at household, school, and community level culminates with communities initiating projects the children identify. For example, the initiative of the Bal Sangathan in the Dabrul village resulted in a villager donating land for a recreational park adjacent to the school. The village council followed with a financial donation of 1000 Rupees. This recreational park has been planned as a “garden of learning”, with the goals of providing children with play facilities and demonstrating various elements of environmental sanitation.

Children are applying social pressure on adults to demand better sanitation systems and to work towards a cleaner environment. The children's enthusiasm has triggered activities that allow adults to make important sanitation-related decisions and actions at household and community levels. For example, children in the Harshi village wanted to put basalt around the platforms of seven handpumps in their village. They succeeded in persuading farmers to donate two bullock carts for this purpose, even though it was the middle of the peak harvest season.

The Bal Sevak approach rests on the belief that change is most effective when it emanates from the community. This approach demonstrates a productive application of an abundant and energetic human resource, often ignored by programme planners. It ensures sustainability, since it involves working today with tomorrow's adults. The programme promotes equity because the children involved come from the most marginalized families and special priority is given to girls. (See Paying attention to gender in sanitation programmes.) Finally, it is rooted in prevention with the goal of breaking the faecal-oral cycle of transmission.


The programme has had both intended and unintended outcomes. The intended impact has been in the area of hygiene behaviour. The unintended outcome has been the creation of a powerful force in the children themselves. As many Bal Sevaks enter young adulthood, they continue to retain a strong spirit of voluntary cooperation and commitment.

Personal hygiene behaviours

A community-based trial of the Bal Sevak intervention showed that women in the intervention group were four times more likely to wash their hands with soap than women in the non-intervention group, after controlling for literacy, occupation, and age (1).

Table 1. Women's soap use by number of reported Bal Sevak visits in past month (N=264)

Number of times women were visited in past month

Number of women

Number of women using soap for handwashing

Per cent using soap





















In 1990, handwashing levels were 25-28 per cent in the intervention and control groups. Three years later, 66 per cent of the respondents reported washing hands with soap or ash in the intervention group, compared to 32 per cent in the control group. Table 1 indicates how soap use increased with the number of Bal Sevak visits in the intervention group.


An important goal of the programme is to reduce inequities. IHMP believes that encouraging gender sensitivity among children, especially boys, will address a deeply entrenched inequity in Indian society.

The Bal Sevak approach promotes equity because the children come from marginalised families, and special priority is given to girls.

The programme focuses on gender in two main ways: girls are recruited as Bal Sevaks, and the content and visuals of the newsletter promote gender equity. Additionally, a special issue on gender was published recently.

Bal Sevaks leadership development

Some of the Bal Sevaks who participated in the early phase of the programme are now young adults. They are demonstrating a strong inclination to continue their involvement in development work. Many want to continue living in their villages and serving their communities.

An example of this leadership development is demonstrated by Bal Sevak “graduates”, who, while still in their teens, started Bal Sevak programmes in neighbouring villages, helped prepare audiovisual materials for a sanitation campaign, and trained Bal Sevaks for the Institute's urban slum programme. Their greatest contribution is in serving as role models for younger children.

Box 1. Should a female Bal Sevak drop out of school to look after a sibling?

Children were asked in one issue of the monthly newsletter, Bal Shakti, to complete an unfinished story in which Mangal, an intelligent 10-year-old Bal Sevak girl, is forced to drop out of school to look after a younger sibling. Her brother, Raju, 8 years old, continues going to school. Children were asked to write responses to the question: “Should Mangal drop out of school?”

IHMP received more than 500 letters in response to this query. Most boys who sent letters stated the need for boys to participate more actively in household chores. Here are a few excerpts:

“You're talking about one Mangal, I can show you a hundred such Mangals in our villages. Mangal's brother should help their mother with household chores and take over some of Mangal's household responsibilities. Mangal should go to school.”
Amot Vadhane, 12-year-old boy, Panranjangaon village.

“Raju should help Mangal with housework and look after the youngest sibling. Mangal must continue her education.”
Mangala Narke, 12-year-old girl, Takti Ambad village.

“In our Maharashtra, girls are deprived of an education, even if they're intelligent; but a boy is given a chance to continue his education, even if he's not. Mangal should continue with her education and fulfil her ambition of becoming a village leader.”

Vaidya Bhagwat, 13-year-old boy, Unchegaon village.

Public policy

The Maharashtra government recently appointed IHMP as advisor to a large-scale rural sanitation campaign in four districts of Maharashtra. The government has accepted the premise that children are an optimal medium for reaching people in rural areas.

Difficulties encountered

· Initially, parents were not willing to let their daughters be Bal Sevaks. This was resolved by asking school-teachers to motivate the girls' parents.

· Some Bal Sevaks were teased by village youth. This issue was addressed during an in-service training session. The children were told to report to their teacher or IHMP supervisor if the situation became difficult.

· Despite the children's intervention, some families did not change their handwashing behaviour. One successful alternative strategy was developed by two Bal Sevaks, who delegated the responsibility of persuasion to talkative and influential women.

· The topic of defecation causes embarrassment. The children had to overcome their own embarrassment before approaching their community.

· Establishing a viable and efficient distribution system for the newsletter has been difficult. The same has been true of other audiovisual materials used by Bal Sevaks.

· The frequent transfer of policy-makers at district and state levels created difficulties in influencing policy.

Lessons learned

The key lessons learned from this programme are:

· Children are an abundant, energetic grass-roots resource.

· Children constitute an important pressure group with the potential to propel communities into action.

· Children's groups can be an effective tool for promoting better sanitation systems.

· Children can influence adult hygiene habits.

· Children are effective in applying group pressure on households.

· Change in habit-related hygiene behaviours requires intensive interpersonal contributions.

· To maintain behaviour change, additional contributions need to be incorporated into the programme planning process.

· Children's involvement generates change in two generations.

· The programme hinges on the support received from various community resources, such as village school-teachers and local groups. Sustaining the school-teachers' interest and motivation in the programme is key to its success.

· Community-based participatory approaches are essential for the creation, use, and sustainability of better sanitation systems.

Key institutions and responsible persons

Dr A. Dyalchand and Ms Manisha Khale
Institute of Health Management, Pachod
P.O. Pachod
Dist Aurangabad 431121
Maharashtra, India
Telephone: +91 2431 21382
Fax: +91 2431 21331

Dr N. Kapadia-Kundu
Institute of Health Management, Pachod
Bombay Sappers Society, Plot No. 13
Pune 411014, India
Telephone: +91 212 68546
Fax: +91 212 685462


(1) Kapadia-Kundu N. An empirical test of the Sadranikaran communication theory to defecation hygiene behaviour: evaluation of a child-to-community intervention in Maharashtra, India [Dissertation]. Baltimore, MD, Johns Hopkins School of Hygiene and Public Health, 1994.

© Nandita Kapadia-Kundu and Ashok Dyalchand, Institute of Health Management, Pune, India, edited by WHO with permission of Nandita Kapadia-Kundu and Ashok Dyalchand, 1997.

Prepared in association with SARAR TransformaciC.

The HESAWA school health and sanitation package - Eben S. Mwasha1

1 PHC Ambassadors Foundation, Moshi, Tanzania.

Participation of villagers in their own development is a key factor in the success of any community development project because participation is an essential part of human growth. Communities can be mobilized by the army to dig a trench for their own water supply or build better houses for their families without going through the dynamic process that leads to true community participation. True community participation must be able to release the people's own creative energies for their development.

Sustainability and replicability of community based development projects depends entirely on how well the community participates in the project from the early stages of planning and phasing in to the final stages of evaluation and phasing out. The process of soliciting community participation is long, slow and tedious. Often donors press for quick results and implementers are tempted to take short cuts in order to meet pre-set deadlines. There are no short cuts for soliciting true community participation. It takes time but in the long run this time will be compensated for during the implementation phase because once the community is properly sensitized and mobilized, implementation becomes easier and faster.

The problem based learning (PBL) methodology, on which the HESAWA School Health & Sanitation Package is based, has proved to be a very appropriate way of entering communities to start community based development projects because it presents a dynamic process which enables villages to become more aware of their own situation, of their real health problems, the causes of these problems and the actions that they themselves can take to change their situation. This process of awakening and raising levels of consciousness constitutes a process of self-transformation through which people grow and mature as human beings.

The school health approach has been used in the Sida (Swedish International Development Authority) supported HESAWA (Health through Sanitation and Water) project in the lake zone (Tanzania) and has proved to be a very effective tool for sensitizing and mobilizing communities to participate actively in solving their sanitation related health problems. The package consists of screening school children to identify the main health problems affecting them and calling a parents' meeting to analyse these problems by identifying underlying causes for each problem and agreeing on specific actions that they will take collectively and individually to solve the problems.

Steps for implementing the HESAWA school health and sanitation package

Pre-screening procedure

Stage 1: The chief facilitator organizes a workshop for the district PHC (Primary Health Care) committee to introduce the main concepts contained in the package and solicit intersectoral collaboration. The necessary resources for carrying out this exercise are listed and the feasibility of implementing the package in their district is discussed in great detail. At the end of the meeting the committee selects the screening team that will be taught how to implement the package practically.

Introducing the idea to the teaching staff.

Stage 2: The district health promotion team discusses the idea of screening children with the teaching staff of the selected school, stressing the importance of health education to school children, school health clubs and intersectoral collaboration. The teachers are also introduced to simple forms that will be used by senior pupils to collect environmental sanitation baseline data from their village.

Stage 3: The screening team, together with the head teacher, make an appointment to discuss the program with the local village committee. This meeting should stress the community participation and prevention aspects of the program.

During this meeting the promotion team must explain clearly the importance of the parents' meeting to work out a prevention strategy for their children and the community as a whole. The success of this program will depend, by and large, on the quality of this meeting.

Stage 4: Ask the head teacher to appoint 20-30 intelligent pupils from senior classes and teach them how to fill in the special home visiting forms for collecting baseline information on the current state of latrines, refuse pits, drying racks in the village. Teachers should assist the pupils to collect this information before the actual screening is done.

Prior to the screening exercise, the teachers will record the name, age, sex, class, weight and height of each child on a special form to be provided by the health team. Make an appointment with the head teacher to specify the actual days for implementing the activities in his/her school. Make sure you have the following staff and equipment.

Technical staff (selected by the district PHC committee)

1. Clinician - one medical assistant or RMA
2. Lab technician or a trained microscopist
3. Trained nurse
4. Nursing assistant or health assistant

Non-technical staff (selected by the screening team)

1. For weighing - one person
2. For measuring height - one person
3. For registering - one person
4. For assisting the lab technician - two persons


1. One ream of duplicating paper or rough paper
2. Seven marking pens and two rulers
3. Three marking pens to write on slides and test tubes
4. Waterproof brown adhesive tape for marking slides and test tubes
5. Slides - 400
6. Test tubes - 200(10 cc)
7. Spirit 500 mls
8. Cotton wool - one roll
9. Disposable prickers - 600
10. Applicators - 100 (can be made locally)
11. Gloves - six pairs
12. Antiseptic - 100 cc
13. Microscope - one
14. Hand centrifuge - one
15. Filter paper #1 - two pieces
16. Tallqist chart for Mb. estimation
17. Test tube rack for 100 tubes - one
18. Tape measure - one
19. Pair of scissors - one
20. Weighing scale - one

With the above equipment and staff the screening team can examine about 100 to 150 pupils daily for the following:

1. Height

2. Weight

3. Haemoglobin

4. Stool for immediate microscopic examination

5. Urine for immediate microscopic examination

6. Clinical examination which should include answering one or two specific questions, e.g. episodes of diarrhoea in the last month, eating habits, etc.

7. Quick physical examination for obvious clinical abnormalities

Note: The non-technical staff listed in Stage 4 can be teachers from the school, senior pupils, the driver, or existing Village Health Workers (VHWs).

Detailed screening procedure

On the screening day, the teachers should give each of the 100-150 pupils listed for that day a small clinical form (10 x 15 cm) with the pupil's name and serial number on it. Each pupil will then carry this clinical form through the following steps:

Step I: Collection of stool specimens

One day prior to the screening day, the head teacher will ask the first 100-150 children on the roster to bring a small amount of stool specimen in an empty match box. One of the non-technical staff will collect these specimens and label them ready for immediate microscopic examination by the microscopist.

The microscopist/lab technician will record the findings on a separate urine and stool examination form to be handed over to the clinician for compilation at the end of the day.

Step II: Collection of urine specimens

Immediately after receiving a stool specimen the nursing assistant gives a labelled test tube to each pupil and asks him/her to fill it up with his/her own urine. One of the non-technical assistants will centrifuge each urine specimen before handing it over to the laboratory staff for immediate microscopic examination. If a centrifuge is not available, the urine specimen should be allowed to settle for 30 minutes before the sediment or the last drop at the bottom of the test tube is put on a clean slide for microscopic examination. The technician records his/her findings accordingly.

Step III: Haemoglobin estimation

After handing over the urine specimen each pupil moves to the next step where a nurse estimates his/her haemoglobin using the Tallqist method. The nurse records this estimated haemoglobin on the pupil's clinical form.

Step IV: Short history and clinical examination

At Step IV, the clinician takes a short clinical history, conducts a quick clinical examination and records all positive findings on the clinical form. This form remains with the clinician after the examination.

Screening of children

Data analysis and report writing

At the end of the day, the clinician, in collaboration with the other members of the technical staff, completes entering data from the technical staff on the original forms which had partially been filled by the teachers. Examination/interview results from the technical team on stool, urine, Hb, history of diarrhoea, eating habits etc. are added to these forms.

The clinician in charge, in collaboration with the technical staff, will now work on data analysis and report writing for each pupil, as well as for the entire school as a community. The team will identify and list the top five health problems affecting the children. The health team will prepare relevant health learning materials based on these problems to be ready for the parents' meeting which should be held not later than seven days after completing the examinations.

Parents' meeting

The parents' meeting is a crucial event in this program. In order to strengthen intersectoral collaboration, key actors from sectors other than the health and education departments should attend this meeting. Ward leaders and village chairpersons from neighbouring villages should also attend.

Parents' meeting

The first activity during this meeting is to present a written medical report to each parent. This report should list the health problems affecting each child. It should also state clearly what action the parent should take to solve the child's problem as soon as possible. The health team must see to it that medical ethics are observed when communicating individual reports to parents. The parents whose children have no medical problem should be congratulated and encouraged to maintain their children's good health.

Having done this, the district team, which should include the District Medical Officer (DMO) and other members of the district health promotion team, will go over the top five medical problems affecting the children and discuss them in detail with the parents. Problem Based Learning (PBL) and other learner centred adult teaching techniques should be used. The health team members will act as facilitators rather than lecturers. At the end of this meeting, parents should be able to:

· State the top three to five health problems in the school.
· Describe underlying causes of each problem.
· State/list possible solutions for each problem.
· State what they have agreed to do to solve each problem.

During this meeting, the parents will be facilitated by the health team, under the chairmanship of the village chairman, until they have worked out a detailed plan of action specifying:

· What is going to be done?
· Who is going to do what?
· When it is going to be done?

Selection and training of a village health committee

The parents' meeting should elect a village health committee (VHC) if it does not exist. This new or reinforced committee should consist of about 8-12 people, of which half should be women. The committee should be empowered to deal with all health and sanitation problems in the village. The village chairperson and secretary should be ex-officios in this committee.

Soon after the parents' meeting the overall village government should meet to discuss all parents' resolutions to legalize them while re-enforcing existing village by-laws on sanitation when and if necessary. District and sub-district trainers should organize a six-day seminar for the (VHC) not later than 30 days after the parents' meeting. Recommended are four hours of training three times a week for two weeks. This seminar should cover, among other topics, the following:

1. Detailed health education on the main health problems affecting their children.

2. More detailed plans for implementing the parents' resolutions.

3. The role of Village Health Workers (VHWs) and Village Fundis in implementing their plan of action including recruitment, selection, supervision and motivation of these key workers.

4. Write their own constitution to outline how they will run their affairs.

5. Other program specific concepts like HESAWA concept and gender issues.

Selection and training of village health workers (VHWs)

At the end of the seminar, the VHC should be given two weeks to work with the village government and villagers to select VHWs and Village Fundis for training. Ideally, they should select one VHW/VF for every 50 households. It is recommended that training of the selected VHWs/VF be done within the village by sub-district trainers.

Six hours of training per day, three days a week for three months should be enough to cover the Ministry's syllabus for VHWs.

Training of VHWs

Health education and school health clubs

Organize a workshop for the teachers in the village primary school where the screening was carried out. Two hours a day, two days a week for three weeks running concurrently with VHW training within the village would be ideal.

This workshop should aim at equipping the teachers with the knowledge and skills for implementing an effective health education campaign in the school. It should be based on the health problems found among the pupils. The teachers will be provided with the necessary books and other materials for health education. Pre and post tests will be given to pupils to assess the amount of knowledge transferred to them. AIDS shall be included in the health education curriculum as a special subject for all schools.

Formation of school health clubs can be discussed in detail during this workshop. The following steps will be discussed and adopted:

1. Teachers select 20-30 pupils (from Std V and above) who are always clean and smart.

2. One teacher accompanied by a trainer will visit the homes of each of these 20-30 pupils to certify whether they have a good latrine, refuse pit and drying rack. Those who qualify are then officially declared the founding members of the school health club. Each one is given a school bag, mathematical set, T-shirt or any other incentive that will raise the other children's interest to join the club. The founding members should then elect a chairperson, a secretary and a treasurer. The health teacher or domestic science teacher should be their patron/matron.

3. Each group should establish specific and detailed criteria for joining the club. They will take over the role of inspecting other pupils' personal hygiene and homes for qualification to join the club.

4. The district health promotion team will facilitate and encourage health clubs from different schools in a given ward to compose health songs, stories and short plays, or design posters to educate the public on health and sanitation related problems. The best performers will be rewarded accordingly.

The Health team will also be expected to facilitate health clubs to run mini projects like rabbit farming, vegetable gardens and raised stoves.


The teachers will keep copies of all data related to this program for the purpose of monitoring and evaluation. The district team will conduct KAP studies from time to time to evaluate changes in knowledge, attitude and practices related to school health and environmental sanitation activities in the village as a whole.

As stated earlier, each village will be encouraged to discuss their progress regularly. At the end of each year, the whole exercise will be repeated from Steps 1 through 6. The parents will be congratulated for any improvements achieved during the year and new problems will be dealt with accordingly. This will lead to appropriate modification of their plans of action to be implemented in the following year. This process will be repeated until the villagers are satisfied that the problems in question have been reduced to an acceptable level.

Results from implementation in pilot districts

In 1993 this methodology was tried in three districts in the program area, and the following results were obtained:

· Over 80% attendance at parents' meetings.

· Active participation by all parents during meetings.

· Action oriented meetings - implementation of village action plans effective up to 75% within six months in some villages (see Bwanga results below).

· Villagers were willing to use locally available materials for latrine construction.

In October 1993, the Department of Health Behaviour and Education of AMREF was asked by Sida to evaluate this approach and make recommendations accordingly. AMREF came up with the following main conclusions.

1. The school health package (SHP) has succeeded in creating awareness on environmental sanitation related health problems, their causes and solutions among the target populations.

2. Communities have been motivated to participate actively in implementation of environmental sanitation activities.

3. The school health strategy has made remarkable progress in promotion of the use of available materials and in increasing sanitary facilities (latrines, dish racks, refuse pits and bathrooms). There is a high potential for sustainability of construction of these facilities.

4. The SHP has promoted interaction between government extension workers, teachers and community members in finding solutions to prevalent health problems, especially at the community level.

5. There exists a high potential for replication of environmental sanitation activities promoted through the SHP.

6. To some extent, the SHP has promoted community participation in decision making through parents' meetings.

Figure 1. SHP effect on village environmental sanitation

VIP latrine melam type

The following graphs are extracts from the AMREF evaluation report that was submitted to the Sida/HESAWA annual review mission in November 1993. Based on this report, Sida accepted the HESAWA school health and sanitation package and recommended that this approach be used throughout the HESAWA program area with effect from July 1994.

Figure 2. New latrine growth profile

The growth of latrines since 1991 was investigated. Results are shown in Figure 2.

In all the three sites, there is a remarkable growth in the number of new latrines during the year 1992/93. However, the school health intervention villages registered better performance compared to other sites.

Construction and use of new dish racks, refuse pits and bathrooms showed similar growth profiles and the following conclusion was made by AMREF:

“Overall the assessment of the construction of latrines, dish racks, refuse pits and bathrooms shows a better performance in the HESAWA school health intervention villages compared to the control villages. The better performance of the HESAWA school health intervention villages can be attributed to the influence of the problem based learning approach.”

A comparison was made on existing facilities in the non intervention villages and villages neighbouring the school health intervention area. The results are shown in Figure 3 overleaf.

Figure 3. Level of replication of sanitary facilities

As shown on the graph, the villages neighbouring the school health intervention areas (RE) have performed much better than the non intervention areas.

Children as health and hygiene promoters in South Africa - Edward D. Breslin1, Carlos Madrid2 and Anderson Mkhize3

1 Mvula Trust, Johannesburg, South Africa.

2 Operation Hunger, South Africa.

3 Operation Hunger, South Africa.

The importance of hygiene and health promotion in maximizing the impact of water supply and sanitation interventions is well known. These are also commonly recognized as the most difficult programmes to plan and implement. In practice, health and hygiene promotion is often uninspired and underfunded add-on to water supply and sanitation programmes. Most health/hygiene programmes are targeted at adults or formal health care sector personnel and emphasize the one-way communication of pre-fabricated hygiene information and practices. Mothers, fathers, care-givers, doctors, and community health workers are then responsible for transferring the acquired health/hygiene knowledge and modifying inappropriate practices at the household and community level.

The growing child-to-child movement has begun to challenge the notion that adults and formal health sector personnel are the only, or even the best, promoters of behaviour change and better health within the household and broader community.

The potential benefits and advantages of the child-to-child approach are many. First, children are unusually candid about hygiene-related beliefs and practices. They often identify critical gaps in the transmission and enforcement of health/hygiene messages from the “educator” to the adult and into the household.

Second, children are stable members of households with relatively plentiful supplies of free time and energy. In contrast, adults who have been “trained” are often not home while they search for work or complete other household tasks.

Third, children's behaviour is often unaffected by promotional campaigns targeted at adults. It is not uncommon for children to be excluded from hygiene facilities or discussions on hygiene practices. These problems are compounded by confusion over who within the household or broader community is responsible for teaching children about health and hygiene issues. For instance, it is not always clear who is specifically responsible for teaching children to use a toilet (mother, father, grandparents, teacher) and what to do when that particular person is absent from the household/community for long periods of time.

Fourth, peer groups and peer pressure for acceptance often have a far greater influence on child behaviour and attitudes than adult - child interactions.

In addition (perhaps because of preconceptions about differences in how adults and children learn), child-to-child programmes tend to be much more interactive. Children are not simply lectured on appropriate behaviours but rather encouraged to act upon these messages at school and within the home. Broad experience shows that practices that are familiarised and repeated over a long period of time (and in many respects monitored) within school have a better chance of being applied at home than promotional campaigns where the gap between the training course and the home is often great. Children also take on the initiative as a project, which breaks the monotony of school and creates a greater sense of self-respect and control over the process.

Finally, it seems likely that health/hygiene practices learnt at an early age will have a beneficial impact on future household health as these children become parents.

This article describes a child-to-child programme that is being implemented in Maputuland, KwaZulu/Natal by Operation Hunger, a South African NGO providing sanitation support in the area (1). The programme emerged as staff realised that previous hygiene initiatives were having very little impact on behaviour within the household or at local schools.

Learning from Children

Operation Hunger initiated the programme at the Mabadleni High School with Standard 9 pupils. The students indicated that they wanted to initially explore issues of handwashing, but the initiative expanded to address the problems of the safe disposal of infant and toddler faeces as well.

A modified version of the game snakes and ladders as well as other SARAR methods (2) was used to establish the framework for the programme. The strategy was to first identify the reasons why handwashing and the safe disposal of infant and toddler faeces was not occurring, and then develop a plan of action to address at least one aspect of the problem.

Despite showing a good awareness of why handwashing is important (germs, the transmission of germs from hand to mouth, or hand to food to siblings' mouth) the children argued that people do not really wash their hands after using the toilet. As the programme developed, it became clear that people in the area do not wash their hands for both structural and social reasons. According to children at the school these included:

- limited knowledge within the community on why handwashing is important;
- water shortages in the area mean that there is not enough water for handwashing;
- people are uncivilised;
- people do not see handwashing as important for health;
- people think hands are clean (germs not visible); and
- while people have been told of the linkage between handwashing and disease, many do not believe there is a direct link.

Children debated many of the points raised above, particularly over the issues of being uncivilised and lacking adequate water. As one child said, “do you think I am uncivilised because I do not wash my hands? If so, then we are all uncivilised because none of us wash our hands after relieving ourselves.” This discussion highlights a gap between widely-held knowledge (handwashing is recommended) and prevailing attitudes (handwashing is not truly valued) which will have to be overcome for this project to be successful.

Children also discussed the disposal of infant and toddler faeces.4 At first, children concentrated on a structural issue - the toilet holes are too large and children will be afraid. This is a common claim and often leads to strategies to make child-friendly toilets with small holes. However, when the issue was explored in more depth, it was found that this problem masked an additional obstacle to changing practices in the area: people do not believe infant and toddler faeces are harmful. And as a result, people do not believe infant and toddlers' faeces needs to be covered or disposed of safely (3). User-friendly child toilets will therefore not have a dramatic impact on child use unless this belief is countered.

4 In Kwa-Jobe, toddlers are encouraged to use a toilet when they reach the age of 4, which is unusually young when compared with other parts of the country where children often do not use toilets until they reach the age of 6 years.

Children Take Charge

Children in Standard 9 developed a series of strategies designed to combat the problems identified above. To begin with, they committed to promoting proper hand washing within the school. As a first step, they designed signs which were placed at all toilets reminding students to wash their hands after using the sanitation facilities. Secondly, Operation Hunger committed to purchasing a basin, towel and introductory supply of soap for each toilet within the school compound. Children would have to ensure that the basins had water in them and would resupply soap or ash once the original supply was used. Children would also monitor whether the basins were being used by all the children and teachers at the school.

From this, a number of additional interventions are being considered or will be implemented shortly. First, Operation Hunger has committed to constructing additional toilets at the school. Children will be involved in the construction of the toilets so that they can better promote VIP systems at home and at other schools. Second, Operation Hunger will conduct a hydrological survey at the school to determine whether a handpump can be installed to reduce the burden of collecting water for hand washing. The children will have to manage, maintain and repair the water system as part of a school project.

Third, students committed to conducting a similar exercise at other village schools so that the message and programme can spread from Mabadleni High School. Operation Hunger will only play a support role to this process and monitor the messages conveyed. The organization has also committed itself to providing hand washing materials (basin, towel and introductory supply of soap), assisting the children to construct additional toilets, and if feasible, water systems at the schools where students to outreach education.

Finally, children have committed to bring home messages about hand washing, the importance of proper sanitation facilities and the need to safely dispose of infant and toddler faeces.

The next step is for Operation Hunger to begin measuring the impact of the children's efforts by determining (through observation, qualitative and quantitative surveys) whether:

- households have hand washing materials (basin, towel, soap/ash and water) readily available (and perhaps exclusively available);

- children from other schools become part of the initiative;

- children and toddlers can demonstrate proper hand washing;

- infant and toddler faeces are covered or disposed of properly;

- there is an increase in applications for toilets in the village; and

- whether household members can verify whether the points listed above were the direct result of their child's influence.

Methods for including children (as well as community health workers) in monitoring this programme will have to be explored.


Although still in its infancy, the child-to-child programme emanating out of Mabadleni High School offers practitioners an alternative approach to conventional health/hygiene promotion strategies. The potential capacity of children to actively promote, health/hygiene campaigns is significant and under-exploited. They can complement health/hygiene efforts originating in the formal health care sector, and may often have a greater influence on other children's behaviour than programmes where the main facilitators are adults.

There may also be indirect benefits to the school. In addition to infrastructural developments such as new toilets, hand washing facilities and water systems, students who have proven their capacity to manage and promote a project which they developed may take a greater interest in school itself.

Operation Hunger must also continue to develop its capacity to support children's educational efforts. Messages communicated through children are unlikely to be universally accepted by adults unless they are reinforced through other channels. In addition, support for children's programmes must be offered in such a way that children see it as constructive and supportive rather than stifling and controlling.


(1) Breslin ED, Madrid C, Mkhize A. Subsidies and sanitation; increasing household contributions to sanitation in KwaZulu/Natal. 1997. (Paper presented at the 23rd WEDC Conference, 1-5 September 1997, Durban, South Africa). WEDC Conference Proceedings, Loughborough University, Leeds, UK, 1998.

(2) Srinivasan L. Tools for community participation: a manual for training trainers in participatory techniques. New York, UNDP, 1990, (PROWWESS/UNDP Technical Series Involving Women in Water and Sanitation).

(3) Pickford J. Low-cost sanitation: a survey of practical experience. Intermediate Technology Publications, London, 1995.

Promoting sanitation through community participation in Bolivia - Betty Soto T.1

1 Community Development Advisor, YACUPAJ Project, UNDP-World Bank Water and Sanitation Program.

The Bolivian YACUPAJ project engages men and women in scattered Bolivian highland communities in the process of choosing technologies appropriate to their sanitation needs and economic capacity. The technical component of the project is matched by a strong hygiene and environmental sanitation education programme, sensitive to the cultural characteristics of the region. In helping communities decide their own development needs, implement the project, and acquire new skills, it assures the long-term sustainability of services.

A demand-driven, decision-making approach that works

The YACUPAJ basic sanitation project for scattered rural populations uses a demand-driven, decision-making approach that permits both men and women to identify technical options and select service levels according to their water and sanitation needs and economic capacity. Technical choices are made within the framework of nationally developed and tested appropriate technologies. The implementation strategy, including a community development component, allows for different participatory tools to be used and true community participation to take place. The specific contents of the hygiene and environmental sanitation education programme are inspired by the cultural and economic characteristics of the region.

Project objectives

· To improve the economic and health conditions of the inhabitants of widely scattered communities in the highlands of Bolivia, by providing potable water, sanitation, and sanitary education - with special consideration given to sustainable strategies, appropriate technology, and the active participation of women.

· To assist the Government of Bolivia in developing strategies for supplying sustainable water and sanitation services to the scattered, rural highland population. This should serve as a foundation for designing sector policy and large-scale investment programmes.

· To help the department of Potosevelop its capacity to plan and implement water supply and sanitation services, by preparing plans for three provinces and implementing model projects that will benefit some 75 000 people.

Project description

The YACUPAJ project was initiated in 1990 in response to deficient water and sanitation services in the rural areas of Bolivia. Conditions included the following:

- weak sector institutions, including an absence of sector and funding policy;

- lack of coordination between donor agencies and investment funds;

- excessive focus on the technical aspects of water and sanitation projects;

- limited consideration of service sustainability; and

- limited coverage of water and sanitation services (24 per cent and 17 per cent, respectively) in rural areas where 42 per cent of the country's population lives.

Project site

YACUPAJ was implemented in the department of Potoslocated in the southeastern Bolivian highlands. Potosomprises about 10 per cent of the country's total population, with a higher ratio of rural population (66 per cent) than the national average. The department is one of the most economically depressed in the country, with annual per capita income of US$ 434, life expectancy of 52 years, infant mortality of 118 per 1000, a 38 per cent illiteracy rate, and a 96 per cent migratory rate.

Eligibility criteria for community participation in the project included:

- villages with a population of 50 to 250 inhabitants;
- request generated by the community itself; and
- technical viability for service provision.

If accepted into the programme, beneficiaries were expected to abide by the project's funding policy and take responsibility for operating and maintaining the services long-term.

Project strategy

The YACUPAJ programme strategy was based on the following elements.

Community management. Community members played a key role in managing the entire process. To assure sustainability, they were expected to define their own needs and identify the level of their participation and the type of project they were willing to work for and contribute to financially.

Involvement of women. The active participation of women in each stage of the project was ensured.

Appropriate technology. Facilities were simple, low-cost, and easily maintained by users.

Latrine construction. Household latrines were constructed by family or community personnel.

Community contribution towards investment costs. This facilitated local ownership of the programme and reduced state subsidies.

Hygiene and sanitation education and training. This key activity ensured the effective and sustained use of services.

Strengthening of local resources. State and private institutions remained involved after the project was concluded, to ensure sustainability.

The YACUPAJ project was implemented from 1991 to 1994 at a total cost of US$ 2.8 million. The main funder was the Dutch Government.

The project operated in over 520 communities, training rural teachers, health workers, and water system operators (for examples of training material used in the project see Figure 1). Water systems and basic sanitation services were installed, providing basic sanitation facilities for 30 000 and drinking water to over 31 000. (See Table 1 overleaf for the stages of the project's implementation strategy.)

To reduce costs and ensure user maintenance, the project promoted technologies that were within the financial and technical means of the community. Technical options were chosen according to the physical and hydrological conditions of the area, including community distribution and distance between houses. The types of latrines built were:

- VIP;
- water seal; and
- double alternating pit.

Figure 1a. Rules for correctly using a latrine - Reglas para buen uso de letrinas

Figure 1b. Rules for correctly using a latrine - Reglas para buen uso de letrinas

Figure 1c. Rules for correctly using a latrine - Reglas para buen uso de letrinas

Figure 1d. Rules for correctly using a latrine - Reglas para buen uso de letrinas

Figure 1e. Rules for correctly using a latrine - Reglas para buen uso de letrinas

Figure 1f. Rules for correctly using a latrine - Reglas para buen uso de letrinas

Training methodology

The SARAR non-formal education and training methodology was followed in the project. The methodology was a critical element for stimulating the communities' capacity to make decisions, plan, create, organize, express ideas, and take collective responsibility. The process fully respected the communities' cultural, social, and economic characteristics.

Table 1. Project implementation strategy at the community level



Activities/Materials used/Objective

1 month

Assessment of target communities

Potential communities are identified

1 month

Project promotion

Communities receive information about the project, including scope and funding policy

Community self-diagnosis

Initial contact is made through the following SARAR1 participatory activities:

· Community mapping - population, distribution of houses, etc.

· Water sources/water uses - identification of community water sources

· Customs and habits - related to disposal of excreta and garbage

· Unserialized posters - creating awareness of predominant customs and problems

· Healthy child/sick child - identifying causes of sickness in children under five years of age

1-2 months

Generation of a demand for sanitation

· Variety of model latrines constructed in centrally located communities and in schools and health centres.

· Masons trained as sanitation promoters during construction process

Reflection and analysis on the problem of excreta disposal:

· Contamination cycle - identification of excreta contamination routes

· “Tom Cat” slides - recognition of the need for a place for sanitary disposal of excreta

· Three-pile sorting - analysis of diarrhoea-related diseases and excreta contamination routes (especially effective in schools)

· Faecal-oral cycle - recognition of the importance of clean hands and basic hygiene

· “Higinia” - focus on total community development

Communities request participation

Communities request the project to improve their sanitation systems

1 month

Technical and social feasibility

Technical and social base-line information is gathered

Presentation of different sanitation technical options and service levels

· Flip chart demonstrates different technical options (including advantages and disadvantages) for family, multi-family, and school facilities

· Cash and in-kind contributions are defined

Latrine selection

Latrine is constructed by family or community, with support of trained masons and advice from project personnel

1 month

Operation and maintenance of latrines

Effective and hygienic use of latrines is reinforced:

· Healthy latrine/sick latrine

· Posters in schools with guidelines for latrine care

· Booklets and pamphlets on cholera

Follow-up and evaluation

Provincial teams provide ongoing follow-up and evaluation

1 SARAR participatory methodology: Self-esteem, Associative strengths, Resourcefulness, Action-planning, Responsibility for follow through.

The approach clearly demonstrated that participatory methods and tools should be carefully selected, with a clear understanding of the expected results. The SARAR methodology assisted the communities in determining their own development priorities, implementing the project, and acquiring new skills for effective use and sustainability of the services.

Rural teachers, nurse aides, and extension personnel participated in designing visual, audiovisual, and written materials that were thoroughly field-tested with the communities.

The methodology:

- facilitated a participatory process for reflection, analysis, and information-sharing with groups of illiterate women in 85 per cent of the communities;

- encouraged schoolchildren to participate in the process and to share information in new ways;

- stimulated rural teachers to use innovative methods and participatory tools in the classroom; and

- facilitated the training of health care workers in health, hygiene, and sanitation.

Training process

The structure of the training programme is summarized in the table below.

Table 2. Structure of the training programme

The central project teams provided training and ongoing support to provincial teams, which in turn worked closely with promoters in replicating the process in the communities.


· Even though the project worked with the poorest people in the country, more than 50 per cent of the funding was provided by the communities, including 30 per cent of the cost of non-local materials.

· Within their economic means, communities selected the best technical option and service level for covering their sanitation needs.

· Demand for latrines surpassed programme expectations.

· 596 community operators were trained, including training in the sanitation component.

· More than 4200 community development activities were implemented, with over 125 000 persons participating - 35 per cent women, 43 per cent men, and 22 per cent children.

· A sustainability study in 1995 showed that 82 per cent of the latrines were still in use.

· Sixty per cent of the families perform regular maintenance tasks - cleaning the slab periodically and disposing of paper used for anal cleansing.

· Showers and washbasins have been installed in 40 per cent of water seal latrine facilities.

· Trained masons continue to build latrines with direct responsibility to client families and no need of external support.

· A notable change of attitude relating to latrine use has taken place.

Difficulties encountered

· Some technical personnel were reluctant to explore a participatory approach.
This was resolved experientially, by encouraging them to be on-site trainers at the community level.

· There was resistance to changing the predominantly technical, and conventional approach to implementing sector projects.
This was overcome when preliminary results of project performance indicated a clear advantage over projects with a strictly technical focus.

· In some male-dominated communities, women's participation was not permitted - even in meetings of an informative nature.
Information was given first to groups of men, initiating demand-generating processes. Later, the importance of sharing this information with women became evident, considering their primary role and responsibility for family health care.

· Women were resistant to attitude and behaviour changes, because of deeply-rooted traditional beliefs revealed in the following comments: “No personal hygiene or hair combing! The extent of dirt crusts on the body is a sign of a person's wealth. There is fear of losing identity, of ceasing to be what we have always been. Cattle may be lost - or loved ones' lives.”

Health and hygiene training was begun with children and young women. Although adult and elderly women took part in the sessions, they were not influenced in the same manner as the young people.

· Elderly women rejected the use of VIP latrines. They believe the hole represents a permanent opening in the “Venerable mother earth, to whom we owe respect and must not keep open, because she becomes angry and makes women sick, blowing into their natural opening (vagina).”

The use of the VIP latrine was promoted among younger women and children, with good results, proving that latrine use does not cause common female illnesses.

Also, women were provided with information about these illnesses and how to prevent them.

Lessons learned


· Poor beneficiaries are willing to choose and pay for sanitation services.

Training process

· Training processes are most effective when they empower people to learn to do things for themselves.

· The best training strategy focuses on enabling people to eliminate the obstacles that prevent sanitation facilities from producing health benefits.

Human resource capacity-building

· The implementation team must be multidisciplinary, because success depends on the synergy of different specialties.

· Extension workers or fieldworkers must recognize and accept indigenous campesino knowledge, forms of organization, authority structures, and decision-making processes. They must acknowledge that campesinos are acting on their own territory, within the context of their economic situation and family life,

Community development

· Sustainable development cannot be achieved by imposing technology. Local choice, management, control, and responsibility imply the freedom to make one's own mistakes. When the community takes the initiative, this freedom exists, and there is potential for building something greater than just water or sanitation facilities.

· Community self-financing is at the core of community management and is the fundamental element for developing a sense of ownership.

· The community's assimilation rate is different from the physical implementation schedule; the time designated for training should reflect this situation.

· The training and community participation plan should take into account that a high percentage of campesino women are illiterate.

Future plans

The YACUPAJ project was designed as a demonstration project to test service provision strategies for the widely scattered rural population of Bolivia and to use this experience to prepare a nationwide programme. YACUPAJ highlighted innovative ideas: in terms of cost-efficiency, demand-based investment, government cooperation, use of intermediaries, women's participation, and hygiene education. By creating awareness of these ideas among sector personnel, YACUPAJ helped create the foundation for developing national policy.

The YACUPAJ project results have been essential for preparing the IDA-financed Basic Rural Sanitation Project - PROSABAR, whose preparatory phase began in 1993 and nationwide implementation in 1995.

Key institutions and responsible persons

Lic. Alain Mathys, Programme Director and
Ing. Rafael Vera, YACUPAJ Project Director
UNDP-World Bank Water and Sanitation Program
La Paz, Bolivia
Telephone: +591 02 316718/357911
Fax: +591 02 392769

Ing. Juan Carlos Tito
Department Director for Basic Sanitation (DIDESBA)
Department of PotosR>PotosBolivia
Telephone: +591 062 27348

Dr Antonio Gumiel
Regional Health Secretariat of PotosR>PotosBolivia
Telephone: +591 062 26413

Dr Grover Linares
TomKatari Polytechnic Institute (IPTK)
Sucre, Bolivia
Telephone: +591 064 53898/62447

Dr Guillermo Benavides
Center for Investigation and Campesino Support (CIAC)
Telephone: +591 062 22874

Dr Betty Soto T.
Community Development Advisor
La Paz, Bolivia
Telephone: +591 02 327675

© Dr Betty Soto T., Community Development Advisor, YACUPAJ Project, UNDP-World Bank Water and Sanitation Program, La Paz, Bolivia, 1995, edited by WHO with permission of Dr Betty Soto T., 1997.

Prepared in association with SARAR TransformaciC.

Strengthening a rural sanitation programme using participatory methods in Uganda - John Odolon1

1 Network for Water and Sanitation (NETWAS), Entebbe, Uganda.

The Rural Water and Sanitation (RUWASA) Project (Phase I) of the Ugandan Government was started in January 1991 with the aim of improving the standard of living of various rural populations by reducing diseases related to unsafe water and poor sanitation.

Specific objectives included the following:

- to provide protected water sources and hygienic sanitation facilities to the population in the project area; and

- carry out information, education, and training activities for both project-level staff and users aimed at adoption improved hygiene behaviour.

Problems faced by the RUWASA Project in 1993

In 1993, the findings of the Joint Review Mission,2 project monitoring reports and studies, as well as observations by project visitors, indicated that the efforts of social mobilizers (health assistants and community development assistants) were not bringing about the desired behaviour, especially at the level of the water-user committees (WUC). In particular:

· WUC members could not easily identify who was using their water source.

· Precise details of the sanitation situation of the water users were not known.

· There was a tendency for the community to rely heavily on external support (from health workers, RUWASA or NGOs) to identify and provide interventions for sanitation and hygiene problems.

· There was hardly any evidence of extensive practice of hygienic behaviour, for example, handwashing, after latrine use.

2 The RUWASA Joint Review Mission, an independent body that does not include project staff, is part of the project's monitoring and evaluation mechanism. Membership includes: Ministry of Health (Departments of Environmental Health and Health Education), Ministry of Gender and Community Development, Ministry of Finance/Planning, Consultants (Engineers and Socio-Economists), and DANIDA.

So what was the problem? Partners' participation at household and community level had been limited to providing cheap labour and available materials. It was assumed that, having been duly instructed on their roles, the WUC would ensure water source maintenance and the practice of hygienic behaviour.

A closer look at the mobilization and training techniques revealed that the approach did not adequately equip the mobilizers with the necessary skills to bring about participation or a sense of ownership at community level. The training methodology was mainly didactic, interspersed with classroom-based discussions, role playing and video shows on operation and maintenance. The result was that the WUCs had little contact with the realities of hygiene, sanitation, and the water use and behaviour around them.

Response to the problems identified

On the recommendation of the Joint Review Mission, and in collaboration with WHO and with SARAR training experts from the UNDP/World Bank Regional Water and Sanitation Group in Nairobi, the project undertook to develop and try out PHAST participatory tools. A Guide for training water user committees using participatory tools was developed to assist the social mobilizers in their training activities. A pilot project was carried out in Mukono District, and on the strength of its success, the participatory training methodology was extended to cover the other districts where RUWASA was active. The subjects covered included community map-building, hygiene education, WUC responsibilities, and evaluation. The designed training was not limited to hygiene education and sanitation. The tools used were:

- mapping;
- sanitation ladder;
- poster and picture activities for discussion of faecal routes and barriers;
- gender task analysis;
- story with a gap; and
- other planning exercises.

(See Table 1 for more detailed description of the tools.)

Results of using the PHAST participatory approach

The principal benefits of using the PHAST participatory methodology were that the WUC and other community members actively participated in discussions related to sanitation, hygiene behaviour, water source maintenance, gender, and planning. The use of pictorial illustrations facilitated and generated discussion. This was a positive departure from the previous didactic approach.

The community members demanded the tools so that they too could train others. This reflected a feeling of empowerment: community members wanted to take charge of project activities themselves. It also showed that the tools were easy to understand and use at grass-roots level. Lessons learned included:

· The methodology is user-friendly.

· The methodology is interesting, provokes discussion, and brings out real-life experiences that cannot be brought out using traditional training methods.

· The approach is learner-centred, empowering the learner to think, and to identify and address (find solutions to) problem situations.

· The methodology eases work on the side of the trainer-facilitator.

· The methodology can be used in a structured manner, as in the RUWASA Project, or in a non-structured manner (e.g. Water Aid and KUPP use informal community members who are trained to train other community members).

· Training is continuous at the community level.

Table 1. Description of participatory tools




Group participants use whatever materials are available to them to create a map of their community showing its water-supply sources and sanitation facilities. This helps communities to visualize their overall situation. The simplest method is to use a stick to draw in the earth. If paper is available to the group, it can draw on this and stick cloth, feathers, beads, and seeds, etc. to it, for the purposes of illustration. The group then uses this map as a discussion point to look more deeply into the water and sanitation issues that the community is facing. This activity is an investigative one and helps the group to identify important issues.

Sanitation ladder

This uses a set of pictures or photos of different sanitation options. Participants arrange these on a scale from worst to best, like steps on a ladder. They identify their own situation and look at the merits and feasibility of moving up the scale (ladder).

Poster and picture activities for discussion of faecal routes and barriers

This activity starts with a set of posters-pictures showing different ways in which faecal-oral contamination can occur. Participants organize these pictures based on what they know about diarrhoeal disease transmission. The second part of the activity involves working out how these transmission routes can be blocked. To help with this part, participants are provided with pictures of common “barriers” (both technological and behavioural) that can be used to block any of the transmission routes of faecal-oral disease. The “barriers” are then looked at and classified according to their effectiveness and practicality.

Gender task analysis

This activity involves group participants sorting a set of pictures which depict normal household and community tasks on the basis of who would normally perform them: a man, a woman, or a man and woman jointly. This activity enables the group to objectively assess the way tasks are distributed by gender. It highlights any disproportion between the tasks done by men and those done by women.

Story with a gap

Members of the group use two pictures, one showing a “before” scene (a problem situation) and the other showing an “after” scene (a greatly improved situation or the problem's solution). The group uses these two pictures to stimulate discussion on the steps that would have been involved in moving from the “before” situation to the “after” situation. In this way, they fill in the “gap” in the story. This is a useful planning tool for group participants because it helps to simplify the planning process by breaking it down into a series of steps.

Three-pile sorting

Participants sort pictures or photos of hygiene- and sanitation-related situations, according to whether they are considered “good”, “bad” or “in-between”.

Assessment of the tools used

Table 2 overleaf shows the tools that were pretested and adapted by the project, and the experience of their use.

Outcomes of the RUWASA Project

To closely monitor the effect of using the PHAST participatory methodology for training at the grass-roots level, the mobilization and training units of the project followed up 19 WUCs in three different subcounties of Ikumbya (Iganga District), Bussede (Jinja District), and Kauga (Mukono District). A checklist of indicators of good WUC performance was drawn up as follows:

- proper record of water source users;

- existence of operation and maintenance funds, collection and use;

- existence of caretakers (for preventive maintenance and hygiene education);

- good general condition of the water sources (fencing, cut grass, soakaway, drains); and

- hygiene education activities (e.g. production of posters on hygiene).

The following observations were made:
- 79 per cent of WUCs had updated lists of water source users;

- 64 per cent of WUCs had collected and were using operation and maintenance funds to pay handpump mechanics, and buy grease and spares;

- 71 per cent of WUCs had proper records related to using operation and maintenance funds;

- 100 per cent of caretakers had spanners and were carrying out preventative maintenance;

- 15 per cent of the WUCs remunerated their caretakers with Shs 800-2000 (US$ 0.90-2.10);

- 100 per cent of WUCs had hygiene and sanitation messages embedded in their bylaws (for example, stipulation of use of clean utensils for collecting water) but there was no indication of direct intervention, such as meetings on hygienic behaviour; and

- 5 per cent of WUCs had an updated list of latrine and sanplat coverage of its water users as a basis for follow-up on sanitation activities.

Table 2. Pretested tools adapted by the project



Unserialized posters, photo parade

Easy to use as starters

Community mapping

Very good for establishing base-line - sanitation, infrastructure, etc.

Sanitation ladder

Easily understood and used; also establishes sanitation base-line

Faecal routes

Useful to start off a hygiene education discussion

Faecal barriers

Enables community members to think of solutions to hygiene problems that are within reach

Gender task analysis

Evokes lively discussion, which is difficult to halt; brings to light gender roles and distribution; ice breaker

Story with a gap

Eases planning discussions

Three-pile sorting

Useful for hygiene behaviour discussion

Health case study

Not much used

Roles and responsibility chart

Has been applied with success in RUWASA area by mobilizers

A total of 18 homes of water users were visited. Of these, latrine coverage was 89 per cent: 72 per cent of the latrines were hygienic (clean floor with sanplats), and 6 per cent had a hand-washing facility. The availability of these data contrasted sharply with the previous situation when it was difficult to obtain accurate information at the WUC committee level.

Acceptance of participatory approaches at institutional level

So far, the acceptance and use of the PHAST participatory methodology has largely been limited to water and sanitation projects. At policy level (ministries or agency headquarters), the Ugandan Ministry of Health supports the Uganda Community Based Health Care Association, which uses a lot of PRA approaches, although support is still very limited. The methodology is sometimes thought to be time-wasting! Training institutions, such as the Nzamisi School of Social Development and the School of Hygiene, Mbale, have embraced this methodology, especially for the practical training of students in the field.

Generally, decision-makers exposed to the methodology have shown serious interest and implicitly supported its use.

Acceptance at the community level

The communities appreciate use of the PHAST approach during training. In the RUWASA Project area, WUC members have requested PHAST tools because they would like to use them to mobilize other community members! They have been spurred into action.

Reactions of other community members

· There is full community participation in discussion, irrespective of gender, social status or educational levels.

· Communities have recommended the use of PHAST for all training activities and that everyone should be trained using this approach.

· The participation in training is consistent throughout the period.

· During community-level meetings, tasks are allocated and sanctions agreed on for non-performance.

· Some behaviour changes have been observed, including handwashing.

· The general level of cleanliness has improved.

Constraints experienced

· Supervisors and policy-makers not exposed to the methodologies have shown a lack of support.

· Tools have not been durable enough, although lamination has been tried out with some success.

· Artists who draw pictures for the participatory tools are not always available and need training when present.

· Producing materials on a small scale is expensive.

· Training costs may be prohibitive, since a full-scale workshop requires about 10 working days.

· The participatory approach is time-consuming.


The RUWASA Project experience has largely consisted of re-activation of the roles of WUC committees, extension workers, and their supervisors.

Over the last two years, PHAST participatory techniques, based on the SARAR methodology, have been successfully tried out, to bring about community-level transformation of hygiene practices related to sanitation, and water collection, storage, and use.

Information on participatory approaches can also be found in the following articles: Participatory approaches to hygiene behaviour-change and sanitation, The PHAST initiative, and Using participatory methods to promote sanitation in Bolivia.

Background reading

SDC. Participatory rural appraisal (PRA): working instruments for planning, evaluation, monitoring and transference into action (PEMT). Berne, Swiss Directorate for Development Cooperation and Humanitarian Aid, 1993.

Pretty JN et al. A trainer's guide for participatory learning and action. London, International Institute for Environment and Development, 1995 (Participatory Methodology Series).

Simpson-Hrt M, Sawyer R, Clarke L. The PHAST initiative: participatory hygiene and sanitation transformation, a new approach to working with communities. Geneva, World Health Organization, 1996 (unpublished document WHO/EOS/96.11).

Srinivasan L. Option for educators: a monograph for decision makers on alternative participatory strategies. New York, PACT Communications Development Service Inc., 1992. (PACT can be contacted at: 777 UN Plaza, New York, NY 10017, USA.)

Srinivasan L. Tools for community participation: a manual for training trainers in participatory techniques. New York, UNDP, 1990, (PROWWESS/UNDP Technical Series Involving Women in Water and Sanitation).

Towards an ecological approach to sanitation - Uno Winblad1

1 WKAB, Pataholm 5503, 5-384 92 ALEM, Sweden. The views expressed in this article are controversial and not necessarily shared by all members of the Working Group on Promotion of Sanitation or the World Health Organization. However, the author's viewpoint stimulates thinking and debate in the sector and may encourage further research, development and field trials of alternative sanitation systems. Some of the alternative systems are featured in other articles in this book.

Many of us have a bathroom; we turn a tap and get water, we flush the toilet and get rid of whatever we have put there. We take these facilities for granted. But most people in the world have no piped water in the house and many (WHO estimates nearly 3000 million) lack even the most basic sanitation (1).

There is a need for a paradigm shift away from the present non-ecological, “flush-and-discharge” approach, to a holistic approach, taking into account that sanitation is a system where the environment is an important component. To meet the requirement for ecological sanitation we must have ecological toilets. This article presents a tentative list of criteria for ecological sanitation systems and gives examples of ecological toilets from around the world. The basic theme of this article is: Don't mix!


“Sanitation” is a better term that “toilets”. A flush toilet is basically a machine for mixing human urine, faeces and water. Sanitation, on the other hand, is a system. The main components of that system are nature, society, process and device (Figure 1).

When discussing sanitation, and particularly sanitation in relation to the environment, we have to consider all these components. We cannot afford to neglect any one of them.

The crisis in sanitation

Sanitation is a problem that in many places around the world has reached crisis proportions (2). The main reasons behind this global sanitation crisis are rapid population growth and an unsuitable technological response.

Rapid population growth

Rapid human population growth results in ever increasing densities, in urban growth, in the establishment of squatter areas and in a high burden of disease.

Figure 1. The main components of a sanitation system

Figure 2. Human population density changes over the last 10 000 years; 1 dot = 5 million people (3).

Densities. There was a time in history when sanitation was less of a problem - or no problem at all: the human population was small and dispersed over a large area.

But the situation is changing rapidly. The human population is now 1000 times greater than it was 10 000 years ago. Over the past 30 years it has doubled and it may double again in the next 40-50 years. One consequence of this population growth is that we now live closer together, at ever increasing densities, putting higher and higher pressure on the environment. The closer together we live, the more important it is for us to have access to, and make use of, good sanitary facilities (Figure 2).

Urban growth. Today 2500 million people live in urban areas. Thirty years from now the urban population will reach 5000 million (Figure 3).

Figure 3. Urban population 1995-2025, less developed and more developed countries (4).

Squatter areas. If present trends continue the majority of urban dwellers in the world will live in unplanned, unserviced squatter areas in small and medium-sized towns. The typical urban dweller of the next century is not going to live in a pleasant, comfortable flat or house, with paved streets, electricity, a sufficient, pure and reliable supply of water, flush toilet, garbage collection and everything else that we tend to take for granted. Twenty to thirty years into the next century the typical urban dweller is more likely to live in a health-threatening environment: in a temporary shack along a filthy unpaved lane, water collected from a communal tap with erratic supply or bought from a water vendor, no toilet, and no garbage collection.

Disease burden. There is a marked difference in health between those who live in poor and in non-poor areas as reflected in the respective infant mortality rates. Infant mortality rates (meaning number of infant deaths per 1000 live births in one year) are far higher in the poor sections of many cities than in better-off sections. The examples in Table 1 show that the infant mortality rate in poor areas is 3-10 times higher than in the non-poor areas (5).

Table 1. The effect of poverty on the infant mortality rate




Manila, Philippines



SPaulo, Brazil






Karachi, Pakistan



Delhi, India



Poor environmental conditions give rise to high rates of diarrhoeal diseases, to helminth infections like ascariasis and hookworm, and to vector-borne diseases like malaria, dengue fever and Japanese encephalitis. More than three million people die of diarrhoea every year, most of them infants and young children; 1500 million people are currently infected with intestinal worms, all of which are spread through human excreta (6).

Unsuitable technological response

Conventional sanitation based on flush toilets, sewers and central treatment plants cannot solve these problems. Nor can they, in high-density urban areas, be solved by systems based on pit latrines of different kinds.

Flush-and-discharge. Flush-and-discharge systems make the problems of sanitation much worse. Under these systems a relatively small amount of dangerous material - human faeces - is allowed to pollute a huge amount of water. In spite of this, flush-and discharge is universally regarded as the ideal option for urban areas. Almost without question it is promoted in cities and town around the world, even in poor countries where people cannot afford it and in arid areas where there is hardly enough water for drinking (Figure 4).

Figure 4. Flush-and-discharge

This glorification of flush-and-discharge is based on a number of assumptions:

- that the problem is one of “sewage disposal”;
- that fresh water is an unlimited resource;
- that at the end of the pipe the sewage is treated; and
- that the environment can take care of the discharge from the treatment plant.

However, none of these assumptions is correct;

- the basic problem is the disposal of human faeces and urine, not “sewage”;

- outright shortage of water is, or will very soon become, a major problem for most Third World cities;

- only a tiny fraction of all sewage produced in the Third World is treated; and

- all over the world we can find examples of natural ecosystems destroyed by the discharge of untreated or partly treated sewage.

Each of these points is discussed in more detail below.

Sewage disposal vs. management of urine and faeces. A human body does not produce “sewage”. Sewage is the product of a particular technology. The human body produces urine and faeces. These are often referred to as “human excreta” but it is important to remember that they are in fact two different substances which leave the body through separate openings and in different directions.

Each person produces about 500 litres of urine and 50 litres of faeces per year. Fifty litres of faeces should not be too difficult to manage. It is not a very pleasant product and may contain pathogenic organisms. But the volume is small: when dehydrated it is actually no more than a bucketful per person per year. The real problem is that in the flush-and-discharge system faeces are not handled on their own. They are mixed with urine. This means that instead of 50 litres of a heavily polluted substance we have to take care of 550 polluted, dangerous and extremely unpleasant litres.

One of the reasons behind the unpleasantness of the mixture of urine and faeces is that faeces contain a bacterium, Micrococcus ureae, which when mixed with urine produces a very unpleasant smell (7).

Water scarcity. A flush system does not work without water. To flush away the 550 litres of faeces and urine in a sewered toilet each person uses about 15 000 litres of pure water every year. In most cities in the world there is nowhere near enough water to provide that amount for each of its inhabitants. The typical Third World city solves this problem by providing flush-and-discharge only to the rich, which of course means that there is even less water available to the poor.

Globally, some 80 countries with 40 per cent of the world's population are already suffering from water shortages at some time during the year (8). Chronic freshwater shortages are expected by the end of the decade in much of Africa, the Middle East, northern China, parts of India and Mexico, the western United States, northeastern Brazil and in the former Soviet Central Asian republics. China alone has 300 cities facing serious water shortages (9).

Wastewater treatment. Ninety-five per cent of all sewage in the Third World is discharged completely untreated into surface waters (10). Many cities do not have any sewage treatment system at all, and of those that do, most serve only a small fraction of the population.

Even where there is treatment, the vast majority of sewage treatment technologies in use today still contribute significant amounts of pollutants to the environment. Even modern treatment facilities cannot cope with for example phosphates and nitrates. Nor are treatment plants designed to detoxify chemical wastes. Primary treatment simply filters out floating and suspended material; secondary treatment facilitates the biological degradation of faeces and urine and other similar material; and disinfection destroys infectious organisms. Most of the industrial and household toxic wastes released into sewers are either discharged into receiving waters, or remain in the sludge.

Ecosystem overload. In the past it was a common assumption that the pollution which results from conventional sanitation technologies can be safely assimilated by the environment. This assumption is not correct. Some chemicals will decompose and be removed by natural processes, but most will remain in the environment. The inevitable end products of a sewage system are polluted waters and toxic sludge.

The four conventional sludge disposal methods are ocean dumping, landfilling, incineration and application on agricultural land. From an environmental point of view all these methods are unacceptable and from all over the world we have reports of the degradation of the environment due to sewage discharge and sludge disposal.

Drop-and-store. The alternative to flush-and-discharge is “drop-and-store” (Figure 5).

Such systems can be simple and relatively low-cost, and they are easy to understand and to operate. But they have many drawbacks: smell, fly breeding, risk of pit collapse, and often a relatively short life. From time to time new pits have to be dug. This may be difficult on crowded sites. In many cases drop-and-store systems cannot be used at all: on rocky ground, where the groundwater table is high and in areas periodically flooded. Recent experiments using biotracers indicate that the risk of groundwater contamination from pit latrines is greater than generally assumed (11).

Figure 5. Drop-and-store

Drop-and-store systems resulting in large number of excreta-filled pits are not feasible in densely built up urban areas. Nor is the Japanese jokaso system (“jokaso” is a Japanese technology for collection and treatment of nightsoil) a realistic option for poor countries. With manual collection the jokaso system is unacceptable for health reasons. With collection by vacuum pump truck, as in Japan, the system is extremely expensive in terms of initial investment, operation and maintenance.

A new approach

Conventional sanitation in the form of flush-and-discharge offers no solution to the global sanitation crisis. We need a new approach, a new paradigm in sanitation.

The major question in sanitation today is: How can a rapidly growing city short of money and water and with limited institutional capabilities achieve safe, non-polluting sanitation for all its inhabitants?

A new approach to sanitation must be based on equity, prevention and sustainability. Sanitation systems of the future should:

- ensure equity in the distribution of water;
- prevent harm to human health;
- achieve zero pollution discharge;
- enable us to recycle human urine and faeces as plant nutrients;
- adjust to small municipal budgets and low-income households; and
- offer a level of convenience comparable to that of conventional options.

We can call this new paradigm ecological sanitation. The first principle of ecological sanitation is: Don't mix!

Don't mix:

- human urine and faeces;
- human excreta and water;
- blackwater and greywater;
- household wastes and industrial wastes; or
- wastewater and rainwater.

By keeping urine and faeces apart, problems of bad odours and fly-breeding are reduced or even eliminated, and storage, treatment and transport are made easier.

If urine is not going to be used, it can be soaked into the ground or evaporated. However it is better to recycle urine because it contains nitrogen and phosphates in forms that are easily absorbed by plants. Urine, diluted with water, can be used directly in the garden or it can be stored and used at a later date (Figure 6).

Figure 6. Alternatives for managing urine

Faeces can, if necessary, be processed in several steps before they are reused (Figure 7).

In an ecological toilet, that is a dry toilet with urine separation, they are subject to primary treatment, basically dehydration, which also effectively destroys most of the pathogenic organisms. If this local primary treatment is insufficient, the dry output from the toilet can be transported to a neighbourhood composting station for secondary treatment. If a sterile product is required a tertiary treatment could be incineration.

The amount of treatment required depends on the health status of the users as well as on the intended end use of the product. Most pathogenic organisms can be destroyed by the primary on-site treatment which is usually dehydration or decomposition. Where intestinal parasites are common, some form of secondary treatment may be required, for example high-temperature composting. Tertiary treatment by incineration, for example, should not be necessary but remains an option in exceptional circumstances.

By not mixing human excreta and flushing water the sanitation problem is limited to managing a comparatively small volume of urine and faeces. As a result, a lot of water can be saved, expenditure on pipe networks and treatment plants is reduced, jobs are created and the environment is preserved.

By not mixing greywater and blackwater a number of relatively simple on-site treatment methods can be used for the wastewater generated by food preparation and washing.

By not mixing stormwater and wastewater relatively simple methods can be used to store, treat and recycle stormwater locally (12).

Industrial wastewater containing dangerous, poisonous chemicals must of course be taken care of at source, by the industry generating it. All the heavy metals and toxic chemicals used in industrial processes must be retained in closed loops. This can be accomplished by the introduction of the polluter-pays principle. Such a change is economically and technically feasible but in many places politically difficult.

Figure 7. Treatment of faeces in stages

Examples of ecological sanitation

“Don't mix” is central to the new paradigm and to the concept of ecological sanitation.

There are three methods by which urine and faeces can be kept apart (Figure 8). The most straightforward method is never to mix the two. This way the urine remains relatively sterile and can be reused without any further treatment. Another possibility is to mix and then drain. The third possibility is to mix and then evaporate. These different methods are illustrated in the examples of ecological sanitation, some old, some new, described below.

The first example is from Sanaa in Yemen (Figure 9): a one-chamber dehydrating toilet with urine separation placed in a bathroom several floors above street level. In a traditional Yemeni town house the upper floors have toilet-bathrooms next to a vertical shaft that runs from the top of the house down to the level of the street. The faeces drop through a hold in the squatting slab. The urine drains away through an opening in the wall of the house, down a vertical drainage surface on the outer face of the building. Anal cleaning with water takes place on a pair of stones next to the squatting slab.

Figure 8a. Ways of separating urine and faeces - keep separate

Figure 8b. Ways of separating urine and faeces - mix then drain

Figure 8c. Ways of separating urine and faeces - mix then evaporate

The water is drained away the same way as the urine. As Sanaa has a hot, dry climate the faeces quickly dry out. They are collected periodically and used as fuel (13).

The second example is from Vietnam and Guatemala. It is a two-chamber dehydrating toilet with urine separation (Figure 10). The toilet chambers are built above ground. Urine is collected and piped into a container or soakpit. Faeces are dropped into one of the chambers, the other one is kept closed. Papers used for anal cleaning are put in a metal bucket and burnt.

Each time they defecate, people sprinkle some ashes, lime or soil on the faeces. When the chamber is nearly full it is topped up with soil and the drop hole is sealed with mud. (In Guatemala a plastic bag is placed over the seat.) The second chamber is then used. When that one is nearly full, the first chamber is opened and emptied. The dehydrated faecal material is used as a fertilizer and soil conditioner.

Figure 9. Section through a house in the old part of the town of Sanaa. On the upper floors there are bathrooms with urine-separating toilets

Figure 10. The Vietnamese double-vault, dehydrating toilet, here shown without superstructure. The LASF toilet in Guatemala is of similar design although provided with two seat-risers rather than a squatting slab with two holes

This type of latrine is also used in high-density urban squatter areas, for instance in Hermosa Provincia, in the centre of San Salvador, the capital of El Salvador (Figure 11).

In a further development of the LASF toilet is has been equipped with a solar heater. The main purpose of the heater is to increase evaporation from the chamber. The example below is from the community of Tan near San Salvador (Figure 12).

Figure 11. LASF toilets in a densely-populated squatter area in central San Salvador

Figure 12. A dehydrating toilet with urine separation and solar-heated vault. El Salvador

Figure 13. A composting toilet with solar heating but no urine separation, Mexico

A prefabricated version of the solar-heated toilet has been produced in Mexico for more than 15 years (Figure 13). It can be used either as a dehydrating toilet or as a composting toilet; there are versions with and without urine separation and with one or with two chambers.

Ecological sanitation is not only for poor countries. In Sweden a number of ecological toilets have been on the market for many years. One type, “WM Ekologen” system, is based on urine separation and dehydration (Figure 14). Urine is stored in an underground tank until reused as a fertilizer. Faeces are dehydrated in a bucket directly under the toilet seat. The toilet is placed indoors. The system is usually combined with separate, on-site treatment of greywater.

Another example, the Clivus Multrum (Figure 15), has no urine separation and is based on decomposition of faeces and organic household wastes. Urine and faeces are mixed with organic household refuse, in this case via a refuse chute from the kitchen. The chamber is placed in the basement, directly under the bathroom and kitchen. This system is by now well tested in Scandinavia as well as in North America and has actually been on the market for nearly 50 years.

Figure 14. A dehydrating toilet with urine separation, Sweden

The failure of conventional sanitation technologies to prevent pollution is of particular concern on small islands. Nearly every Pacific island nation has identified critical environmental problems resulting from conventional disposal methods. The CCD toilet in Yap was developed by Greenpeace in an attempt to achieve zero-discharge (Figure 16). It is a single-chamber composting toilet combined with a greenhouse for evapo-transpiration of urine and water. A nylon fishing net, hanging from hooks imbedded in the chamber walls, is used to separate solids from liquids. A mat woven from palm leaves sits in the net to catch solid materials deposited through the toilet seat. In some units, strips of polyester from old clothing hang from the net to enhance evaporation by acting as wicks to draw up liquids into the airflow generated by the large diameter vent pipe (14).

Figure 15. A composting toilet without urine separation, Sweden

Figure 16. The CCD composting toilet with evapo-transpiration, Yap

The final example is a two-chamber, solar-heated composting toilet from Ecuador, high up the Andes mountains (Figure 17) (15). At this altitude there is no need for urine separation as natural evaporation takes care of any excess liquid. Although called a “composting toilet” it is more likely to function as a dehydration toilet.

Figure 17. A solar-heated dehydrating toilet developed by FUNHABIT in Ecuador

These examples from around the world show that ecological sanitation exists, that it works and is feasible.


This article has raised a number of issues related to the environment and toilets. The conclusions are short and simple: Don't mix! Don't flush! Don't waste!

· Don't mix urine and faeces - keep separate!
· Don't flush away faeces - dehydrate!
· Don't waste a valuable resource - fertilize!

Ecological sanitation is not merely an option for the future of our cities - it is a necessity!


(1) WHO. Creating healthy cities in the 21st century. Geneva, World Health Organization, 1996 (unpublished document WHO/EOS/96.9).

(2) Black M. Mega-slums: the coming sanitary crisis. London, WaterAid, 1994.

(3) Boyden S, Dover S. Natural-resource consumption and its environmental impacts in the western world - impacts of increasing per capita consumption. Ambio, 1992, 21(1):63-69.

(4) UN. World urbanization prospects 1994. New York, United Nations, 1995.

(5) EHP (Environmental Health Project) Health and the environment in urban poor areas - avoiding a crisis through prevention. In: Capsule Report, No 1, March 1996. Cambridge, Massachusetts, USA, 1996.

(6) WHO. Community water supply and sanitation: needs, challenges and health objectives. Report of the Director General. Forty-eighth World Health Assembly, Provisional agenda item 32.1, Geneva, World Health Organization, 1995 (unpublished document A48/INF.DOC/2).

(7) Wolgast M. Rena vatten - om tankar i kretslopp. Uppsala, Creanom HB, 1993 (in Swedish).

(8) UN Habitat. Water crisis to strike most developing world cities by 2010. UN Habitat press release, Nairobi, 1996.

(9) UNDP. Habitat II, Dialogue III: Water for thirsty cities, Report of the Dialogue. United Nations Development Programme, United Nations Conference on Human Settlements, June 1996, Istanbul.

(10) WRI. World resources, 1992-1993. New York, Oxford University Press, 1992.

(11) StenstrA. Water microbiology for the 21st century. Paper presented at workshop 3, Stockholm Water Symposium, 7 August 1996, Stockholm.

(12) Niemczynowicz J. New aspects of urban drainage and pollution reduction towards sustainability. Water Science and Technology, 1994, 30(5).

(13) Winblad U, Kilama W. Sanitation without water. London, Macmillan, 1985.

(14) Rapaport D. Sewage pollution in Pacific island countries and how to prevent it. Eugene, Oregon, Centre for Clean Development, 1995.

(15) Dudley E. The critical villager - beyond community participation. London, Routledge, 1993.

© Uno Winblad, 1996, edited by WHO with permission of Uno Winblad, 1997.

Promoting composting toilets for Pacific Islands - Leonie Crennan1

1 Ecological Sanitation, Stockton, Australia.

This article summarises the process of introducing composting toilets in two countries of the Pacific region. The first was in Micronesia in the Republic of Kiribati 1994-1996 and the second in Polynesia in the Kingdom of Tonga 1996-1998. Although Tonga and Kiribati have some cultural and development differences, the lessons learnt in Kiribati were carried into the subsequent Tongan project.


The overall objective of the trial was to explore an innovative technology and its promotion in contexts where alternatives to existing systems were obviously needed owing to groundwater pollution. The specific objectives of the activity were to promote a sanitation technology that:

- would minimise pollution of the groundwater with pathogens or undesirable nutrients;
- would not use limited water resources;
- was easily maintained; and
- would create awareness of the value of recycling nutrients and the health risks associated with inadequate sanitation.

The technology selected was a double bin composting toilet.

The composting toilet

The composting toilet is a dry sanitation technology that requires the addition of carbonaceous material such as leaves or sawdust to be added after use. This is to obtain the necessary carbon/nitrogen balance and provide aeration for composting. After a required period for composting and destruction of any pathogens in the material, the end-product can be used as a fertiliser or disposed of safely in the ground.

The design uses an alternating bin system so one side could be used while the other side is composting (Figure 1). Any excess liquid that does not evaporate in the composting process drains through a slotted plastic pipe into a lined evapotranspiration trench and is absorbed by adjacent vegetation (Figure 2). In areas where the groundwater is high, the evapotranspiration trench is lined with builder's black plastic (polyethylene) sheeting to stop any effluent leaching down to the groundwater. (Fibreglass or ferrocement could be used instead of plastic sheeting but involves more expense and extra work.)

Figure 1a. Alternating batch composting toilet, Kiribati

Figure 1b. Alternating batch composting toilet, Kiribati

Figure 2. Evapotranspiration treatment trough of Kiribati composting toilet

Background to the Kiribati Trial

In the early 1970s on the coral atoll of South Tarawa, Kiribati (7.2 square kilometres and population in 1998 of 35 000), a reticulated sewerage system had been installed which had over time been problematic technically and culturally. It was apparent that an alternative was required. The donor agency, AusAID, did not wish to trial a new method on this densely crowded main island so a sparsely populated coral atoll 3300 kilometres from Tarawa was chosen. Kiritimati (or Faraway Island as it is known in local language) had approximately 4000 residents. As it was a large atoll (363 square kilometres), the traditional habit of defecating on the beach was effective and reasonably hygienic outside the village area, however for convenience, especially for women, on-site house toilets were desirable. Septic tank flush toilets or pit latrines were available in most government employee houses and some private homes. From the donor agency's point of view, composting toilets were appropriate because the agency was about to replace individual wells with a reticulated water supply system. The source of the reticulated system was the same groundwater and it was being polluted by seepage from the pit latrines and septic tanks. Pathogens that were causing common enteric diseases in the population were found in the groundwater. Dye tracing experiments had indicated routes of ingress from the toilets to the groundwater. The water supply project had been planned since 1982. The sanitation component was an enlightened afterthought.

Process of the Kiribati Trial

Initial meeting. Two Australian consultants, both women, visited Kiritimati for three weeks to connect with local health workers and the community. One was the designer of the toilets and the other was a community facilitator. The local counterparts were the Health Inspector and the Community Health Officer, also both women. This was the first time a sanitation system had been introduced by expatriate or local women. The team held introductory discussions using photographs and illustrations with the residents in the local meeting house (maneaba) and with women's groups and with government officials. There were to be twelve toilet units (ten in domestic locations and two at schools) trialed and after the presentations were completed, people were asked to volunteer to be participants. Fortunately, a suitable cross section of the community volunteered. The local government officials were inclined to use the project to fulfil their obligations to provide toilets for government employees, but gentle insistence by the team extended the trial to other residents.

It was obvious on this first visit that most people were interested in the new toilet because it was an aid project and it would not cost them anything to have one. It was also apparent that they would not really understand the design and its purpose until they could see a working example. The link between existing toilets and pollution of village water was demonstrated by pouring cup of vegetable dye in the bowl of a flush toilet connected to a septic tank and the colour was observed some weeks later in a nearby well. Most I-Kiribati2 did not believe the germ theory of disease transmission but had a strong aversion to faeces based on beliefs in sorcery. So they were horrified to think they might be drinking or washing in another person's body products. And some started making connections between the severe ongoing diarrhoea of their children and the well water.

2 Local name for people from the Republic of Kiribati.

Construction. Materials for construction of the toilets were then transported from Australia to Kiritimati. This took about 5 months due to irregular shipping. During the next visit of three weeks by the Australian team (the female designer and a male colleague), the toilets were constructed using local labour, and much time was spent with the participants showing them how to use and maintain the toilets. At the same time an educational video was shot by the team involving the participants and scripted by the Kiritimati counterparts. A design was prepared for a project T-shirt and poster and a song composed with the assistance of the Chief of Police (who was a poet) and the Curriculum Development Officer. The song was taught to the school children and this was filmed using a video camera. The educational materials illustrated the relationship between the use of the toilet and clean water, clean environment, fertile gardens and good health. The teachers from one of the schools choreographed a dance that demonstrated the message contained in the song. The teachers from the other school intended to compete with an “even better dance” but this did not eventuate, probably due to insufficient ongoing contact with the sanitation team. The Kiribati counterparts had to continue their other duties as Heath Inspector and Community Health Educator and probably did not give enough time to the sanitation project between visits by the Australian team members.

Further Construction and Monitoring. Four months later the Australian team members returned with the completed video, posters and T-shirts to monitor the composting process and the use and acceptance of the toilet. The donor agency had also been persuaded by the Australian team members to allow construction of three more toilets using locally available materials. The first twelve toilets had been prefabricated in Australia and did not really fit into the local environment. The prefabricated toilets required dependence on aid or imports for repairs.

The Kiribati Sanitation Promotion T-shirt - A

The Kiribati Sanitation Promotion T-shirt - B

The locally constructed toilets had thatched roofs and walls (Figure 1). The male householders collected the thatch and the women wove it for the roofs. The video was shown in all the meeting houses and was followed by discussion. There was no television or local radio on the island. Some residents had video machines in their homes. For many l-Kiribati this was the first time they had seen themselves, their neighbours or anyone from their country on the screen. This attracted a lot of interest and so easily spread the word about the toilets, the polluted water, and necessity to wash hands after defecating and before handling food. The second half of the video had an English section and showed the same type of composting toilets being used in rural and urban homes in Australia. This had quite an impact, as residents had thought this simple new technology was “only for poor backward people like us”. It was considered a status symbol to have a flush toilet although very few of them functioned for long and quickly became blocked and unusable. More people became interested in the composting toilet when they saw Australians dressed in business suits using them in modern bathrooms. The video ended with an Australian clown singing her own song about her preference for composting toilets. In a Pacific Island country where everyone is a musician, this was much appreciated. Both the Kiribati and Australian toilet songs could be heard being sung and whistled about the villages.

The posters were widely distributed but did not often appear on the walls of people's homes. With some feeling of frustration, the project team decided to sell the T-shirts. $A10 (approx. $US7) was the agreed price, quite costly in an economy where nurses only earned $30 a month, middle level public servants earned about $US 100 a fortnight, and extended families of up to twenty persons were often dependent on one wage earner. To the team's surprise, 300 T-shirts sold in a couple of days without any advertising. A message was received from a religious minister requesting that next time the T-shirts should be made with collars, as more than half his congregation were wearing them to church! The money from the sale of the T-shirts was used to buy prizes for a gardening competition. The competition was a Health Department initiative to encourage the community to eat a more balanced nutritious diet. During this visit the Australian team distributed non-hybrid flower and vegetable seeds to those interested, and assisted with fencing off areas in preparation for use of the compost.

Further monitoring. Four months later the Australian team returned to Kiritimati and participated in the opening of the fallow bin of the composting toilet to observe the end-product. This was a tense and very public event as the l-Kiribati were convinced that the excreta could not possibly transform into an acceptable fertiliser. The appearance of a sweet smelling leafy soil amazed everyone and the team were suddenly inundated with requests for toilets. The compost was tested and found to be safe and then used around fruit trees such as pawpaw and banana.

The evapotranspiration trenches were dug up to monitor what was happening to any liquid run-off from the bins. The trenches were surprisingly dry in all cases, with roots of nearby pawpaw trees observed to be growing down into the damp area at the bottom of the trench in two sites.

To ensure that the compost was safe to handle, microbiological studies were carried out throughout the trial. This process included taking fresh sample of faeces from the householders to establish what enteric diseases they were suffering from. Also, samples from the top of the pile in the toilet bin were taken to ensure that these pathogens had been excreted into the toilet, and then samples of the end-product or compost were taken to observe whether or not the composting process had destroyed the pathogens. No bacterial enteric pathogens were isolated from the compost that had matured in the fallow bin for six months. Microscopic examination demonstrated absence of all parasites found in fresh faecal samples with the exception of trichuris ova (trichuria). However none of the ova contained embryo and were therefore not infectious. Collecting faecal samples was a slow and delicate business. For cultural reasons people were very reluctant to provide body products to someone they did not know well and trust. It required many return visits and much consultation before the samples were provided.

A required time for safe composting was built into the design of the alternating bins of the toilet. This was done by estimating the volume required by an average extended family (10-20 people) for six months which allowed the fallow bin to remain untouched for six months while the active bin was in use.

End of trial. Fifteen months after the AusAID trial began, the monitoring visits by the Australian project team ceased as the donor agency decided to “see what would happen” to the programme without any external support. In the writer's opinion this was unfortunate, as the project had just started to take off in the community and the Australian team members had become familiar and accepted. The two local counterparts felt somewhat abandoned and the promotion programme slowly died. It was too soon to withdraw support for such an under-resourced and controversial project.

Expansion. Learning from this experience that ongoing promotion is necessary, the donor agency decided to install 300 composting toilets along with the reticulated water supply system. The extension project had just begun at the time of writing (March 1998) using a new expatriate sanitation team and a new composting toilet design. The Health Inspector and Community Health Educator were not included in the new team.

Outcomes from the Kiribati project

The sanitation promotion programme achieved its goals despite the short period over which it was conducted.

· A technology was introduced and trialed that does not pollute the environment either with pathogens or undesirable nutrients.

· The toilet system does not use the limited water resources for flushing.

· The toilet system is easily maintained by the household.

· Using leaves the women sweep up every day, carbon is added to the toilet. Formerly they burnt these leaves, but now they collect them in bags or baskets and leave them by the toilet.

· Emptying and disposal of the compost is also managed without problems.

· Songs, dances, videos and T-shirts were successful in creating awareness of the value of recycling nutrients, and the health risks associated with inadequate sanitation.

· Of the twelve initial imported prefabricated composting toilets, four were still being used to varying degrees two years after the promotion programme was terminated. Of the three locally built toilets, one was being used in an exemplary fashion and one occasionally. The primary cause for the non-use of toilets was lack of sustained promotion. However, other causes such as change of resident family, structural damage and septic toilets being built in adjacent meeting houses also contributed to non-use. As the l-Kiribati Health Inspector commented “it took twenty years for the septic (flush toilet) to be accepted - we can't expect everyone to like this already”.

· As a result of the trial on Kiritimati, many people on the main island of South Tarawa were interested in the composting toilet as a solution to the serious public health and environmental pollution problems. To extend the composting toilet to a densely crowed application, the main challenges would be finding sufficient bio-mass to use as a carbon additive to the toilet and space to dispose of the compost. Neither of these challenges would be prohibitive however.

Lessons learned

· Active local participation in the design and production/performance of any educational material is essential. The trial allowed technological adjustments to be made to the design that suited the cultural preferences of the community. It also indicated which methods of promotion were most effective.

· It is important to maintain the working relationships and momentum of the promotion programme during the period between the trial and the extension (which in this case was two years). This saves time, energy and money at the extension stage, validates the efforts of those involved in the trial and encourages locals to develop their own contributions to the programme in the interim. It is also a valuable monitoring period, both technically and culturally.

· Friendships and cooperative working relationships established between the Australian and I-Kiribati team and other members of the community were important determinants in the success of the promotional exercise. The I-Kinbati and most Pacific Islanders value good relations above all else, and they will politely ignore programmes that are introduced by people with whom rapport is not established. This can initially take time and patience but is well worth the effort in the long term. When the new sanitation team arrived to undertake the extension, the community reacted to another set of strangers, to the consultation process beginning all over again and to a different composting toilet design being introduced. This lack of continuity was partly due to the way tendering processes are conducted and aid projects are administered.

· It was beneficial to link the promotion to other well-established ongoing local programmes, such as the gardening competition and the nutrition and fitness project.

· In an oral society (and perhaps in most societies), story-telling in the form of dance, drama and song, and physical demonstration are far more effective in promoting new ideas than is written material.

· Graphics are effective if they are also useful, for example on a T-shirt.

· It was an empowering model for the Kiribati women to have a predominantly female team introducing a new sanitation technology. Access to women in their homes was also facilitated. However the local women leading the project needed ongoing visible external support to maintain the status of the project, as the project could have been denigrated by the local male bureaucrats and expatriate technicians as “just women's business”.

· The use of media and other interactive educational methods was important, as the residents did not feel comfortable inspecting participants' composting toilets unless the participants were closely related. This was despite assurances by the sanitation team that it was OK to do so. Again there were issues of sorcery involved.

· It is essential to ensure that conflicting programmes are not being conducted at the same time. In the Kiritimati project, introduction of the toilets to the schools did not work successfully, as none of the teachers was motivated to carry on the work of the sanitation team. At the time of the sanitation project, the government was building new houses for the teachers in the school grounds with septic tank flush toilets. This was despite the fact that existing flush toilets at the school had long been abandoned because of insufficient water for flushing and blocking of the toilet from rough materials used for anal cleansing. All the children were using the nearby beach or the bush to defecate which was a confined area and most unhygienic, especially due to the presence of hookworm. There was no tap available in this area for them to wash their hands and no associated education to do so. The children knew the teachers were using their new flush toilets and so became suspicious of the composting toilet and stopped using it.

· It is important to find common ground between the priorities of the locals and the values of the promotion team. If people don't believe in the germ theory, then one must find out what they do believe that can be targeted in the education programme. This often takes considerable detective work, as people can be reluctant to expose their beliefs to the contempt of western scientific scrutiny.

Extending the Kiribati trial to Tonga

In relation to sanitation promotion, Tonga differs from Kiribati in the following respects:

- the quality of the soil is rich and productive and therefore not so much in need of compost for use as a fertiliser;

- many people have relatives in Australia, United States, and New Zealand who send money and provide access to the wider world;

- almost every household has a toilet of some kind: pit latrine, pour flush or septic tank flush; and

- some villages have a reticulated water system.

Tonga is similar to Kiribati in the following respects:
- dependence on groundwater that is polluted by toilets;

- insufficient or inconsistent water supply for flushing;

- toilet paper being unavailable or too expensive resulting in use of materials that block the toilet;

- groundwater chemicals destroying fittings in toilets causing malfunction and leaks which wastes copious amounts of precious water;

- lack of awareness or conviction of the need for handwashing or covering food; and

- defecation by small children in and around the house.

The composting toilet trial was a joint Tonga Water Board/Ministry of Health experiment to try and find solutions to common problems. Also funded by AusAID, this trial differed from the Kiribati trial in the following aspects:

· The lead time for the Tongan trial was longer. Over several months, the Australian sanitation facilitator conducted informal in-depth discussions with a cross section of the households in the selected village on all manner of water and sanitation practices and attitudes. This allowed a more planned promotion strategy based on the resident's needs and priorities.

· Technology transfer was more comprehensive, as construction was managed entirely by a local contractor which meant that further construction could promote local business. Fifteen toilets were built from locally available materials, thirteen in private homes and one in a school and another in a school/church compound. The units were more robust, better drained and easier to empty than the Kiribati version of the design.

· To increase a sense of ownership, the first households that volunteered to be part of the trial were required to pay 100 pa'anga or $US 95 for their toilet to be built. It was too complex to have a sliding scale, so some were burdened more than others by this contribution. All except one family demonstrated an active control and management of their system.

After the experience of introducing the toilets to the schools in Kiritimati, the sanitation facilitator was reluctant to trial the system in a school or any public application. One of the schools requested to be part of the trial, as their water bills for the school's flush toilets were using half of the monthly budget. They were also having trouble with the flush toilets being blocked and overflowing when rough material was used instead of toilet paper. Contact was made with the science teacher to try and solve the problem. Boys were told they could no longer use the flush toilets and would be responsible for a new composting toilet. After use, they could not return to the classroom unless they washed their hands and the tap was in view of their classroom. After initial shyness and reluctance, the boys became most enthusiastic about the new toilet. Other classes wanted to use the toilet. The water bill for the school dropped 70%. The principal sought funding from another donor, CanadaFund, to build a unit for the girls only two months after the trial began. The education programme was tied to a UNESCO project demonstrating groundwater pollution from existing sanitation system. The news about the new toilet and its purpose spread quickly to the community through the children.

After four months of the trial, many residents expressed the opinion that a trial was unnecessary. They said they were already aware of the advantages of the new system and were waiting for expansion of the programme. However before expanding, it is necessary to observe reactions to the final stage of maintenance, that is, the removal of the compost from the fallow bins before it can be concluded that the composting toilet is an appropriate and accepted sanitation alternative for Tonga. The fallow bins should be ready for emptying at the end of 1998.


It is apparent that alternatives to established sanitation systems are needed in some circumstances. Research into these alternatives has largely been undertaken by committed individuals and small businesses and is generally in the early stages of its full potential. Thorough research and development should be encouraged and institution-ally supported to the same extent that existing systems are supported, so that in any country the most appropriate technology can be applied in each location. Selection from a range of equally accessible options should be based on a appraisal of the cultural, socio-economic and ecological context to be serviced.

Key institutions and responsible persons

Dr Leonie Crennan
Ecological Sanitation
85 Dunbar St,
Stockton, NSW 2295, Australia.
Fax: 61-2-49284082

Greg Berry
Centre for Environmental Studies
University of Tasmania
GPO Box 252C. Hobart 7001, Australia.
Fax: 61-3-62262834

Mr. Lomano Hausia
Science Teacher
St. Joseph's School
Pangai-Hihifo, Ha'apai

Peri-urban sanitation promotion in Mozambique - Darren Saywell1

1 Research Associate, Water, Engineering and Development Centre, Loughborough University, UK.

National Programme for Low-cost Sanitation (PNSBC)

The programme is a widely acknowledged success in Mozambique. It has established a series of well-functioning production units in every province in the country that provide poor, peri-urban communities with access to affordable and durable low-cost improved latrines. The sanitation technology used is based on a simple, but effective, unreinforced domed concrete slab with a tight-fitting lid to reduce odour and insect nuisance. A flexible mix of construction options has been developed to cater to varying physical and socioeconomic conditions. The programme runs in parallel with a strong social development effort, based on employing sanitation animators, to promote the latrine programme and reinforce hygiene behaviour and education messages. Efforts to help alleviate poverty are being made through creation of employment opportunities in latrine production units. Future plans are to decentralize programme activities to municipal city councils.

Programme objectives

Programme objectives were to:

- identify and develop a suitable technology and method for large-scale implementation of improved sanitation in peri-urban areas; and

- contribute to improved living conditions and alleviate poverty by reducing the morbidity and mortality resulting from unhygienic living conditions; and creating local employment opportunities and management capacities, focusing on the needs of vulnerable groups, through establishment of latrine production and sales units.

Programme description

Mozambique is one of the world's least developed nations, with general development having worsened over the last three decades. Human development indices and measures of economic wealth and prosperity fell markedly during the 1980s. Sixteen years of civil war, drought, and related economic and social factors have left between 60 and 90 per cent of Mozambicans living in serious poverty. Estimates of those living in absolute poverty range between 50 and 60 per cent.

After Mozambique's independence from Portugal in 1975, the Government identified sanitation as a critical factor in improving national health. In 1976, the Ministry of Health launched an intensive national self-help latrine construction programme that comprised the construction of thousands of latrines over a short period. However, insufficient technical guidance in latrine design and construction, a shortage of building materials and the lack of awareness of environmental conditions meant that many of these latrines became structurally unsafe, unusable, and a health hazard to users. The consequences of technical weaknesses and negative impacts on health were most severely felt in densely-populated peri-urban environments, where the majority of the nation's urban population settled. In response, a research project was commissioned in 1979 to identify and develop a suitable technology and methodology for large-scale implementation of improved sanitation in peri-urban areas. Project results led to creation of the PNSBC in 1985, implemented through the National Institute of Physical Planning.

The pilot project identified and tested a technology based on the concept of a simple, unreinforced domed concrete slab that is placed over a lined or unlined pit. Slabs are built to a standard 1.5 m in diameter and a thickness of 40 mm, rising 100 mm from ground level at the centre, to give the characteristic flat dome. Its shape reduces the need for expensive steel reinforcement, since the weight of the load is distributed to the peripheral zone and kept within the range of what the non-reinforced concrete can support. A small inward slope of 100 mm width around the squat hole is incorporated to direct any waste into the pit. Footrests placed on either side of the squat hole guide the user to the correct position for defecation. A tight-fitting lid is placed in the squat hole when the latrine is not in use, as an effective seal to prevent odour from escaping or insects from entering the pit. The lid can be attached to the latrine superstructure by a wire or cord to prevent deposition in the pit. The exterior surface of the slab is compacted and smoothed to facilitate cleaning. It bears the initials of the mason who constructed it and the quantities of cement, sand, and aggregate used, as a means of quality control.

Figure 1a. Unreinforced domed slab

Figure 1b. Unreinforced domed slab

Construction techniques are fairly simple, and have been aimed at using the least possible amount of cement, normally three-quarters of a 50 kg bag. A flexible mix of construction options have been developed, and differ, depending on varying physical and socioeconomic conditions. Complete latrines, with lining blocks for pits, predominate in areas of high-water tables or difficult soil conditions, whereas in most other areas, slabs placed over unlined pits are the norm. A characteristic superstructure, without roof, made of local materials (reed and palm leaves), surrounds the latrine, as a privacy screen for users.

The activities of the PNSBC are based on:

- the construction, promotion, and use of improved latrines in peri-urban settlements;

- sanitary education through the activities of animators, health officials, and theatre groups to maximize latrine use and the benefits of construction;

- coordination of sanitation interventions with water supply; and

- development of local capacity to construct latrines.

The programme operates in 15 cities nationwide, with 35 production units centred in peripheral settlements, employing 271 workers. Each production unit employs a number of workers drawn from the local community. Twenty per cent of all workers are women.

The PNSBC is funded by three major sources: donors, the central government and user communities. Donor funding supports technical assistance, equipment, production costs (purchase of cement), and some operation and maintenance costs. Government funding has focused on a direct subsidy for part of the production costs, in addition to some support for staffing and running costs. Communities pay a proportion of production costs, through direct sales of latrines, construction of the superstructure to surround the latrine, and transport of the slab from production unit to household plot. Communities pay about 4 per cent (US$ 1) of the total production cost of a simple slab, and US$ 7 for a “complete” latrine (with concrete lining blocks for the pit). Donor agency and government contributions to production costs are 83 per cent and 13 per cent respectively.

The PNSBC works in poor communities in peri-urban settlements. The programme's target population falls under three categories:

- most vulnerable families, existing in conditions of absolute poverty (as defined by health and income indicators, such as elderly over 60 without income, or family income per capita below MT 13 000, US$ 1.3). Families classified as vulnerable will get their slab free of charge and where necessary have their pit lined.

- families functioning at minimum survival income levels (minimum income was defined in 1996 as US$ 20 per person per month); and

- families surviving on an income of 2 or 3 minimum incomes. Households dig their own pits and decide the location of the latrine.

Promotion techniques

PNSBC promoted sanitation in the following ways:

· The social development programme was consolidated to emphasise hygiene education activities (through inputs from Ministry of Health staff). Greater appreciation of the importance of sanitation was achieved through the appointment of a series of 'animators', who helped to assess the individual needs of those without sanitation, to monitor and evaluate the performance of the programme in the community and to reinforce hygiene behaviour practices.

· Selection of appropriate communication channels was critical in reaching target audiences and reinforcing core messages. Messages built on ideas and concepts which are already present in the community (for example, the fear that children would fall into latrines was addressed through poster campaigns highlighting the benefits of the keyhole shaped squat hole).

· A mixture of promotional techniques and methods were used. These included use of indigenous media (such as employing dance/drama troupes to visit a district) in conjunction with more traditional communication channels (lectures, activities at church and voluntary level, poster campaigns, and radio/television broadcasts). One innovative promotional idea was the distribution of T-shirts, caps and other promotional clothing to publicise the programme. Given the high demand that exists for affordable clothing in Mozambique, this method was an effective way of communicating the programmes' central message (through slogans on the front and back of the T-shirt).

· Production units were a source of information and promotion within the heart of the community. Mobile production units were used to reach small-medium sized towns. Production units acted as catalyst for generating demand.


· Despite economic and political difficulties, from 1979 to May 1996, 170 496 improved latrines were sold and installed, benefiting more than 1 022 916 persons. Production sales capacity is between 25 000-35 000 latrines per year.

· The programme proved to be successful despite the fact that institutionally no one really wanted to house the PNSBC.

· A social development programme was consolidated to emphasize hygiene education activities, appreciation of sociocultural influences on the latrine programme through training of sanitation animators, and support to various community outreach activities, such as theatre and radio campaigns.

· Poverty alleviation was enhanced by creating employment through the establishment of local production units.

Difficulties encountered

· Most of the population continues to live in extreme poverty and the economic situation is worsening. At the end of the civil war, over five million refugees returned to peri-urban settlements throughout the nation. Low-income groups cannot afford to purchase improved latrines.

· The State's excessive political/administrative centralization weakens decision-making capacity, affecting programme management.

· Sector coordination at national and local levels is inadequate. This is particularly true regarding national departments dealing with water, sanitation, and the urban sectors.

· The programme is very dependent on external donor funding.

Lessons learned

· Different levels of purchasing power exist within the peri-urban communities. The programme needs access to this information so that pricing structures for latrines may be targeted more appropriately, in line with the different economic capacities of the populations.

· Monetary incentives and other social benefits can be used as a means for recruiting and retaining qualified staff within the programme.

· It was found that introducing productivity bonuses for production units did not work adequately because there was no direct relationship between what is effectively produced and what is sold. A scheme of “food for work” has proven successful as a motivating factor for workers, bringing direct benefits to them and their families.

· It was found that target communities frequently did not have the means to construct latrines (i.e. dig pits) or erect superstructures, hence latrine slabs were being purchased but not used.

· The Mozambican example proved successful because of its combination of rigid standardisation of low cost slabs and complete freedom for the families to build the superstructure as they want. Excluding subsidies from the superstructures resulted in considerable community contribution.

Future plans

· Decentralizing activities and responsibilities for basic infrastructure services to municipal councils will continue. More attention must be paid to creating management capacity within these units.

· A mechanism that enables subsidies to be provided to the private sector for acquiring tools and production equipment to produce and market improved latrines will be developed.

· Mobile production units to cover areas that are currently isolated or distant from existing production centres will be introduced.

· The programme will be expanded into rural areas, introducing pilot projects into an additional province each year.

Key institution and responsible persons

Carlos Noa Laisse, Acting National Coordinator
Vincente Macamo, Civil Engineer/Coordinator BSS

Programa Nacional de Saneamento a Baixo Custo (PNSBC)
Avenida Acordos de Lusaka 2115
CP 1310
Telephone: +258 1 465850
Fax: +258 1 465407

© Mr Darren Saywell, Research Associate, Water, Engineering and Development Centre, Loughborough University, UK, 1997, edited by WHO with permission of Darren Saywell, 1997.

Prepared in association with SARAR TransformaciC.

Urine as fertilizer in Mexico City - Yoloquetzatl Ceballos1

1 SARAR TransformaciC, Mexico.

An innovative programme success story

As a means of alleviating increasing poverty in Mexico City's slums, the NGO network ANADEGES (Autonom Descentralismo y GestiA.C.) and its affiliate, CEDICAR (Centro de Investigaci Capacitaciural, A.C.), have perfected an approach of growing vegetables in containers, with domestically-produced organic fertilizers. The key to this cultivation technology is the organic, domestically-produced, liquid fertilizer, urine, and a rich compost produced by worm colonies from ordinary organic kitchen waste. Using these free, readily available organic wastes, together with discarded containers, the project is successfully producing luscious vegetables, and over 5000 urban residents are rediscovering their traditional capacity to cultivate food. Plans for the future include cultivating fruit trees and introducing small backyard animals, such as chickens and rabbits. Dry latrines will also be introduced, especially in areas without sewers.

Project description

During the past decade, the “neo-liberal” structural adjustment policies applied in Mexico have provoked a massive migration of the traditional rural poor to urban areas. But yet another major devaluation of the national currency at the end of 1994 has meant that life in the urban and peri-urban areas continues to deteriorate rapidly.

Responding to rapid inflation, high unemployment, and inadequate nutrition, the NGO network ANADEGES launched an urban agricultural project nine years ago. This project, managed by CEDICAR, an ANADEGES affiliate, seeks to help the residents of Mexico City slums develop their capacity to grow their own food organically in small backyards or on patios, balconies, and rooftops. The technology used was selected and adapted to fit the local circumstances, which bore the following profile:

· Peri-urban residents have minimal or no land that can be utilized for conventional kitchen gardens.

· Poor project participants can afford only minimal investment in infrastructure, or none at all.

· Programme participants cannot afford to purchase chemical fertilizers, insecticides or other synthetic inputs; and

· Growing containers had to be made of lightweight materials to permit rooftop cultivation.

The project is based on a cultivation technology originally developed in California by Dr Barbara Daniels.2 Vegetables are grown in containers (ideally 18 to 20 litres) stuffed with deciduous tree leaves or grass clippings up to four-fifths of their capacity, and topped with a 3-5 centimetre layer of good soil, into which seeds are planted or seedlings transplanted. To maintain a permanent reservoir of water in the container, a drainage hole is perforated in the side, 5-10 centimetres from the bottom. The exact height of the hole depends upon the type of plant grown. A container thus prepared weighs far less than one filled with regular soil.

2 Daniels, B. Growing plants in containers: new guidelines for a deck garden. Multi-copied. Farifax, CA, 1981.

The key to this technology is an organic, domestically-produced, liquid fertilizer - urine (referred to as “liquid organic fertilizer,” or LOF) - which is free and abundantly available. Once fermented, LOF is an excellent source of nitrogen for plants, and also contains traces of other nutrients. Urine is collected in a one-quart to one-gallon glass or plastic bottle. A small handful of good soil is added to accelerate the fermentation process. The container is then covered loosely and stored for three weeks at some distance from the living quarters, since it soon develops a strong ammonia odour. After diluting the LOF with water at a ratio of 1:10, the now-odourless liquid can be applied to the plants. (A higher ratio of LOF to water is used during the rainy season; a lower ratio, once the leaves have decayed.) Raw, unfermented, or undiluted urine must never be used.

After initial experimentation demonstrated that the technology worked well, a three-year pilot stage was initiated in 1989, with a group of about 30 families. When it could be seen that these families accepted the use of LOF and the overall results were satisfactory, the project was expanded. In the last six years, approximately 850 families have participated, benefiting 5000 persons in 10 different barrios (neighbourhoods) of Mexico City.

The programme has been tried in different kinds of low-income neighbourhoods. Whereas most programme areas are fully sewered, others, especially poorer squatter settlements, have pit latrines, usually of unsatisfactory design and quality. As a result much of the urination by men has been done in the open. Use of this technology, however, is a good means of dealing with this potential public health problem. More-over, urine diversion, collection, and use as a fertilizer has been successful because of the perceived economic and nutritional benefits to the families involved.

The project is in the process of establishing autonomous resource centres to continue to support urban gardening in each of the communities, thus permitting ANADEGES to expand into new areas.

Illustrations from a promotional brochure for the project

Illustrations from a promotional brochure for the project

Preliminary findings

The results of initial trials can be summarized as follows:

· LOF was an excellent source of nitrogen, readily absorbed by the plant and essential for leaf growth.

· Plants grew more rapidly, larger, and healthier than those grown with conventional agricultural techniques - and less water was needed.

· There was a deficiency of phosphorus and potassium in the fertilizers, which inhibited fruiting.

· Thus a need for testing for minor nutrients was identified.

· The initial intense aerobic composting of the leafy material raised temperatures and acted as a hot bed, which helped plants in their early growing stages.

· The resistance of plants to pests and diseases was puzzling. In one instance, tomato plants grew near a tree heavily infested with white flies. Although many of these flew around the plants, rather than attacking, as normally takes place, they simply flew back to the tree without even landing on the leaves. Apparently the process taking place inside the container helped the plants to become not only stronger, but also resistant to pests.

· At the end of a year the composted leaves turned into beautiful, rich soil. Each container produced enough soil to supply the top five-centimetre layer in 10 new containers.

· In areas that are sewered, the programme confers an additional water-saving benefit because urine is not flushed in conventional waterborne toilets. A rough estimate is that a typical six-member family can save about 53 litres per day. (With a totally dry toilet, the water saved could increase to 89 litres per day.) Finally, kitchen refuse is recycled, instead of being added to the mountains of garbage that are being generated by Mexico City.


After the initial trials, the deficiency of phosphorus and potassium was corrected by using synthetic, chemical fertilizers. Nevertheless, for the technology to be really affordable for poor families, a cheap, abundant, and readily available organic source of these elements was needed. Moreover, since the three- to four-month growing cycle of the plants is so short, these two major nutrients had to be available in a form that could be immediately absorbed. Organic materials requiring longer decomposition periods were ruled out.

As is often the case, the solution was found serendipitously. ANADEGES had already begun to experiment with raising red worms (Eisenia foetida). Worm colonies are capable of converting ordinary organic kitchen waste into a rich compost. Their castings, which are produced abundantly and at virtually no cost, provided the readily absorbable phosphorus and potassium that the plants needed. In addition, the worm castings provide necessary minor nutrients which are not supplied by LOF and decaying leaves.

The problem of how to provide adequate space to grow root crops or very wide leafy vegetables was solved by using discarded car tyres as large pots, an idea contributed by a group of Nicaraguan campesinos on a study tour in Mexico. The ANADEGES experimental centre is now testing a prototype machine for cutting and folding used tyres inside-out to form wide-mouth containers which have sufficient room for crops of this type. The use of tyres also recycles another waste product.

Financing accomplishments

Since the programme beneficiaries are mostly very poor families, they could not afford to pay for the full cost of setting up the required infrastructure in each of the community resource centres. Consequently, some financial support has been received from the St. Nikolaus Foundation in Sweden, GATE-ISAT in Germany, Caritas Sweden, the Swedish Government, and the Demos Foundation in Mexico. In addition, a chain of Mexico City supermarkets has donated a supply of discarded containers. Financial support has recently also been forthcoming from the Mexican Government. The programme's ultimate goal is to become self-financing, rather than to require a permanent subsidy.

ANADEGES sells a kit to each family that includes 10 containers, 3 tyres turned inside out, a wide variety of plant seedlings, and a kilo of worms. Although the full value of the kit is approximately US$ 35 ($270.00 Mexican pesos), the families are required to pay only about 20 per cent of the value in cash. The balance is covered by a loan from a revolving fund. Thus the families can begin to benefit from their garden after paying a very small down payment. Fed on kitchen scraps, the worms reproduce quickly. After only a few months, two kilos of worms, worth more than US$ 32 ($250 pesos), are returned to ANADEGES, thus paying off the loan with interest to the revolving fund.

Lessons learned for promotion and implementation

· Initially, mostly women are interested in container vegetable gardening, but eventually the whole family becomes involved. Gardening is always a community activity and children enjoy it and benefit the most.

· LOF was readily accepted, as long as the decision was reached after discussion and medical assurance given that LOF is harmless when properly fermented.

· People need to be adequately motivated to tend their vegetable gardens consistently. Motivating factors include: improved nutrition; economic savings; a hobby for the whole family; healthy, fresh organic food; revival of agricultural skills - most elders come from rural communities; closer contact with nature; increased independence from government assistance; ecological concerns: recycling of garbage and containers; ornamental plants; relaxation from urban stress; and friendship with others who are also raising plants.

· With appropriate financing mechanisms, families were willing to pay the actual cost of the kit. Produce harvested during the first year is usually at least equivalent to the cash down payment, thus fully recuperating initial costs.

· Women eventually requested ornamental flowers, in addition to vegetables. These were readily provided by the project.

· It is important to work through organized community groups, so the implementing agency does not need to take responsibility for organizing people and promoting the project from scratch.

· Communities selected for this type of programme should have relative social stability, to ensure that people have enough time and energy to dedicate to their gardens.

Preparing rooftop containers from used tyres for growing vegetables

Planting vegetables in soil fertilized with urine

Future challenges

· To expand the project to include approximately 1200 families by the end of 1997.

· To seek additional external financing and government support for developing various aspects of the project, including introducing dry, urine-diverting toilets, and the reuse of tyres as wide-mouth containers (which would also help to address a staggering ecological problem in Mexico City - the virtual mountains of used tyres).

· To work more effectively with the scientific community to encourage more research in to this new horticultural technology to improve sanitation and save water in urban environments.

Key institutions and responsible persons

Dr Rodrigo A. MedellE., Director (sociologist)
Ing. Angel Rold(agronomist)
ANADEGES (Autonom Descentralismo y GestiA.C.)
Tabasco 262-502
Col. Roma Norte
Mco DF 06700, Mco
Telephone: +52 5 208 2118
Fax: +52 5 511 2581

Ing. Guadalupe Torres (agronomist)
Ing. Francisco Arroyo (rural development specialist/agronomist)
CEDICAR (Centro de Investigaci Capacitaciural, A.C.)
(ANADEGES affiliate, responsible for managing the project)

© Uno Winblad, SANRES, edited by WHO with permission of Uno Winblad, 1997.

Prepared in association with SARAR TransformaciC.

Experimenting with dry toilets in El Salvador - Ron Sawyer1 and George Anna Clark2

1 SARAR TransformaciC, Mexico.
2 Espacio de Salud, AC, Mexico.

A successful solution to an environmental challenge

Environmental factors, including a chronic water shortage, and high groundwater in parts of the country have made it necessary to adopt drastic measures in El Salvador. Increasing priority is being given to constructing dry toilets, which require no water for the disposal of human waste and, when properly maintained, represent a safe, sustainable alternative for family sanitation. Committed NGOs, the Ministry of Health and the Social Investment Fund, with the financial and technical support of UNICEF, USAID, and Sida have constituted a strategic alliance to bring this appropriate technology to E Salvador. This technology is being replicated, adapted, and sustained on a large scale. A comprehensive educational strategy that integrates the construction, use, and management of dry toilets with personal hygiene and ecological sanitation is a key component of the programme.

Programme description

Environmental factors in El Salvador have made it necessary for the country to adopt extreme measures for improving its sanitation coverage. A chronic water shortage in much of the country has made conventional water-borne sewerage unrealistic, while the high water table characteristic of much of the coastal area of El Salvador makes traditional pit latrines virtually unthinkable. One significant change has been the increased priority given to the construction of dry toilets, which require no water for the disposal of human waste, while the use of impermeable above-ground chambers prevent the contamination of sub-surface water.

A growing awareness of environmental problems and the commitment of NGOs, the Ministry of Health and the Social Investment Fund, together with financial and technical support from UNICEF and USAID, have helped to bring the modified Vietnamese double-vault toilet to El Salvador. As a result of experiments and evolving government policies, this appropriate technology is being replicated and sustained on a large scale. With approximately 100 000 of these dry toilets and an ongoing research and development programme funded by UNICEF and Sida, this Central American country is rapidly becoming a world leader in sanitation without water.

The dry toilet

The dry toilet relies on a special toilet bowl that diverts the urine to an absorption pit or to a container where it is collected for use as fertilizer. The faeces fall into the chamber below the toilet and are dehydrated to destroy pathogenic organisms, so that the substance can be reused as a fertilizer and soil conditioner.

The maintenance of the system involves a set of simple activities. After defecating, the user sprinkles dry materials such as ashes or lime (or a mixture of dry soil or sawdust with ash or lime) over the faeces. Every week the contents of the chamber should be stirred with a stick and more dry material added.

The separation of urine from faeces and the addition of dry material, reduce unpleasant odours and flies, which are serious problems of traditional latrines. The toilet's double chamber allows the contents on one side to lie idle, while the family continues to use the other side. Under normal circumstances the chamber in use fills up in not less than six months, which is enough time to assure that the material in the other chamber has dried adequately. By drying the faecal material for at least six months, even the most long-lived pathogens will be destroyed, leaving an innocuous material that can be removed and disposed of or reused as a soil conditioner.

Pathogen destruction

To properly use and maintain a dry toilet, it is useful to understand how and why the system works. Whereas the term “dry sanitation” can refer to either dehydration or decomposition, it is helpful to appreciate the basic differences between the two processes.

Dehydration means that the humidity of the contents of the vault is brought down to below 20 per cent. For effective composting, humidity must be kept above 60 per cent. In a dehydrating system, pathogens are destroyed by depriving them of water and by increasing the pH above tolerable levels. Users help the process by adding dry materials and lime (or ash) as part of routine management.

The humidity interval of 20-60 per cent should be avoided, because it results in incomplete dehydration, malodorous decomposition and fly breeding.

Dry toilet cycle.

Source: Redrawn from Letrinas secas: una polca nacional en El Salvador and Saneamiento sin agua, El Manantial. Boletde la Red Regional de Agua y Saneamiento para Centroamca (RRAS-CA), A, # 1, August 1996.

Begin use

You must empty the urine receptacle regularly

When the first chamber gets full, you move the toilet bowl to the second chamber

While the second chamber is filling, the first one is decomposing

Once the second chamber is full, you empty the first one, and you move the toilet bowl again

The cycle begins again

Figure 2. The double-vault (LASF) toilet

Source: Cr Ae, Helechos No. 5, Col. Jacarandas, CP 62420, CuernavacMorelos, Mexico.

Had these critical facts been better understood by many sanitation pilot projects worldwide, many unfortunate failures could have been avoided and the unjustifiable mistrust of dry sanitation technology much more quickly overcome.


Education and mobilization

UNICEF has played a vital role in developing an educational approach that integrates the social and technical aspects of dry sanitation. Initially, the focus was at the family level, involving household visits by trained community promoters (visitadoras), who follow a programmed sequence of learning modules. This has been complemented by regular monitoring of key aspects of individual and family hygiene, as well as toilet use and maintenance.

In 1996, to get communities more involved in the water and sanitation programmes, SARAR TransformaciC provided training in participatory methods (including PHAST) to technical and field staff of key NGOs, the Ministry of Health, and UNICEF. The comprehensive educational strategy, which integrates the construction, use, and management of dry toilets with personal hygiene and ecological sanitation is proving to be critical for promoting the acceptance and sustainability of alternative sanitation approaches. An important result of this participatory learning process has been the consolidation of an inter-institutional team of trainers sponsored by UNICEF. These trainers, promoting participatory methods, train staff from other institutions and other sectors, and adapt and produce non-directive learning materials.

Three very different experiences are discussed below to illustrate the significant learning that is taking place in El Salvador.

Hermosa Provincia. After one child fell into a pit latrine, the Hermosa Provincia peri-urban neighbourhood in the capital city of San Salvador was motivated to build a dry sanitation system. As a result of intensive education in using and maintaining the dry toilets provided by the Ministry of Health, plus effective community organization and follow-up support from a local church, the 130 units in this community have been functioning successfully over the past six years. Although most of the toilets are actually built into the houses, there are no unpleasant odours, nor any flies. After a year, the dehydrated material is removed from the chamber and is used in a communal nursery, occasionally sold (at US$ 4.65 per 100 kg), or used as landfill on a nearby site belonging to the church.

Figure 3. Constructing a double-vault, desiccating toilet with urine separation

Source: Uno Winblad, Pataholm 5503, 38492 em, Sweden.

Tan. The Ministry of Health, with technical support from UNICEF and SANRES (see Box 1) is developing and testing experimental solar-heated toilets, with urine diversion in the semi-rural village of Tan. Unlike most other dry toilets, this type of solar toilet has just one chamber and uses solar energy to accelerate the desiccation process. Built entirely above ground, the 36 experimental units include urine diversion, and produce a dry product from the human faeces that can be safely used after storage of at least six months.

Box 1. SANRES Project3

SANRES (Sanitation Research) is a Sida-funded project that has been supporting dry sanitation research and development activities in El Salvador since 1994. The SANRES project is currently active in seven countries (Bolivia, China, El Salvador, Guatemala, Mexico, South Africa, and Vietnam) and has created an informal network in 20 countries. SANRES holds that any intervention in sanitation must take into account that sanitation is a system including the natural environment; society (with its beliefs, values, practices, technologies); a device (the physical structure that receives the human excreta; and processes (the physical, chemical, and biological processes, such as dehydration or decomposition, that take place inside the device). Unless each of the system's elements is considered with equal rigour, effective and sustainable intervention will be difficult to achieve.

3 For more information, contact Uno Winblad, SANRES, fax: +46 499 24253 or email:

The Tan toilets produce no flies or odours, but do require that the user shifts the pile under the toilet seat to the back of the chamber every one or two weeks. On some units, a mechanical “pusher” is used to shift the pile without opening the chamber. Because of the chamber's limited size, the material at the rear of the chamber must then be emptied every second or third month, to be stored until disposed of or used in the garden as a soil conditioner or fertilizer, composted or used as the drying agent in the toilet.

This project is demonstrating that the size of the dry toilet can be significantly reduced (the volume of the chamber has varied from 0.35 to 0.6 m3), thus lowering the cost of construction materials. The direct cost (materials and labour only) of a solar toilet is US$ 225, compared to US$ 271 for a standard dry toilet. Space requirements have also been reduced significantly, which is a very important consideration in highly dense urban areas.

Studies are being conducted to reduce maintenance needs to a minimum while still assuring an acceptable level of pathogen destruction, before promoting and constructing solar toilets on a large scale. In addition, the project is continuing to experiment with optimal design and location. The 36 units now in use are being expanded to 500 units to test the applicability of the system on a larger scale. This next research phase will concentrate on the sociocultural issues (user education and training, extension support) associated with safe, sustainable use.

Chicuma. ProVida, an innovative national NGO, supported by UNICEF, has introduced a change to the traditional pit toilets in the rural community of Chicuma, inhabited by former guerrillas. In an otherwise traditional 1.5-2 m deep pit toilet, faeces and urine are kept apart by using the urine-diverting seat.

Over two years ago, about 70 families installed the seats for urine diversion, while a few households built traditional toilets. The latter continue to have odour, fly, and mosquito problems, while the former generally do not. Only during the rainy season, and only for a short period of time, when there is an increase of humidity in the otherwise dry pit, do flies and odour become a nuisance in the modified toilets. It has been observed that the depth of the pit in the modified toilet can be reduced. Overall the community is very satisfied with this innovative pit toilet, which is seen as a positive first step towards gradually introducing the standard dry toilet.

Although evaluations and additional technical studies (for example, on the die-off rate for pathogens and parasites) are necessary, El Salvador's experiences with dry toilets corroborate several basic sanitation principles. As with any sanitation system, to be safe and environmentally sound, dry toilet programmes require a clear understanding of the technology to be used and the prevailing natural conditions. Community organization and education are important components to assure the system's sustainability. Since the family must undertake more maintenance than required for traditional toilets. But wherever these conditions are met, dry toilets have proved to be a sustainable solution for family sanitation.

Key institutions and responsible persons

Jean Gough
WATSAN Project Officer
Apartado Postal 1114
San Salvador, El Salvador
Tel: +503 263 3380
Fax: +503 263 3385

Uno Winblad
SANRES Coordinator
Pataholm 5503
S-38492 em, Sweden
Tel: +46 499 24255
Fax: +46 499 24253

References consulted

Brand T. Letrinas secas: una polca nacional en El Salvador and Saneamiento sin agua, El Manantial - Boletde la Red Regional de Agua y Saneamiento para Centroamca (RRASCA), A, # 1, August 1996.

Winblad U, Dudley E. Dry toilets for urban areas: the findings of the second SANRES workshop. Mexico City, November 23-26, 1994.

Report for consideration at the El Salvador Meeting. Meeting of the Water Supply and Sanitation Collaborative Council, 25-29 March 1996, El Salvador.

Meeting demand for dry sanitation in Mexico - Ron Sawyer1

1 SARAR TransformaciC, Mexico.

A viable sanitation solution to water-scarcity and pollution

Water scarcity and water pollution caused by inadequate and inappropriate sanitation services that use water to transport human excreta motivated Cr Ae and the voluntary organization ESAC (Espacio de Salud - “Health Space”) to develop a complementary strategy to increase access to and use of dry toilets in Mexico. The core elements of their approach are the production and sale of urine-diversion toilet seat risers, health and environmental education, organizational support, and technical training and follow-up. Clients include low-income community groups, governmental agencies, independent architects, and other NGOs. As the demand for these toilets increases in Mexico, Cr and ESAC are refining their range of products, while also grappling with the broader issues related to municipal and environmental planning and management.

The sanitation problem

Espacio de Salud works in southern and south central states of Mexico. In much of this area urban settlements are built upon very porous volcanic rock and beneath the volcanic rock are large aquifers. Wells tapped into these aquifers are the sources of drinking water for these populations.

Sewerage is not an option, firstly because hard volcanic rock would need to be blasted away to lay pipes, and secondly because communities with sewer systems have found that maintenance of these systems and treatment of the wastewater are too costly for their populations. Communities are not willing to incur these high costs and these systems generally fail as a result. Pit latrines are also out of the question. They cannot be dug and even if they could be, they would also pollute the aquifer. As a result, residents build flush toilets over the rock and sink PVC pipes directly into the aquifer below, or in areas that have a thin layer of topsoil, they dig shallow pit latrines that ultimately leach into the groundwater. These toilets have caused extensive pollution of the groundwater and undissolved faeces can actually be seen, through holes in the porous volcanic rock, floating in the aquifer, and in the springs which flow from it.

These areas, not surprisingly, experience frequent epidemics of diarrhoeal diseases, cholera and typhoid. More and more people are making the link between this inadequate method of sanitation and the epidemics. This connection has increased demand for sanitation options that do not pollute the groundwater. Espacio de Salud has tried to meet this need by promoting the use of dry aboveground toilets and removal of the sanitized faeces, usually one to two years later, to land safely away from the aquifer. Their education and promotion activities have raised awareness about dry sanitation options. More and more families and communities have become convinced of the advantages of this sanitation system for their health and want dry sanitation for all. They realize that pollution from one family can contaminate everyone's drinking water.

Espacio de Salud works in these areas of difficult terrain and groundwater pollution, offering assistance to households and communities wishing to convert their existing sanitation systems to dry systems.

Programme description

Production - Cr Ae

Cr Ae is an independent entrepreneur who has spent the past fifteen years producing and advocating the use in Mexico of modified Vietnamese double-vault toilets. ESAC is a small NGO concerned with promoting improved health and environmental conditions among low-income groups. Over time, Cr and ESAC have evolved a collaborative, symbiotic relationship that has contributed to significant improvements in the sector.

Urine-diversion toilet seat

Cr's operation is deliberately unsophisticated. As a family-run business, his workshop produces approximately 30 urine-diversion toilet seat risers per week. More than 6000 toilet seats have been sold. The profit from the sale of the polished cement seats (approximately US$ 17 or 126 Mexican pesos per unit) is used to finance his overall operation, including low-key promotion, training in toilet construction and use, and advocacy for change in environmental sanitation policies and legislation. Cr receives visitors to his home almost daily to order toilets or simply to request information. He is assisted in his outreach by three persons, including his brother.

Cr provides short-term technical training and support, which is included in the cost of the hardware, to individual clients, bricklayers, governmental agencies, and NGOs. An additional quota is often charged for institutional training workshops and special presentations. The pricing structure of the toilet seats permits Cr to partially subsidize the costs of the toilet seats for extremely poor clients who do not have access to adequate financing.

Education and empowerment - Espacio de Salud A. C.

ESAC works primarily with women and provides health and environmental training to organized groups, community leaders, extension workers, and teachers in the states of Morelos, Guerrero, and Oaxaca. Although ESAC does not promote a specific technology, cholera outbreaks in Guerrero and rapid environmental degradation in Morelos have generated frequent requests for improved sanitation, in general, and dry toilets, in particular.

ESAC responds to communities' demands by using participatory methods to assist them in analysing the causes of their problems and to identify possible solutions. When and if the community members decide to build dry toilets, ESAC trains them in construction, use, and maintenance, and provides follow-up monitoring and support.

Because of its limited resources on the one hand, and a focus on empowerment and fortifying democratic processes on the other, ESAC only responds to requests from organized popular groups. The NGO's experience and expertise in training community workers and in strengthening organized groups has spread by word of mouth, especially among grass-roots religious communities whose motivation for changing current conditions - including environmental conditions - is based on Biblical reflection. These groups expect to participate actively in decision-making.

All individual and group requests for hardware support are referred to Cr, who sells either the toilet seats or the fibreglass moulds and provides training in the production process. Although the groups are also offered advice on how to use modified buckets to make their own urine-diverting toilet seats, almost all prefer to purchase their seats ready-made.

As the demand for dry toilets has increased, Cr and ESAC have decided to make the training of community workers their highest priority. As a result of this focus, they have jointly developed and produced educational and training materials - including an attractive, full-colour poster showing a range of dry toilet models, as well as the basic technical design drawing.

Figure 1. The modified Vietnamese double-vault toilet

Technology - modified Vietnamese double-vault toilet

The modified Vietnamese double-vault toilet is designed to permit reuse of human excrement for agricultural purposes after it has been “treated” by keeping it in a sealed chamber for a minimum of six months. During that time the faeces become very dry, making it impossible for pathogens to survive. The two sides of the double vault toilet are alternated every six months at minimum. As excreta are not traditionally used as fertilizer in Mexico, there is no incentive to open a vault before the minimum six months of drying time is complete. The usual waiting period is 8 to 18 months before removal. It is estimated that a family of five to six members can produce a little less than half a cubic metre “harvest” per year.

Because of the impossibility of laboratory analysis for every toilet in use, it is recommended that the product not be used in vegetable gardens. However, it can be used in fruit orchards and to grow grains. Composting to improve the product's texture and fertility, and to modify its pH, can be undertaken.

Fermented urine is recommended as a fertilizer. Before sealing the container to avoid loss of nitrogen, users often add a handful of soil as a catalyst for the fermentation process. For fertilization purposes, users have reported varied dilution ratios of urine to water (from 1:5 to 1:20).

Unfermented urine can be sprayed as a fungicide. Indigenous people in southeastern Mexico claim that the use of urine as a fungicide was a traditional Mayan practice.


Raising awareness. One of the most important accomplishments of the programme has been the greater awareness that has been generated regarding sanitation-related environmental and health issues. Dry toilets are less often requested primarily on the basis of convenience, and more often on the basis of health concerns.

An increase in requests for dry systems from local architects reflects a greater environmental awareness (and demand) on the part of their middle-class clients.

Product development. In response to the increasing demand from diverse sectors of the population, Cr has been able to develop a broader range of products, including improved designs of toilet seats, using a variety of different materials. The brightly painted polished concrete remains the standard material used for the urine-diverting seat, as well as a companion urinal for men who are so inclined. Cr has produced a prototype portable fibreglass seat for public fairs, large private parties, and other special events; and together with another nongovernmental group, he is experimenting with recycled-plastic seats. An up-market ceramic seat is also under consideration.

Replication. Although the marketing is very low-key, the demand for urine-diversion seats is gradually increasing. To satisfy requests for dry toilets further afield, Cr sells the moulds (for 2500 Mexican Pesos, or approximately US$ 320) and assists local groups in establishing small workshops to produce the seats and to generate local employment. Beginning with the establishment of three independent workshops in Oaxaca in 1990, there are now about 15 independent, small-scale manufacturers of urine-diversion units, in different parts of the country.

Policy and regulatory environment. Cr is a political cartoonist, often commenting on environmental problems. His aesthetically appealing drawings, used in educational materials, invite the reader to reflect upon broader social and political values. As part of an awareness-building campaign and to increase social pressure for modification of the state environmental legislation, he also writes articles for local newspapers. An important, recent “victory” is that the state Architects Association will be submitting a proposal to the municipality of Cuernavaca, a city of over half a million people, whereby dry toilets become acceptable under the standards permitted for issuing housing permits.

Difficulties encountered

The most significant difficulty has been overcoming the negative reputation of project “failures”. When an external agent imposes its own resources and rhythms on the community, the project often fails. In these cases, the community has not identified alternative sanitation as a necessity. It has no knowledge, much less interest, in the dry toilet or in how it should be built and maintained. Fieldworkers are often uninformed about the technology, as well as community empowerment approaches.

A classic example is during election times, when a government entity decrees that a given number of toilets will be built, whether the community wants them or not. Likewise, in an economically stressed country, with a history of paternalistic relationships, many communities have become accustomed to passively receiving a variety of project offers from governmental and nongovernmental agencies. Often the community agrees to whatever is proposed, whether the need is felt or not, expecting that some advantage will be gained.

The families in these cases typically use the constructed toilet as storage space or a pigpen. When the dry toilets do not “work”, word gets around very fast. Overcoming the negative reputation of a technology is extremely difficult.

As the “flush and forget” mentality invades Mexico, choosing dry sanitation over conventional sanitation is rare. Having “modern” conveniences is a status symbol, while being environmentally “correct” carries no prestige.

Owing to the large and increasing demand, coupled with institutional financial constraints, consistent follow-up has not always been possible. At times, it has been necessary to make the difficult choice between either responding to another, new community or continuing with the old. Under these circumstances it has been equally difficult to give adequate attention to systematic monitoring and evaluation. For example, there is no clear data on how many of the 6000 urine-diversion seats produced are actually in use.

Lessons learned

The programme has discovered that:

· Large-scale promotion of dry sanitation should be avoided. Experience has shown that the lack of adequate education and institutional follow-up can lead to failure and abandonment of the approach.

· The various advantages of the dry toilets can be better appreciated and assimilated by users when they are explained and supported by established, organized groups.

· Dry systems are significantly less expensive than conventional waterborne systems. Although the costs of the specific components vary considerably, depending upon the materials used, a complete unit, including the superstructure and a cement roof, is approximately 1200 Mexican Pesos (US$ 150+);

· There are important environmental advantages to using dry toilets. Rather than producing 100 000 to 150 000 litres of contaminated sewage water per family per year (enough to fill a 2 x 2.5 x 30 m cistern), the dry system produces approximately 5000 litres of liquid fertilizer (urine) and 300 to 500 litres of “composted” soil conditioner.

· Seeing is believing! A visit to a home with a dry toilet, preferably one which is integrated within the house, rather than operated as a separate structure, is especially helpful for convincing potential users.

· Extension workers, who are generally considered of high status, are taken quite seriously when they have dry toilets in their own homes. This is a particularly important consideration when working in a region where past dry sanitation projects are considered to have “failed”.

· It is advisable not to talk about financing mechanisms (whether revolving loans, outright gifts or demonstration models) during the first discussion. Otherwise, there is a strong likelihood that this subject will become the focus, and distort the needs assessment.

· Encouraging families to be responsible for their own wastes is certainly acceptable; forcing them to accept any one technical solution is not. Extension workers should know when to bow out gracefully, leaving communication lines open, when communities decide (whether explicitly or implicitly) not to accept an innovative sanitation approach.

· Rather than succumb to the temptation of building the first toilet for public use, it is best to wait patiently until a few families decide to take the risk to experiment. Public toilets are notoriously dirty. Dry toilets are no exception.

· Several demonstration models are better than just one, to prevent the “brave” family from being pressured from all sides - either to succeed or fail. A “brave souls” support group can be helpful, with frequent trouble-shooting check-ups of the toilets by community workers.

· To counteract the destructive impact of “modern values” and conventional wisdom, groups should be actively involved in a participatory critical analysis of their situation. If provided with the tools to make informed choices, participants will generally assume responsibility for making decisions regarding their impact on the environment. Whether they decide to construct a dry toilet or not, this learning process should benefit them.

· Alternative systems should be attractive. Supplying “modern-looking” urine-diverting toilet seats in a wide range of colours has helped tremendously, as have educational posters, which show dry toilets installed within a variety of settings, including “luxurious” bathrooms.

Future plans

Proposals for future work include:

· Developing a guide for the handling and use of the processed faecal material (including guidelines for laboratory analysis).

· Developing a guide on the handling and use of the urine.

· Updating the existing construction manual, including a range of toilet styles and construction materials.

· Updating the existing users operation and maintenance guide.

· Developing small posters on proper use, appropriate for hanging in the bathroom.

ESAC is particularly interested in modifying the dry toilet system to incorporate red worm “vermi-culture”. It is anticipated that this innovation might require only one chamber, thus reducing construction costs, and result in a far superior compost product. ESAC is presently experimenting with vermi-composting of the harvested dry toilet compost, mixed with horse manure.

Additional laboratory analysis and research is necessary to determine acceptable levels of pathogen counts during different stages of the process and under different conditions. Thus far, the programme has relied exclusively on tests done by others.

The programme is beginning to make links with parallel urban composting centres to establish practical mechanisms for reuse of dry latrine output as the programme continues to expand.

Key institutions and responsible persons

Cr Ae
Helechos #5
Colonia Jacarandas
Cuernavaca, Morelos
62420 Mexico
Phone and fax: +52 73 15 49 11

George Anna Clark
Espacio de Salud, A. C. (ESAC)
Apartado Postal 1-1576
Cuernavaca, Morelos
62001 Mexico
Phone and fax: +52 73 18 07 20

Low-cost sewerage - Duncan Mara1

1 Professor of Civil Engineering, University of Leeds, UK.

Research and development undertaken by the World Bank during 1976-1986 (1, 2, 3) has shown clearly that possession, proper use and maintenance of a sanitation facility are more important, in terms of improving health, than the actual sanitation technology employed, provided that it is affordable and socioculturally acceptable. Nevertheless, sanitation technology choices have to be made, and the principal choice is between on-site and off-site systems, as follows:

On-site technologies:

· VIP latrines (or other types of pit latrine)

· pour-flush toilets

· septic tanks

Off-site technologies:

· conventional sewerage

· low-cost (unconventional) sewerage

- settled sewerage

- simplified sewerage

These technologies are described in the literature (see, for example, Mara (4, 5), Mara and Sinnatamby (6), Otis and Mara (7), Sinnatamby (8), Bakalian et al. (9) and, more generally, Mara (10)). The two low-cost sewerage technologies are less well known. Yet, in low- income areas with an adequate water supply these are viable sanitation options - often, depending on housing density, they are the only feasible options. This article reviews these low-cost sewerage options, their potential and their limitations. It also provides guidance on how to choose the most appropriate option, and gives examples of their successful application (see also (16)).

Nomenclature of low-cost sewerage

Both settled sewerage and simplified sewerage use small-diameter sewers laid at shallow depths and in which the flow is, ideally, due to gravity. Other terms, such as small-bore sewerage, small-diameter gravity sewerage or shallow sewerage are unclear. The definitions used in this article follow the Portuguese terminology developed in Brazil (see (11)) and are outlined below.

Settled sewerage: a system in which wastewater from one or more households is discharged into a single-compartment septic tank (usually called a solids interceptor tank). The settled (or solids-free) effluent from the septic tank is then discharged into shallow, small-bore gravity sewers. Settled sewerage is thus the same as small-bore sewerage as described by Otis and Mara (7), small-diameter gravity sewerage (12) and common effluent drainage (13). (In Portuguese it is called redes de esgotos decantados; in French, raux d'eaux us dnt; and in Spanish (17), alcantarillado sin arrastre de sos.)

Simplified sewerage describes shallow sewerage as used by Sinnatamby (8) and its in-block variant called backyard or condominial sewerage (15). This system does not convey presettled sewage, and is essentially conventional sewerage stripped down to its hydraulic basics. (In Portuguese, it is called redes de esgotos simplificadas; in French, raux d'eaux us simplifies; and in Spanish, alcantarillado simplificado.)

Disadvantages of conventional sewerage

Conventional sewerage has two principal disadvantages - high cost and the need for an in-house water supply.


A World Bank study (1) of eight large cities in Africa, Asia and Latin America showed that, while the costs of conventional sewerage are highly site-specific, they are always very high. Capital costs in the 1980s ranged from US$ 600 to 4000 (1980 $) per household, and annual economic costs (i.e. amortized capital costs plus operation and maintenance costs, including the economic cost of water used for flushing toilets) were US$ 150-650 per household (1980 $). Low-income communities evidently cannot afford such costs, unless they are massively subsidized (which is unlikely in practice).


Generally, conventional sewerage requires an in-house multiple-tap level of water supply service. This is because cistern-flush water-seal toilets (water closets) are normally connected to the in-house water supply. Most low-income peri-urban communities in developing countries do not have this high level of water supply. Instead, they often rely on hand-carried supplies from public tapstands (standpipes), shallow wells or surface waters. At best they may have a yard-tap supply (one tap per household, usually situated immediately outside the house). It has been reported that conventional sewerage can be operated with this level of water supply - for example, at Tondo Foreshore, Manila (17). However, this was before development of simplified sewerage, which is more appropriate with yard-tap water supplies.

Figure 1. Promotion of lost-cost sewerage - here an engineer from the sewerage authority explains to the community how the system works, why it is appropriate, how much it will cost and what the operation and maintenance requirements are.

Promotion of low-cost sewerage

As with all sanitation technologies, low-cost sewerage systems need to be promoted effectively so that they will be accepted by the community, and operated and maintained properly - this generally requires an effective partnership to be developed between the sewerage authority and the community.

Low-cost sewerage can be cheaper, depending on housing density, than on-site systems; and, when housing densities are too high for on-site systems (as in many peri-urban areas), low-cost sewerage - principally the condominial variant of simplified sewerage - is generally the only viable sanitation option.

The sewerage authority must work closely with the community to promote low-cost sewerage (Figure 1). Costs and operation and maintenance responsibilities must be carefully explained, and an explanation also has to be given why other sanitation technologies are inappropriate.

Low-cost sewerage - technical descriptions

Settled sewerage

In a settled sewerage system (Figure 2), the sewers receive only settled sewage, and are designed very differently from conventional sewers. The most obvious differences are that they are not designed for self-cleansing velocities (i.e. velocities to ensure transport of solids), and that the flow in the sewers can change along their length, from normal gravity open-channel flow to full-bore pressure flow and then back to open-channel flow. In comparison with conventional sewerage costs, settled sewerage costs are quite low. This is mainly due to the shallow excavation depths and the use of small-diameter pipework (commonly 75-100 mm PVC), and the use of simple inspection boxes instead of large manholes. The pipes are carefully laid and simply embedded to avoid damage (this is usually easy as they are laid away from vehicular traffic).

Figure 2. Schematic diagram of settled sewerage. The interceptor tank can be shared between adjacent houses to reduce costs in peri-urban areas.

Settled sewerage is most appropriate for areas which already have septic tanks, but where the soil can no longer accept all the septic tank effluent. So it is often a lower-cost solution in middle- or upper-income areas. Saving money in this way should mean that more public funds become available which can be used to serve low-income areas.

Settled sewerage was developed in Zambia (see below), and is now frequently used in Australia (where it is called common effluent drainage), and also in the United States, Colombia and Nigeria. Its increasing use in the United States for new housing developments is due to its low cost (around 50-60 per cent of conventional sewerage) and the fact that, from the users' perspective, it differs little from conventional sewerage.

Figure 3a. Schematic diagram of condominial sewerage in planned peri-urban areas.

Figure 3b. Schematic diagram of condominial sewerage in unplanned peri-urban areas.

Simplified sewerage

Simplified sewerage systems are designed to receive all household wastewater without settlement in solids interceptor tanks. Small-diameter sewers laid at shallow gradients are used to convey the sewage. The sewers are often laid inside housing blocks (Figure 3), when the system is known as condominial sewerage; or they may be laid outside the block, usually under the pavements on both sides of the street, rather than in the middle of the road, as is the case with conventional sewerage.

The costs of simplified sewerage systems are low (see below), sometimes even lower than those of on-site sanitation (Figure 4). This is because simplified (especially condominial) sewerage, in common with settled sewerage, uses shallow excavation depths, small-diameter pipework and simple inspection units (in place of large manholes). Additionally, the sewer gradients of a simplified sewerage system are much flatter than those of a conventional sewerage system. For example, UK practice for conventional sewers is to lay a 150 mm diameter sewer at a gradient of 1 in 150 (i.e. 1 m vertical to 150 m horizontal, or nearly 0.007 m/m) (18). In contrast, the earliest simplified sewerage schemes in northeast Brazil used 100 mm diameter sewers laid at 1 in 167 (0.006 m/m), and more recent schemes (based on minimum tractive tension, rather than minimum self-cleansing velocity) use a 100 mm sewer laid at 1 in 255 (0.004 m/m).

Simplified sewerage is most appropriate in high-density, low-income housing areas which have an on-plot level of water-supply (i.e. one tap or more per household) and no space for on-site sanitation pits or for the solids interceptor tanks of settled sewerage, It was developed as condominial sewerage in the early 1980s by CAERN, the water and sewerage company of the state of Rio Grande do Norte in northeast Brazil, as an affordable solution to the until then intractable problem of how to provide sanitation in high-density low-income areas (see below). It works well owing to the high initial rate of connection to the network (often well over 90 per cent; with conventional sewerage it can take many years to reach this level of connection), and when resulting sewage flows are correspondingly high. Blockages are very rare, even in the upper reaches of the network where the flow is intermittent: solids progress in a sequence of deposition, transport, deposition, transport until the sewer has drained a sufficiently large area for the flow to cease being intermittent. This deposition-transport-deposition - transport sequence is more efficient in small-diameter sewers than in large-diameter sewers.

Simplified sewerage systems are now used widely in Brazil and elsewhere in Latin America, and were introduced to Pakistan in 1985 in Christy Nagar, a very low-income slum area of Orangi in Karachi (see below). Simplified sewerage, especially its condominial version, without doubt represents one of the most important advances ever made in sanitation. Given the extremely high rate of urbanization which is creating high-density low-income areas in many developing countries, it will often be the only technically and institutionally feasible, economically appropriate and financially affordable sanitation option.

The case for settled sewerage

The case for settled sewerage has to be made on financial grounds. If the community already has septic tanks, and assuming the soil can no longer accept the septic tank effluent, settled sewerage will probably be cheaper than simplified sewerage. This must of course be checked in each case.

If the soil can no longer accept septic tank effluent because in-house water consumption is high (>100 litres/caput/day) and wastewater generation correspondingly high, in-house water conservation techniques, such as the installation of water-saving plumbing fixtures (see (19)) should be seriously considered in order to reduce the wastewater flow so that the soil's capacity to accept the septic tank effluent is restored.

Figure 4. Variation of annual costs per household of conventional sewerage, condominial sewerage (formerly called shallow sewerage) and on-site sanitation systems with population density. Data from Natal, northeast Brazil, showing that in this case condominial sewerage becomes cheaper than on-site sanitation at a population density of 160 persons per hectare.

The case for simplified sewerage

Simplified sewerage is worth considering as the sanitation technology of first choice for low-cost urban sanitation programmes and projects, especially those for high-density areas. But only if simplified sewerage is confirmed as:

- cheaper than on-site sanitation, and
- cheaper than settled sewerage.

Generally, though, the only areas for which simplified sewerage would not be the cheaper alternative are areas of low population density or areas already served by septic tanks (even currently malfunctioning septic tanks).

A decision must also be made concerning whether to adopt condominial (or backyard) sewerage or in-street sewerage. The former is more generally favoured in northeast Brazil, for example, and the latter in southern Brazil where SANEPAR, the water and sewerage company of the State of Paranoften installs “double sewers”, i.e. a sewer on each side of the street under each pavement. Whether the reasons for this are always valid is not clear, but “double in-street simplified sewerage” is around two-thirds more expensive than condominial sewerage (10, 20).

Selection criteria for low-cost sewerage


Cost - both economic and financial - is the most important criterion (1, 2). Costs must be evaluated with care taken to ensure that all costs, including, for example, those borne by the householders are taken into account. Generally, the most appropriate method is to determine the total annual economic and financial costs per household based on average incremental costs using the techniques of discounted cash flow analysis (i.e. converting future capital and operation and maintenance costs to their present values - see (2), chapter 4).

Unfortunately such annual costs are not usually calculated. The World Bank (9) and the Pan American Health Organization (21) quote the following ranges for the capital (i.e. investment) costs of sewerage (excluding the cost of sewage treatment) in Brazil:

Settled sewerage (northeast Brazil)

US$ 35-85 per person

Condominial sewerage (northeast Brazil)

US$ 65-105 per person

Simplified sewerage (southern Brazil)

US$ 170-240 per person

Conventional sewerage (southern Brazil)

US$ 240-390 per person

The costs of settled sewerage obviously depend on whether or not households already have septic tanks. As for simplified sewerage, the condominial (backyard) version is significantly cheaper than the non-condominial version (and very much cheaper than conventional sewerage). Condominial sewerage is therefore generally to be preferred. The financial costs of condominial sewerage are still very low though. In Natal in northeast Brazil (where condominial sewerage was developed in the early 1980s), capital costs in 1981 were USS$ 325 per household; the Water and Sewerage Company was able to recover its costs over a 30-year period by surcharging the water bill by only 40 per cent (rather than by the 100 per cent for households served by conventional sewerage). The charge for water was the “minimum tariff” (i.e. an assumed unmetered consumption of 15 m3 per household per month) of US$ 3.75. So the financial costs of simplified sewerage were really low: only US$ 1.50 per household per month (8, 22, 23).

Water supply

Ideally, an on-plot level of water supply should be available, although in Pakistan, simplified sewerage works well with a hand-carried water supply service level (see below).

Population density

As shown in Figure 3, population density is a key parameter in determining the cost and appropriateness of low-cost sewerage. In Natal in northeast Brazil, condominial sewerage was cheaper than on-site sanitation systems at a population density of 160 persons per hectare, but this must be checked in each particular case.

Community participation

The success of condominial sewerage in northeast Brazil is the result of an effective partnership between the sewerage authority and the community. The community is responsible for the operation and maintenance of the condominial sewers within the housing block. The sewerage authority is responsible only for the public sewers (i.e. the sewers outside the housing block). Assignment of these responsibilities must be discussed with the community before such a scheme is implemented. Community members must understand what their responsibilities are to be and why these responsibilities have been assigned to them (generally to reduce sewerage costs and enable a service to be provided). Essentially these responsibilities tend not to be great, involving only the removal of blockages (which are extremely rare and normally due to wilful abuse of the system). In Brazil, the community usually devolves its responsibilities to individual householders. In practice, this means that they are responsible for operation and maintenance of the length of condominial sewer which passes through their property (24, 25).

Institutional appropriateness

Usually, sewerage authorities are perfectly willing to accept responsibility for low-cost sewerage schemes. This is very important as they do not generally accept responsibility for on-site sanitation systems, leaving this to the municipal council, which may or may not be able to discharge the associated tasks (especially emptying of latrine pits) effectively. On-site systems are consequently often not fully satisfactory. In contrast, a good partnership between the sewerage authority and the community means that low-cost sewerage systems are operated and maintained very well (25).

The wastewater collected in low-cost sewers requires treatment before discharge into a surface watercourse or reuse for crop irrigation or fish culture. Usually, the most appropriate treatment process is carried out by waste stabilization ponds (see 26, 27 and 28). It is also worth noting that on-site systems can be upgraded over time, with corresponding improvements in water supply, to settled sewerage systems (see 2, 10).

Table 1 summarizes the characteristics, advantages and disadvantages of both settled and simplified sewerage.

Field examples of low-cost sewerage

Settled sewerage in Zambia

Settled sewerage was originally developed in the late 1950s by Mr L J Vincent, Manager of the then African Housing Board of Northern Rhodesia (now the Zambian National Housing Authority) (29). Conventional and sullage aqua-privies did network well in Northern Rhodesia and so settled sewers were developed to remove the settled wastewater (toilet wastes and sullage) from the aqua-privy tanks. The first such system was installed in 1960 at Kafue, an industrial township 50 km south of Lusaka (30). The land here, known as the Kafue Flats, is very flat, with a fall of only 1 in 2000. The sewers were designed for daily peak velocity of 0.3 m/s, and the pipes were 100 mm minimum in diameter, laid at a minimum gradient of 1 in 200. They were designed to flow when only partially full and not, unlike the more recent North American systems described by Otis (7), for surcharged flow. The system at Chipanda in Matero Township, Lusaka, is described below; but several others exist and are described elsewhere (31, 32, 33).

The Chipanda system was installed in 1960 and serves 532 households. Each aqua-privy block serves four households. Each household has a water tap and a sink immediately outside its toilet compartment which discharges its sullage into the aqua-privy tank (Figures 5 and 6). The tank effluent discharges, via a 100-mm diameter asbestos cement connector pipe, into a 150-mm diameter asbestos cement lateral sewer which runs between most of the compounds. Originally the settled sewage was treated in a series of waste stabilization ponds, but these were abandoned when the settled sewers were connected to the city's expanded conventional sewerage system.

Table 1. Summary of characteristics, advantages and limitations of settled and simplified sewerage

Settled sewerage

Simplified sewerage

Initial requirements:

Adequate water supply (preferably on-plot, although the system can work with hand-carried supplies).

Adequate water supply (preferably on-plot, although the system can work with hand-carried supplies).

Main characteristics:

Household wastewater is settled in a solids interceptor tank (single-compartment septic tank). Tank effluent discharged into small-diameter (75 mm minimum) commonly plastic pipes laid at shallow depth, at an inflective gradient. Wastewater treated in facultative and maturation ponds (or discharged into conventional sewer system).

Household wastewater discharged directly (i.e. without settlement) into small-diameter (100 mm minimum) plastic or vitrified clay pipes laid at shallow depth and low gradients (e.g. 1 in 270 (0.0037 m/m) for a 100-mm diameter pipe serving up to 1200 people). Wastewater treated in anaerobic, facultative and maturation ponds (or discharged into conventional sewer system).

Suitability criteria:

Most suitable in areas with existing septic tanks.

Most suitable in high-density low-income areas.

Principal limitations:

Sewerage authority has to assume responsibility for regular (e.g. annual or biennial) emptying of solids interceptor tank, and ensure that only settled sewage connections are made to the sewers.

Community has to accept responsibility for operation and maintenance of condominial sewers laid within the housing block.

Requirements for operation and maintenance:

Sewerage authority: regular inspection of sewers; maintenance of any lift stations; interceptor tank desludging; operation of treatment works.

Community: removal of any sewer blockages within housing block. Sewerage authority: regular inspection of ex-block sewers;* maintenance of any lift stations; operation of treatment works.

Costs: (These are indicative costs. Local costs must be properly estimated).

USA: capital costs of around 50-60% of conventional sewerage in areas where new solids interceptor tanks are installed (less in areas with existing septic tanks).

Northeast Brazil: capital costs of US$ 300-500 per household (compared with US$ 1500 per household for conventional sewerage).

* Ex-block sewers are laid in the public domain, i.e. under a pavement or street, as opposed to inside a housing block or within a private domain. The community would be responsible for maintaining sewers inside housing blocks.

Condominial sewerage in Natal, Northeast Brazil

Shallow sewerage was first developed in the low-income settlements of Rocas and Santos Reis in the city of Natal, the capital of the northeast Brazilian State of Rio Grande do Norte, by the Sanitation Research Unit of the State Water and Sewerage Company (CAERN) (8, 22). Rocas and Santos Reis are two neighbouring squatter settlements where approximately 15 000 people have settled, giving an overall population density of 350 persons per hectare. These settlements were spontaneous and essentially wholly unplanned.

The 3100 houses and buildings in the area were distributed over 86 blocks. Over half the houses were located on plot sizes less than 80 m2 and had constructed areas of less than 60 m2. They were therefore contiguous on at least one side with neighbouring properties with little or no space between them. Some space was usually available at the back of the house for a small garden. Income levels were exceptionally low, with two-thirds of the population earning subsistence wages below the country's poverty line.

Figure 5. Typical sewered aqua-privy in Chipanda, Matero (Zambia).

Despite such a low level of income, the granting of land titles to the householders had, over the years, encouraged the use of good quality construction material throughout most of the two areas. A yard-tap level of water supply was available and only a minimum water tariff levied from the majority of the premises, because of the small sizes of the plots. A quarter of the houses were not connected to any water-supply service, but shared supplies with their neighbours. Most houses had a conventional but manually-flushed ceramic toilet bowl which was connected to leachpits constructed within the plot area; sullage was discharged into the street in front. The high density of the settlement and the need for frequent leachpit desludging meant that the community was very dissatisfied with the system.

Although CAERN had a plan to serve the area with conventional sewers, it was evident that this would prove neither technically nor economically feasible, and that only a small proportion of house connections could be made. Meetings were held with the community to discuss the problem of sanitation in the area, and the advantages and disadvantages of various sanitation systems, including conventional and condominial sewerage. A condominial sewer system was proposed but the community feared that its operation might not be trouble free. One block, consisting of 28 houses, was therefore selected for a pilot test, and plans for laying in-block sewers were prepared. Each household consented to the construction of a common house connection in its backyard and agreed to be responsible for the maintenance of the length of sewer laid within its property; a simple inspection chamber was built for this purpose at each household connection to the sewer.

Figure 6. Typical sewered aqua-privy block in Chipanda, Matero (Zambia).

The pilot in-block condominial sewer was constructed in 1981 and operated for over a year while the planning of other block and street sewers proceeded. Block meetings were then arranged for the remaining 85 blocks, and residents in these blocks were encouraged to visit the pilot block and talk to the people living there to obtain their views on the system. This led to spontaneous acceptance of the system and a great demand to extend it to the remaining blocks. An unprecedented connection rate of 97 per cent was achieved in the first year of construction.

Within five years, the shallow sewer system was also being used in other towns within Rio Grande do Norte and was being implemented in all low-income housing schemes in the State without exception. During this period, it also began to be used in other states in Brazil such as Pernambuco, Rio de Janeiro, Minas Gerais and Sergipe. More recently, condominial sewerage has been used on a very large scale in Brazil through the World Bank PROSANEAR I Project (Table 2).

Table 2. World Bank PROSANEAR Project statistics



Number of beneficiaries

Capital cost per person (US$)



126 000




186 000




9 000


Rio de Janeiro

Rio de Janeiro

445 000


Angra dos Reis

70 000


Source: World Bank. People, poverty and pipes: the power of community participation and low-cost technology to bring water and sanitation to Brazil's slums. Washington, D.C., The World Bank (Infrastructure and Urban Operations, Department 1, Latin America and Caribbean Region), 1996.

Condominial sewerage in Orangi, Karachi, Pakistan

Approximately 40 per cent of Karachi's population lives in squatter settlements (locally termed “katchi abadies”). Orangi, the largest squatter settlement in Karachi and in Pakistan, is situated 12 km from the centre of the city. It has an estimated population of 800 000, settled in sub-standard conditions in an area covering approximately 2000 hectares. At the start of the project, average household incomes were at subsistence levels, and infant mortality and the incidence of excreta-related infections were both high.

The settlement was a result of migration from the former East Pakistan, which had taken place during the period immediately before and after the creation of Bangladesh. Although the largest of the katchi abadies, Orangi lacked the minimum of basic infrastructure and essential amenities. In March 1983, the Bank of Credit and Commerce International Foundation (BCCI), in collaboration with UNCHS (Habitat), initiated a three-year community development project, aimed at improving the living conditions of the people of Orangi (see (8)).

The project aimed to promote implementation of low-cost infrastructure interventions, particularly for sanitation, given the urgent need for sanitation improvement in the project area. The water supply to Orangi was via unevenly distributed communal stand-pipes which operated for four hours a day only, in the afternoon. Water was stored in in-compound tanks in most of the houses; on average, 20 to 30 litres were used by each household member each day. Only rudimentary plumbing fixtures were present in the area, and most washing was confined to a special wet room used for both bathing and washing clothes and utensils. The most common form of sanitation in the area was bucket latrines and the socio-religious custom of using water for anal cleansing necessitated the carrying of water to the toilet. “Scavengers”, who undertook the removal of excreta from the bucket latrines, charged US$ 1 per month for the service, but no provision existed for the disposal of sullage.

In 1984, Chisty Nagar, a Bihar community within Orangi, was selected as the first location to start the condominial sewerage programme. The project area contained 555 plots, 408 of which had houses built on them, and an average gross population density of 193 persons per hectare. A remarkable feature of the area was the regularity of its urbanization, with average plot sizes of 100 m2, 50 per cent of which, on average, was occupied by the house. Even more remarkable was the existence of a service lane, designed to provide access for nightsoil removal by the scavengers.

General community meetings were held after midday prayers at the mosque on Fridays. Local community leaders were selected and the programme was described. Discussions held with the community revealed a preference for some form of waterborne sanitation, but conventional wisdom dictated that the unreliable intermittent water supply and low levels of water consumption in the area would rule out use of conventional sewerage. Average water consumption was found to be 27 litres per person per day; with conventional sewerage, consumption is much higher, generally over 100 litres per day.

Only condominial sewerage offered any chance of success. Although condominial sewers had not been previously installed under conditions of such limited water use, and with manually flushed ceramic toilet squat pans, their mode of operation suggested that they would nevertheless function satisfactorily. An analysis of the costs of various sanitation options also indicated condominial sewers to be one of the cheapest options. It was therefore decided that condominial sewerage should be implemented in Chisty Nagar.

Meetings were held with the community to present the proposed designs and to establish a procedure for raising the required capital which had to be found in full by the community. The community nominated a trusted member to be the custodian of the funds raised. It was also envisaged that maintenance committees would be established as social mobilization advanced, in order to maintain the condominial sewers after installation.

Condominial sewers, laid in the service lanes (until then only used by scavengers for emptying nightsoil buckets), were designed according to criteria similar to those developed in Brazil; they received the wastewater from the manually flushed squat pans and all household sullage. A grit/grease trap, made of cement mortar (including fine aggregates) was provided in each house, as the main point of sullage collection and as a preventive maintenance device. One inspection chamber was provided to serve two plots, and each water closet connection was appropriately ventilated. In addition to the service lane sewers, an interceptor sewer was constructed to drain the lane sewers into a communal septic tank. The effluent from the tank was discharged to the nearby dry water course.1 The shallow sewer layout adopted in Chisty Nagar is shown in Figure 7.

1 In most circumstances this is not the best solution. Whenever possible, wastewater should be treated before discharge.

The internal plumbing and lane sewers comprised 30 and 31 per cent respectively of the total cost, which amounted to approximately US$ 45 per plot. An alternating twin-pit pour-flush toilet, which disposes of excreta only, would have cost approximately US$ 51. As in northeast Brazil, condominial sewerage was cheaper than on-site sanitation.

Figure 7. Layout of condominial sewerage in the low-income settlement of Chisty Naga in Orangi, Karachi, (Pakistan).

Following the success of this first BCCI/UNCHS condominial sewerage project in Chisty Nagar, the system was soon also applied in other parts of Orangi, eventually becoming known as the Orangi Pilot Project. So far, around 750 000 poor people have been served by condominial sewerage - a very successful example of technology transfer from one developing country (Brazil) to another (Pakistan).


(1) Kalbermatten JM, Julius DS, Gunnerson CG. Appropriate sanitation alternatives: a technical and economic appraisal. Baltimore, MD, Johns Hopkins University Press, 1982.

(2) Kalbermatten JM et al. Appropriate sanitation alternatives: a planning and design manual. Baltimore, MD, Johns Hopkins University Press, 1982.

(3) Feachem RG et al. Sanitation and disease: health aspects of excreta and wastewater management. Chichester, UK, John Wiley, 1983.

(4) Mara DD. The design of ventilated improved pit latrines. Washington, DC, The World Bank, 1984 (TAG Technical Note No. 13).

(5) Mara DD. The design of pour-flush toilets. Washington, DC, The World Bank, 1985 (TAG Technical Note No. 13).

(6) Mara DD, Sinnatamby GS. Rational design of septic tanks in warm climates. The public health engineer, 1986, 14(4):49-55.

(7) Otis RJ, Mara DD. The design of small bore sewer systems. Washington, DC, The World Bank, 1985 (TAG Technical Note No. 14).

(8) Sinnatamby GS. The design of shallow sewer systems. Nairobi, United Nations Centre for Human Settlements, 1986.

(9) Bakalian A et al. Simplified sewerage: design guidelines. Washington DC, The World Bank, 1994 (Water and Sanitation Report No. 7).

(10) Mara DD. Low-cost urban sanitation. Chichester, UK, John Wiley & Sons, 1996.

(11) Guimar ASP. Redes de esgotos simplificadas. Brasilia, Programa das Nas Unidas para o Desenvolvimento/Ministo do Desenvolvimento Urbano e Meio Ambiente, 1986.

(12) Otis RJ. Small-diameter gravity sewers: experience in the United States. In: Mara D, ed. Low-cost sewerage. Chichester, UK, John Wiley & Sons, 1996:123-133.

(13) South Australian Health Commission. Common effluent drainage system. Adelaide, SAHC (Health Surveying Services), 1982.

(14) Rizo-Pombo JH. The Colombian ASAS system. In: Mara D, ed. Low-cost sewerage. Chichester, UK, John Wiley & Sons, 1996:135-153.

(15) Rodrigues de Melo JC. Sistemas condominiais de esgotos. Engenharia sanita (Rio de Janeiro), 1985, 24(2):237-238.

(16) Mara DD. Low-cost sewerage. Chichester, UK, John Wiley & Sons, 1996.

(17) Middleton RN, personal communication, 1978.

(18) Water Services Association. Sewers for adoption, 4th edn. Swindon, Water Research Centre, 1995.

(19) Mara DD. The conservation of drinking water supplies: techniques for low-income settlements. Nairobi, United Nations Centre for Human Settlements, 1989.

(20) Hamer J. Low cost urban sanitation in developing countries [Dissertation]. Leeds, UK, University of Leeds (Department of Civil Engineering), 1995.

(21) Azevedo Netto JM. Innovative and low cost technologies utilized in sewerage. Washington, DC, Pan American Health Organization, 1992 (Environmental Health Program Technical Series No. 29).

(22) Sinnatamby GS. Low-cost sanitation systems for urban peripheral areas in Northeast Brazil [Thesis]. Leeds, UK, University of Leeds, 1983.

(23) Sinnatamby G, Mara DD, McGarry M. Sewerage: shallow systems offer hope to slums. World water, 1986, 9, 39-41.

(24) Rondon EB. A critical evaluation of shallow sewerage systems: a case study in CuiabBrazil [Dissertation]. Leeds, UK, University of Leeds (Department of Civil Engineering), 1990.

(25) Watson G. Good sewers cheap? Agency-customer interactions in low-cost urban sanitation in Brazil. Water and sanitation currents. Washington, DC, The World Bank, Washington DC, 1995.

(26) Mara DD. Sewage treatment in hot climates. Chichester, UK, John Wiley & Sons, 1976.

(27) Mara DD. Design manual for waste stabilization ponds in India. Leeds, UK, Lagoon Technology International, 1997.

(28) Mara DD et al. Waste stabilization ponds: design manual for Eastern Africa. Leeds, UK, Lagoon Technology International, 1992.

(29) Marais GvR. Personal communication, 1995 (Department of Civil Engineering, University of Cape Town, South Africa).

(30) Vincent LJ, Algie WE, Marais GvR. A system of sanitation for low cost high density housing. In: Proceedings of the Symposium on Hygiene and Sanitation in Relation to Housing CCTA/WHO, Naimey 1961. London, Commission for Technical Cooperation in Africa South of the Sahara, 1963 (Publication No. 84): 135-172.

(31) Feachem RG, Mara DD, Iwugo KO. Sanitation studies in Africa - Site Report No. 4: Zambia (Lusaka and Ndola). Washington, DC, The World Bank, 1978 (unpublished research report).

(32) Feachem RG, Mara DD, Iwugo KO. Alternative sanitation technologies for urban areas in Africa. Washington, DC, The World Bank, 1979 (P.U. Report No. RES 22).

(33) de Kruijff GJW. Aqua-privy sewerage systems: a survey of some schemes in Zambia. Nairobi, University of Nairobi (Housing Research and Development Unit), 1978.

Further reading

Bakalian A et al. Simplified sewerage: design guidelines. Washington, DC, The World Bank, 1994 (Water and Sanitation Report No. 7).

de Azevedo Netto JM. Innovative and low cost technologies utilized in sewerage. Washington, DC, Pan American Health Organization, 1992 (Environmental Health Program Technical Series No. 29).

Mara DD. Low-cost sewerage. Chichester, UK, John Wiley & Sons, 1996.

Mara DD. Low-cost urban sanitation. Chichester, UK, John Wiley & Sons, 1996,

Reed RA. Sustainable sewerage: guidelines for community schemes. London, IT Publications, 1995.

Sinnatamby GS. The design of shallow sewer systems. Nairobi, United Nations Centre for Human Settlements, 1986.

Watson G. Good sewers cheap? Agency-customer interactions in low-cost urban sanitation in Brazil. Water and sanitation currents. Washington, DC, The World Bank, 1995.

Worm composting and vermitechnologies applicable to sanitation - S. Zorba Frankel1

1 Managing Editor, Worm digest, Eugene, Oregon, USA.

The past two decades have seen renewed interest in finding ways to harness earthworms to convert our increasing amounts of organic waste into humus. Various types of earthworm are being used to turn “waste” into a useful resource and enabling some existing waste treatment systems to be operated more efficiently. Waste treatment systems that incorporate worm technologies can accept a wide range of organic matter inputs, including human excreta, can destroy pathogens overtime, and create a nutrient-rich soil amendment as a product.

Some of these systems can be built with simple materials, and on small budgets. They can be built to varying sizes to serve different-sized families and communities. Many require little or no water beyond the amount provided by the organics.

This article provides basic definitions and explanations of vermicomposting and “vermiculture ecotechnology”, and describes their successful use in many different settings. More information on these projects may be obtained from the publications listed at the end of the article.

What is vermicomposting?

Vermicomposting (worm composting) is the conversion of organic wastes by surface-dwelling earthworms into worm castings (excreta). The redworm species Eisenia foetida and Lumbricus rubellus are most commonly used in vermicomposting. In nature they are often found where leaf or other organic litter falls onto the surface of the soil and remains damp. In that setting they play the role of “emergency clean-up crew.” When harnessed, their natural abilities in reproducing quickly and eating up to their weight in organic materials each day are taken advantage of.

In many vermicomposting systems, and particularly those in homes, schools and industries in industrialized countries, redworms are housed in bins. Bins are most often made of wood, but plastic, metal or any material which is not dangerous to the worms' survival can also be used. Some manufacturers offer popular plastic bins for home use, designed with holes for aeration. Models also exist that sport such features as a lower chamber and spigot to collect and drain “worm tea” for watering plants, as well as multiple-worm composting layers, and even a mechanical device for harvesting castings.

As with traditional composting, a balance is sought between carbon-rich materials like leaves and straw, and nitrogen-rich material like food waste and manures. Usually, these two types of material are mixed or layered in the worm beds to ensure more complete decomposition and a good finished product. Worm bins in home settings are first filled with moistened carbon-rich bedding like straw, leaves, or shredded newspaper. Then a small amount of garden dirt is added (the tiny rock particles aid the redworms' digestion), and finally the redworms are introduced into their new homes. Feeding can be daily or less often, depending on the user's schedule. Redworms will eat about half their own weight in food wastes per day (in most bins, under average conditions). As the bedding decays via the activity of bacteria, the worms will simply begin eating it, too! Castings can be harvested within three to five months, depending on how finished a product is desired. After harvesting (there are several methods), the worms are put back into their bin with fresh bedding, to begin the process over again. These are the most basic instructions for small! worm bins. For more detailed information, consult the publications listed at the end of this article.

The following are project examples using redworms which have been reported by Worm digest, a US magazine.2

2 Worm digest began publishing in 1993 with the aim of promoting the raising of redworms to convert organic wastes into humus in households and schools. The range of vermitechnologies known and promoted has widened since then, but vermicomposting with redworms in bins remains the most well-known method. Interest in worm composting in the US seems to be growing, judging from the increased media coverage of worms, worm curricula in schools, and the growing number of requests for Worm digest subscriptions, publications and assistance.

School lunch “wastes” not wasted

At Mill City Middle School in Mill City, Oregon, USA, sixty 5th-grade students use redworms, in a well-designed bin, to vermicompost their food waste. They built five OSCRs (Oregon Soil Corporation Reactor, named after the company that designed it) from plans they purchased. The OSCR is a tall, rectangular plywood bin with large upper and lower chambers separated by nylon rope weaving back and forth every few inches. The upper chamber houses the redworms, and there is a plywood lid to keep pests and light out. Students add food and paper waste to the upper chamber each schoolday. As the composting mass grows higher and the redworms move upward, they leave their castings below, suspended above the nylon rope. The lower chamber, accessed through a hinged door, is a collection area for finished castings. A small rake is used to dislodge the castings into the lower chamber, from which they are easily removed. Although only a year old, this project has converted the food wastes of these sixty students into worm castings, and both students and teacher are enjoying working with worms.

Turning hog manure into a resource

Vermicycle Organics, Inc., in Charlotte, North Carolina, USA has tested the use of redworms to process hog manure into organic fertilizer on a farm in their region. Partners Tom and Chris Christenberry (who, as farmers, had previous experience with worm composting) and Michael Edwards began their tests with open-field worm composting, but found that weather created problems, including a poor end-product. Now they separate the liquids from the solids in the manure and each week spread over five tons of manure solids in thin layers on top of several long, raised wooden worm beds in a greenhouse. A shade cloth, automatic misters, fans and greenhouse curtains help to keep conditions optimal for the redworms. Their product, VermicycleTM Worm Castings, has been received well by retail outlets and the three partners plan to expand their work to more farms soon.(1)

Vermicomposting toilets

Clivus Multrum

Aerobic composting toilets are already used in many parts of the world to turn human waste into soil (2). Redworms can enhance their operation, requiring only the addition of a simple moistening system. Such has been the experience with the Clivus Multrum system which has made regular use of redworms for the past five years. The Clivus system was first created in 1939 in Sweden, and sold in the US and elsewhere by Clivus Multrum, Inc. beginning in 1973. A typical home might include an ultra-low-flush toilet, a kitchen waste-disposal chute and a large composting chamber below the floor or in a basement. “Clivus” means slope, named for the sloping plane within the composting chamber that directs liquids to a separate area below the composting mass, from which it is then removed by pump. A fan-driven ventilation system vents odours from the toilet room. A family of four can expect to remove small quantities of (solid) compost via a door at the front of the composting chamber after a period of one to several years. An estimated 10 000 Clivus Multrum toilets are in use worldwide.



Clint Elston of Minnesota has developed a worm composting system for colder climates. He had experience selling Clivus Multrums while living in Colorado. But when he installed them in Alaska (where most rural villages do not have adequate sanitation systems), he found that the Clivus systems did not operate well due to the extreme cold. So, over twenty years ago, he began work on the AlasCan system, a complete organic conversion system for households. At the heart of the system is the vermicomposting tank, which accepts toilet wastes from an ultra-low-flush toilet (a marine toilet) and from a dedicated kitchen sink with a waste-disposal unit. The tank is super-insulated (R-20+) and pre-warmed by house air in a heat exchanger. The other main component of an AlasCan system is the wastewater treatment system, which accepts all household greywater (including from showers, bathtubs, sinks and washing-machines). The AlasCan system is designed for minimal user involvement and uses motor-driven agitators, a pump, sprayer and exhaust fan to ensure continuous good functioning. According to AlasCan, the system produces about 10 cubic feet of vermicastings per year for a household of two adults and two children. The system's cold-weather capabilities have won it some acclaim. At this time, Buckland, Alaska, a village of 82 homes, has passed resolutions to install the AlasCans exclusively, and has contacted another village in order to help them do a pilot project.

Vermiculture ecotechnology

Dr Uday Bhawalkar is director of the Bhawalkar Earthworm Research Institute in Pune, India. He researches and designs systems that use aerobic bacteria and burrowing earthworms to convert organic wastes (including human excreta) into humus. He calls the basic method he developed “vermiculture ecotechnology” in which “diverse organics, via an already-operating ecosystem (bacteria, managed by burrowing earthworms), are turned into plant nutrients.” The key players are aerobic bacteria living in the earthworm's burrow, gut and surrounding soil, plus the earthworms themselves, which preferentially encourage good bacteria while discouraging unwanted (anaerobic and pathogenic) bacteria.

When choosing a site for vermiculture ecotechnology, a root zone must be available. If the site does not already have plants growing on it, then some trees or taller bushes must be planted there. Next, a thin layer of organic wastes is applied directly on the soil, along with some rock dust (powder) to provide necessary plant minerals and to balance the pH. A moisture-retaining layer of leaves or straw, etc., may be added. When available, some of the vermicastings from another site will get things started more quickly, especially if the soil is not already very biologically active. Food waste can be added at an increasing rate, as bacteria and worm populations grow. Again, for more detailed instructions, consult the books in the resources section.

In India, Dr Bhawalkar has put vermiculture ecotechnology to work at many sites with varying organic waste sources. Most notable has been the project at Venkateshwara Hatcheries, Ltd., in Pune. This poultry processing plant produces four tons of poultry offal daily, which goes to twenty 120 m2 concrete bins inoculated with a culture of the native burrowing species, Polypheretima elongata. Trees have been planted along the mid-line of the bins and, judging by their health, provide assurance that the vermiculture is proceeding well. Bhawalkar calls what is left after the bacteria and worms have worked through the material “biofertilizer”. These microbially-rich vermicastings, full of beneficial bacteria, are sold to farmers under the name of “Biogold”. Venkateshwara Hatcheries, Ltd. plans to use vermiculture ecotechnology at its other 12 operations in India as well.

Although Dr Bhawalkar has shifted his focus to another, newer vermitechnology, several people are still very active in spreading the use of vermiculture ecotechnology. Rahul Babar, a partner in NRG Tech Consultants, offers expertise in vermiculture ecotechnology for setting up complete and ready-to-use solid and liquid waste management projects. Shantu Shenai, director of the Green Cross Society and SOS (Save Our Selves) in Bombay, India, has initiated nearly 20 projects in that area using the Bhawalkar method.

Figure 1: Cross-section of vermifilter

In the vermifilter a group of selected plants provide an active root matrix that creates the desired microclimate for both bacteria and earthworms. This root matrix feeds on the inorganics and other growth factors produced by the bacteria and earthworms, while at the same time sending biofeedback to the bioprocessors, letting them know what the plants need. There is little operation and maintenance required, provided the designed loading rate is not exceeded. (Typical design parameters: Hydraulic loading up to 0.5m/day and organic loading up to 1 kg/m2/day). Stephen White, from Worm digest #8.

Vermifiltration of sewage

The vermifiltration of sewage (3) is an application of vermiculture ecotechnology designed by Uday Bhawalkar. It was adopted at the Sahjeewan School at Panchgani (Maharashtra) after the failure of their septic system due to clayey soil. The project was set up by Bhawalkar, and by 1995, was handling the waste of over half of the school's student population of 750.

The Sujala technique

Dr Bhawalkar is currently involved in promoting his newest technique, “Sujala” (which means “clear water” in Hindi). The technique makes use of the beneficial bacteria fixed on the castings of a specific species of earthworm (again, Pheretima elongata in projects in India). Sujala is in use at the Taj Group of Hotels in India. These hotels, located in remote sites, sought to use natural methods for wastewater treatment. V. Mahendrakar and B. B. Hallett (4) report in issue #15 of Worm Digest'. “In the existing septic tanks, by adding Sujala, BOD [biochemical oxygen demand] levels were reduced from 200 mg/l to about 30 mg/l and odour was reduced and water clarity increased in 3-4 weeks of operation. Approximately 150 kg of Sujala bacteria were added to a 15 m3 septic tank.” To summarize, after three to four months they saw an increase in pH from 6.5 to about 7.1 and an end to odours, a BOD and COD [chemical oxygen demand] reduction of between 50 and 80 per cent, water output at a quality level for use in the garden and a savings of about US$ 16 per day in electricity.


Presently we have a great need for efficient systems that process our increasing organic wastes. At the same time, in many parts of the world, our soils are growing poorer because we do not return to them as many or more nutrients than we take. Both problems have a common solution: we need only ask the capable earthworm for its help.


(1) Riggle D. The business of vermicomposting. Biocycle journal of composting and recycling, September, 1996, 54-56 (Biocycle, 419 State St, Emmaus PA 18049, USA. Tel: +1 610 967 4135.) Single copies US$ 6.

(2) Rapaport R. Aerobic composting toilets for tropical environments. Biocycle journal of composting and recycling, July 1996, 77-82. (Biocycle, 419 State St, Emmaus PA 18049, USA, Tel: +1 610 967 4135.) Single copies US$ 6.

(3) Whites. Vermifiltration of sewage, now being done in India. Worm digest #8, 1995. (Worm digest, PO Box 544, Eugene, OR 97440-0544, USA. Tel: +1 541 485 0456. E-mail:

(4) Mahendrakar V, Hallett BB. Worm digest #15 (see address above).

Background reading

Worms eat my garbage by Mary Appelhof (2nd ed., 176 pgs). The definitive book on small-scale vermicomposting for adults. (Available from Worm digest for US$ 13.)

Worms eat our garbage: classroom activities for a better environment by Mary Appelhof (215 pgs). (Available from Worm digest for US$ 25.)

Squirmy wormy composters by Bobbie Kalman & Janine Schaub (32 pgs). The definitive book for young people on worm composting. (Available from Worm digestion US$ 9.50.)

Turning garbage into gold by Dr Uday Bhawalkar of the Bhawalkar Earthworm Research Institute (40 pgs.). A good theoretical introduction to vermiculture ecotechnology work. Not a how-to book. (Available from Worm digest for US$ 15.00.)

Vermiculture ecotechnology by Dr Uday Bhawalkar of the Bhawalkar Earthworm Research Institute (283 pgs). A treatise on commercial-scale vermiculture. (Available from Worm digest for US$ 150.00. Colour plates version also available for US$ 190.)

Art of small-scale vermicomposting and vermiculture ecotechnology. A 16-page pamphlet teaching the basics of these two worm technologies. (Available from Worm digest for US$ 5.00.)

Turning garbage into gold (47-minute video) by Dr Uday Bhawalkar of Bhawalkar Earthworm Research Institute. See book description above. (Available from Worm digest for US$ 28.00.)

OSCRTM worm bin design plans (Bin: 3' x 4' x 3' high). Vermicomposts up to 12 pounds of food/paper wastes daily, food added from top, castings empty below. (Available from Worm digestion US$ 35.00.)

The toilet papers (1995) by Sim Van der Ryn. Available for US$ 10.95 + US$ 4 shipping from Chelsea Green Publishing Co., 205 Gates-Briggs Building, PO Box 428, White River Junction, VT 05001, USA.

The humanure handbook (1994) by Joseph C. Jenkins. Available for US$ 19 + US$ 4 shipping from Chelsea Green Publishing Co., 205 Gates-Briggs Building, PO Box 428, White River Junction, VT 05001, USA.


Worm digest, PO Box 544, Eugene, OR 97440-0544, USA. Tel/Fax: +1 541 485 0456. Subscriptions: US$ 12/yr. to US, US$ 16 to Canada/Mexico, US$ 20 to other countries. Back issues: US$ 3.50 to US, US$ 4.25 to Canada/Mexico, US$ 5.50 to other countries. Set of 15 back issues: US$ 36 to US, US$ 40 elsewhere. E-mail: Website:

Biocycle journal of composting & recycling. Biocycle, 419 State St, Emmaus, PA 18049, USA. Tel: +1 610 967 4135. Single copies US$ 6. A monthly publication. One- and two-year subscriptions: US$ 63/US$ 103 to US, US$ 85/US$ 147 to Canada, US$ 90/US$ 157 to other countries.

Hallett BB. The Taj West End Hotel, Race Course Road, Bangalore - 560 001 India Tel: +91 80 2255055. Fax: +91 80 2200010, E-mail:

Jeremy Criss, Bio-Recycler Corp., 5308 Emerald Dr., Sykesville, MD 21784, USA. Tel: +1 410 795 2607. Fax: +1 410 549 1445.

Abby Rockefeller, Clivus Multrum, Inc., 104 Mt. Auburn St., Cambridge, MA 02138, USA. Tel: +1 800 425 4887.

Clint Elston, AlasCan Corporation, PO Box 88, Clear Lake, MN 55319, USA. Tel: +1 320 743 2909.

Dr Uday Bhawalkar, Bhawalkar Earthworm Research Institute, A/3 Kalyani, Pune Satara Rd, Pune 411 037 INDIA. Fax: +91 212 43 21 53. E-mail:

Uday Sawant, Manager Operations, OMNI Biosearch Ltd. (a subsidiary of Venkateshwara Hatcheries), Venkateswara House S, #114 A/2 Pune Sinhagad Rd., Pune 411 030, India.

NRG Tech Consultants, B-213, Shantiban Housing Society, S. No. 52 & 79, Paud Road, Kothrud, Pune 411 029, INDIA. Tel/Fax: +91 212 33 59 26.

© S. Zorba Frankel, Managing Editor, Worm digest, Eugene, Oregon, USA, 1997, edited by WHO with permission of S. Zorba Frankel.

Prepared in association with SARAR TransformaciC


Academy for Educational Development and the Annenberg School for Communication. Results and realities: a decade of experience in communication for child survival. A summary report of the Communication for Child Survival or HEALTHCOM Project. Washington, DC, USAID, Bureau of Research and Development, Office of Health, 1992.

Adams, J. ed. Sanitation in emergency situations, an Ox/am Working Paper, Oxfam Publishing, 274 Banbury Road, Oxford, 0X2 7DZ, UK.

Almedom AM, Blumenthal U, Manderson L. Hygiene evaluation procedures: approaches and methods for assessing water - and sanitation - related hygiene practices. International Nutrition Foundation for Developing Countries, 1997.

Appelhof M. Worms eat my garbage (2nd ed., 176 pgs), The definitive book on small-scale vermicomposting for adults. (Available from Worm digest, PO Box 544, Eugene, OR 97440-0544, US$ 13.)

Appelhof M. Worms eat our garbage: classroom activities for a better environment (215 pgs). (Available from Worm digest, see address above, US$ 25.)

Art of small-scale vermicomposting and vermiculture ecotechnology. (Available from Worm digest, see address above, US$ 5.00.)

Attawell K, ed. “Partnerships for change” and communication - guidelines for malaria control. Division of Control of Tropical Diseases, World Health Organization (1211 Geneva 27, Switzerland) and Malaria Consortium (London School of Hygiene & Tropical Medicine, Keppel Street, London WCIE 7HT, UK).

Azevedo Netto JM. Innovative and low cost technologies utilized in sewerage. Washington, DC, Pan American Health Organization, 1992 (Environmental Health Program Technical Series No. 29).

Bakalian A et al. Simplified sewerage: design guidelines. Washington DC, The World Bank, 1994 (Water and Sanitation Report No. 7).

Bateman OM. Sanitation and family education (SAFE) pilot project. Report on the baseline survey. Bangladesh, CARE, 1993.

Bateman MO et al. Report on the monitoring and improvement system. Sanitation and family education. (SAFE) Pilot project, Bangladesh, CARE, 1995.

Bhawalkar U. Turning garbage into gold. Bhawalker Earthworm Research Institute (40 pgs.). (Available from Worm digest, PO Box 544, Eugene, OR 97440-0544.)

Bhawalkar U. Turning garbage into gold (47-minute video). Bhawalker Earthworm Research Institute. (Available from Worm digest, see address above.)

Bhawalkar U. Vermiculture ecotechnology. Bhawalkar Earthworm Research Institute (283 pgs). A treatise on commercial-scale vermiculture. (Available from Worm digestion US$ 150.00. Colour plates version also available for US$ 190, see address above.)

Biocycle journal of composting & recycling. Biocycle, 419 State St, Emmaus, PA 18049, USA.

Black M. Mega-slums: the coming sanitary crisis. London, WaterAid, 1994.

Blackett, IC. Low cost urban sanitation in Lesotho, March 1991. Published in March 1994 as Water and Sanitation Discussion Paper Series Number 10. Washington, DC, The World Bank.

Boot MT. Making the links: guidelines for hygiene education in community water supply and sanitation. The Hague, The Netherlands, IRC, 1990 (Occasional Paper No. 5).

Boot MT. Just stir gently: the way to mix hygiene education with water supply and sanitation. The Hague, The Netherlands, IRC, 1991, Technical Paper Series No. 29.

Boot MT, Cairncross A. Actions speak: the study of hygiene behaviour in water and sanitation projects. The Hague, The Netherlands, IRC, 1993.

Boyden S, Dover S. Natural-resource consumption and its environmental impacts in the western world - impacts of increasing per capita consumption. Ambio, 1992, 21(1):63-69.

Brand T. Letrinas secas: una polca nacional en El Salvador and Saneamiento sin agua. El Manantial - Boletde la Red Regional de Agua y Saneamiento para Centroamca (RRASCA), A, #1, August 1996.

Breslin ED, Madrid C, Mkhize A. Subsidies and sanitation; increasing household contributions to sanitation in KwaZulu/Natal. 1997. (Paper presented at the23rd WEDC Conference, 1-5 September 1997, Durban, South Africa). WEDC Conference Proceedings, Loughborough University, Leeds, UK, 1998.

Buzzard S. The rural water supply and sanitation field testing project, Nepali a case study of participatory monitoring and evaluation. Paper presented at a conference entitled, “The World Bank and Participation”, The World Bank, Washington, DC, September 1994.

Cairncross S. Sanitation and water supply: practical lessons from the decade. UNDP-World Bank Water and Sanitation Program, Washington, DC, World Bank, 1992 (Water and Sanitation Discussion Paper Series DP Number 9).

Caprara A et al. The perception of AIDS in the B and Baoulf the Ivory Coast. Social Science and Medicine, 1993, 36:1229-1235.

CARE (Bangladesh). Don't just say it, do it! Issues for consideration when planning for behavior change in hygiene education programs. Bangladesh, CARE, 1995.

de Azevedo Netto JM. Innovative and low cost technologies utilized in sewerage. Washington, DC, Pan American Health Organization, 1992 (Environmental Health Program Technical Series No. 29).

de Kruijff GJW. Aqua-privy sewerage systems: a survey of some schemes in Zambia. Nairobi, University of Nairobi (Housing Research and Development Unit), 1978.

Dudley E. The critical villager - beyond community participation. London, Routledge, 1993.

EHP (Environmental Health Project) Health and the environment in urban poor areas - avoiding a crisis through prevention. In: Capsule Report, No 1, March 1996. Cambridge, Massachusetts, USA, 1996.

Evans P. Paying the piper. An overview of community financing of water and sanitation. The Hague, The Netherlands, IRC (Occasional Paper 18).

FAO. Participatory monitoring and evaluation: handbook for training field workers. Bangkok, FAO Regional Office for Asia and the Pacific, 1988.

Feachem RG et al. Sanitation and disease: health aspects of excreta and wastewater management. Chichester, UK, John Wiley, 1983.

Feachem RG, Mara DD, Iwugo KO. Alternative sanitation technologies for urban areas in Africa. Washington, DC, The World Bank, 1979 (P.U. Report No. RES 22).

Feachem RG, Mara DD, Iwugo KO. Sanitation studies in Africa - Site Report No. 4: Zambia (Lusaka and Ndola). Washington, DC, The World Bank, 1978 (unpublished research report).

Feuerstein M-T. Partners in evaluation: evaluating development and community programmes with participants. London, Macmillan Publishers, 1986.

Gosling L, Edwards M. Assessment, monitoring, review and evaluation toolkits. London, Save the Children, 1993.

Griffiths M. Social marketing: a key to successful public health programs. Paper presented at the Social Marketing for Public Health Conference, 5-7 March 1991.

GTZ. Community participation and hygiene education in water supply and sanitation. Federal Republic of Germany, Technical Cooperation, 1989.

Guimar ASP. Redes de esgotos simplificadas. Brasa, Programa das Nas Unidas para o Desenvolvimento/Ministo do Desenvolvimento Urbano e Meio Ambiente, 1986.

Hamer J. Low cost urban sanitation in developing countries [Dissertation]. Leeds, UK, University of Leeds (Department of Civil Engineering), 1995.

Hannan-Andersson C. Ways of involving women in water projects. Waterlines, July 1985, 4(1):28-31.

Hornik R. The knowledge-behavior gap in public information campaigns: a development communication view. In: Salmon C, ed. Information campaigns: balancing social values and social change. Sage Annual Review of Communication Research, Vol. 18. Newbury Park, USA. p.113-138, 1989.

Jenkins JC. The humanure handbook (1994). Chelsea Green Publishing Co., 205 Gates-Briggs Building, PO Box 428, White River Junction, VT 05001, USA.

Johnson S, Rogaly T. Microfinance and poverty reduction. Oxfam Publishing, Oxford, UK.

Kalbermatten JM, Julius DS, Gunnerson CG. Appropriate sanitation alternatives: a technical and economic appraisal. Baltimore, MD, Johns Hopkins University Press, 1982.

Kalbermatten JM et al. Appropriate sanitation alternatives: a planning and design manual. Baltimore, MD, Johns Hopkins University Press, 1982.

Kalman B, Schaub J. Squirmy wormy composters. The definitive book for young people on worm composting. (Available from Worm digest, PO Box 544, Eugene, OR 97440-0544, US$ 9.50.)

Kapadia-Kundu N. An empirical test of the Sadranikaran communication theory to defecation hygiene behaviour: evaluation of a child-to-community intervention in Maharashtra, India [Dissertation]. Baltimore, MD, Johns Hopkins School of Hygiene and Public Health, 1994.

Khan AH. The Orangi Pilot Project, reminiscences and reflections. Karachi, Oxford University Press, 1997.

Konde-Lule J, Musagara M, Musgrave S. Focus group interviews about AIDS in Rakai District of Uganda. Social Science and Medicine, 1993, 37:679-684.

LaFond A. A conceptual framework for sanitation and hygiene behaviour programming. Working paper, Arlington, VA, USAID Environmental Health Project, April 1995.

LaFond A. A review of sanitation programme evaluations in developing countries. Environmental Health Project and United Nations Children's Fund, Virginia, USA, February, 1995 (Environmental Health Project Activity Report No. 5).

Mara DD. Design manual for waste stabilization ponds in India. Leeds, UK, Lagoon Technology International, 1997.

Mara DD. Low-cost sewerage. Chichester, UK, John Wiley & Sons, 1996.

Mara DD. Low-cost urban sanitation. Chichester, UK, John Wiley & Sons, 1996.

Mara DD. Sewage treatment in hot climates. Chichester, UK, John Wiley & Sons, 1976.

Mara DD. The conservation of drinking water supplies: techniques for low-income settlements. Nairobi, United Nations Centre for Human Settlements, 1989.

Mara DD. The design of pour-flush toilets. Washington, DC, The World Bank, 1985 (TAG Technical Note No. 13).

Mara DD. The design of ventilated improved pit latrines. Washington, DC, The World Bank, 1984 (TAG Technical Note No. 13).

Mara DD et al. Waste stabilization ponds: design manual for Eastern Africa. Leeds, UK, Lagoon Technology International, 1992.

Mara DD, Sinnatamby GS. Rational design of septic tanks in warm climates. The public health engineer, 1986, 14(4):49-55.

McKee N. Social mobilization and social marketing in developing communities, lessons for communicators. South Bound, Penang, 1992.

Mebrahtu E. Participatory monitoring and evaluation: an introductory pack. Institute of Development Studies, Sussex, UK, 1997.

Mercer M, Mariel C, Scott S. Lessons and legacies. The final report of a grants program for HIV/AIDS prevention in Africa. Baltimore, Md, The Johns Hopkins University, School of Hygiene and Public Health, Institute for International Programs, 1993.

Narayan D. Participatory evaluation: tools for managing change in water and sanitation. Washington, DC, World Bank, 1993 (World Bank Technical Paper No. 207).

Niemczynowicz J. New aspects of urban drainage and pollution reduction towards sustainability. Water Science and Technology, 1994, 30(5).

Nzioka C. Lay perceptions of risk of HIV infections and the social construction of safer sex: some experiences from Kenya. AIDS care, 1996, 8(5):565-580.

OSCRTM worm bin design plans. (Available from Worm digest, PO Box 544, Eugene, OR 97440-0544, US$ 35.00.)

Otis RJ, Mara DD. The design of small bore sewer systems. Washington, DC, The World Bank, 1985 (TAG Technical Note No. 14).

Otis RJ. Small-diameter gravity sewers: experience in the United States. In: Mara D, ed. Low-cost sewerage. Chichester, UK, John Wiley & Sons, 1996:123-133.

Owens B, Klandt K. TB advocacy: a practical guide 1998. Geneva, World Health Organization, 1998, (unpublished document WHO/TB/98.239).

Perrett HE. Involving women in sanitation projects. Washington, DC, Technology Advisory Group (TAG), United Nations Development Programme (World Bank, Washington, DC), 1985 (TAG Discussion Paper No. 3).

Pickford J. Low-cost sanitation: a survey of practical experience. Intermediate Technology Publications, London, 1995.

Pretty JN et al. A trainer's guide for participatory learning and action. London, International Institute for Environment and Development (IIED), 1995 (Participatory Methodology Series).

Rapaport R. Aerobic composting toilets for tropical environments. Biocycle journal of composting and recycling, July 1996, 77-82. (Biocycle, 419 State St, Emmaus PA 18049, USA. Tel: +1 610 967 4135.) Single copies US$ 6.

Rapaport D. Sewage pollution in Pacific island countries and how to prevent it. Eugene, Oregon, Centre for Clean Development, 1995.

Reed RA. Sustainable sewerage: guidelines for community schemes. London, IT Publications, 1995.

Renz L et al. Programme-related investments: a guide to funders and trends. New York, The Foundation Center, 1995.

Rietbergen-McCracken J, Narayan D (compiled by). Participatory tools and techniques; a resource kit for participation and social assessment. Washington, DC, World Bank, 1997.

Riggle D. The business of vermicomposting. Biocycle journal of composting and recycling, September, 1996, 54-56 (Biocycle, 419 State St, Emmaus PA 18049, USA. Tel: +1 610 967 4135.) Single copies US$ 6.

Rizo-Pombo JH. The Colombian ASAS system. In: Mara D, ed. Low-cost sewerage. Chichester, UK, John Wiley & Sons, 1996:135-153.

Rodrigues de Melo JC. Sistemas condominiais de esgotos. Engenhaha sanita (Rio de Janeiro), 1985, 24(2):237-238.

Rondon EB. A critical evaluation of shallow sewerage systems: a case study in CuiabBrazil [Dissertation]. Leeds, UK, University of Leeds (Department of Civil Engineering), 1990.

Sanitation in emergency situations. Proceedings of an international workshop held in Oxford, December 1995. An Oxfam Working Paper. Available from Oxfam, 274 Banbury Road, Oxford 0X2 7DZ, UK.

Sanitation: The missing link to sustainable development. Report from the Eastern and Southern African Region Workshop on Sanitation, Harare, Zimbabwe, UNICEF 1994.

Sara J et al. Rural water supply and sanitation in Bolivia, UNDP-World Bank Water and Sanitation Program, May 1996. Washington, DC, UNDP-World Bank Water Sanitation Program, May 1996.

SDC. Participatory rural appraisal (PRA): working instruments for planning, evaluation, monitoring and transference into action (PEMT). Berne, Swiss Directorate for Development Cooperation and Humanitarian Aid, 1993.

Simpson-Hrt M, Sawyer R, Clarke L. The PHAST initiative: participatory hygiene and sanitation transformation: a new approach to working with communities. Geneva, World Health Organization, 1996 (unpublished document WHO/EOS/96.11).

Simpson-Hrt M, Yacoob M. Guidelines for designing a hygiene education program in water supply and sanitation for regional/district level personnel. WASH Field Report No. 218. Washington, DC, USAID, Bureau for Science and Technology, Office of Health, 1987.

Sinnatamby GS. Low-cost sanitation systems for urban peripheral areas in Northeast Brazil [Thesis]. Leeds, UK, University of Leeds, 1983.

Sinnatamby GS. The design of shallow sewer systems. Nairobi, United Nations Centre for Human Settlements, 1986.

Sinnatamby G, Mara DD, McGarry M. Sewerage: shallow systems offer hope to slums. World water, 1986, 9, 39-41.

Sittitrai W, Phanuphak P, Roddy R. Male bar workers in Bangkok: an intervention trial. Thai Red Cross Society, Bangkok, 1994, (Research Report No. 10).

Smith W et al. A world against AIDS. Communication for behavior change. Washington, DC, Academy for Educational Development, 1993.

South Australian Health Commission. Common effluent drainage system. Adelaide, SAHC (Health Surveying Services), 1982.

Srinivasan L. Option for educators: a monograph for decision makers on alternative participatory strategies. New York, PACT Communications Development Service Inc., 1992. (PACT can be contacted at: 777 UN Plaza, New York, NY 10017, USA.)

Srinivasan L. Tools for community participation: a manual for training trainers in participatory techniques. New York, UNDP, 1990, (PROWWESS/UNDP Technical Series Involving Women in Water and Sanitation).

StenstrA. Water microbiology for the 21st century. Paper presented at workshop 3, Stockholm Water Symposium, 7 August 1996, Stockholm.

Sustainability of water and sanitation systems. Conference proceedings, 21st WEDC Conference, Kampala, Uganda, Loughborough University, UK.

UN. World urbanization prospects 1994. New York, United Nations, 1995.

UNDP. Habitat II, Dialogue III: Water for thirsty cities, Report of the Dialogue. United Nations Development Programme, United Nations Conference on Human Settlements, June 1996, Istanbul.

UN Habitat. Water crisis to strike most developing world cities by 2010. UN Habitat press release, Nairobi, 1996.

UNDP-World Bank Water and Sanitation Program. Annual report, Washington, DC, World Bank, July 1994-June 1995.

Van der Ryn S. The toilet papers (1995). Available for US$ 10.95 + US$ 4 shipping from Chelsea Green Publishing Co., 205 Gates-Briggs Building, PO Box 428, White River Junction, VT 05001, USA.

van Wijk C, Murre T. Motivating better hygiene: report for public health mechanisms of change. UNICEF, The Hague, The Netherlands, IRC, 1995.

Varley RCG. Child survival and environmental health interventions: a cost-effectiveness analysis. November 1996 (Environmental Health Project Applied Study No. 4). (See above for contact address.)

Varley RCG. Financial services and environmental health: household credit for water and sanitation. Prepared for the Bureau for Global Programs, Field Support and Research, Office of Health and Nutrition, US Agency for International Development, January 1995 (Environmental Health Project Applied Study No. 2).

Varley RCG, Yacoob M, Smith S. Beyond participation: locally based demand for environmental health in peri-urban areas. Virginia, USA, Environmental Health Project, December 1996 (Environmental Health Project Applied Study No. 6).

Vincent U, Algie WE, Marais GvR. A system of sanitation for low cost high density housing. In: Proceedings of the Symposium on Hygiene and Sanitation in Relation to Housing CCTA/WHO, Naimey 1961. London, Commission for Technical Cooperation in Africa South of the Sahara, 1963 (Publication No. 84):135-172.

Wakeman W. Gender issues sourcebook for water and sanitation projects. Washington, DC, UNDP-World Bank Water and Sanitation Program/PROWWESS (World Bank, Washington, DC), January 1995.

Wakeman W et al. Sourcebook for gender issues at the policy level in the water and sanitation sector. Washington, DC, UNDP-World Bank Water and Sanitation Program, Water Supply and Sanitation Collaborative Council, October 1996.

WASH. Lessons learned in water, sanitation and health: thirteen years of experiences in developing countries. WASH, 1993.

WASH. Social marketing and water supply and sanitation: an integrated approach, May 1988 (WASH Field Report No. 221), Arlington, VA.

Water Services Association. Sewers for adoption, 4th edn. Swindon, Water Research Centre, 1995.

Watson G. Good sewers cheap? Agency-customer interactions in low-cost urban sanitation in Brazil. Water and sanitation currents. Washington, DC, The World Bank, Washington DC, 1995.

White S. Vermifiltration of sewage, now being done in India. Worm digest #8, 1995. (Worm digest, PO Box 544, Eugene, OR 97440-0544, USA. Tel: +1 541 485 0456. E-mail:

Who are the question-makers? Participatory evaluation handbook. New York, UNDP, 1997.

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).

WHO. Creating healthy cities in the 21st century. Geneva, World Health Organization, 1996 (unpublished document WHO/EOS/96.9).

WHO. Health and environment in sustainable development. Five years after the Earth Summit. Geneva, World Health Organization, 1997 (unpublished document WHO/EHG/97.8).

WHO. Promotion of sanitation. Report of the Sanitation Working Group to the Water Supply and Sanitation Collaborative Council. Geneva, World Health Organization, November 1995 (unpublished document WHO/EOS/95.24).

WHO. The IDWSSD and women's involvement. Geneva, World Health Organization, July 1990.

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).

Winblad U, Dudley E. Dry toilets for urban areas: the findings of the second SANRES workshop. Mexico City, November 23-26, 1994.

Winblad U, Kilama W. Sanitation without water. London, Macmillan, 1985.

Wolgast M. Rena vatten - om tankar i kretslopp. Uppsala, Creanom HB, 1993 (in Swedish).

Wood S, Sawyer R, Simpson-Hrt M. PHAST step-by-step guide: a participatory approach for the control of diarrhoeal disease. Geneva, World Health Organization (unpublished document WHO/EOS/98.3).

Working with communities. Nairobi, UNICEF Eastern Africa Regional Office (Community Development Workers Training Series Number 2).

Workshop on goals and indicators for monitoring and evaluation for water supply and sanitation, Geneva. Washington DC, UNDP-World Bank Water and Sanitation Program, 1990.

Worm digest, PO Box 544, Eugene, OR 97440-0544.

WRI. World resources, 1992-1993. New York, Oxford University Press, 1992.

Wright A. Toward a strategic sanitation approach: improving the sustainability of urban sanitation in developing countries. Internal working document. Washington, DC. UNDP-World Bank Water and Sanitation Program, 1997.

Zeitlyn S. Sanitation and family education (SAFE) pilot project. Report on the qualitative assessments. Bangladesh, CARE, 1994.

Further information on a wide range of sanitation topics and related publications (including some on finance issues) can also be found on the Internet at the following address: and

Back cover

The time has come for a sanitation revolution. Half of the people in the world today lack even basic sanitation, such as toilets and solid waste removal, and as a consequence over three million people die each year from epidemics and chronic disease related to environmental pollution. Governments and aid agencies need to wake up to the problem and act in positive ways to remedy these unhealthy environments.

Sanitation Promotion is the result of four years of work by the Water Supply and Sanitation Collaborative Council Working Group on Promotion of Sanitation. It is a collection of articles designed to give all who wish to promote sanitation the tools to do so effectively. The book helps us to understand the nature of the challenge before us, how to gain the political will and partnerships necessary for success, how to do better sanitation programmes and shares new ideas and case examples of sanitation promotion.

This book is for:

- sanitation policy makers
- sanitation strategic planners
- external support agencies
- nongovernmental organizations
- senior field staff.