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Editor's Note: In this post, Eve Mackinnon, a researcher working on innovative responses and evidence-based solutions to the sanitation crisis, discusses how WASH programs in nurseries or child care centers could protect child health. Eve is a water, sanitation and hygiene practitioner with over five years of hands–on emergency humanitarian response experience across Asia and Africa. Her current research focuses on more effective, sustainable and safer sanitation management, across the entire sanitation service chain to deliver positive changes to the way that human waste is managed. 

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Although global death rates of children under five resulting from diarrheal disease has fallen from a global high of 1.2 million in 2000 to 500,000 in 2015, it still represents the second leading cause of morbidity for this age group. These deaths are mainly preventable; 88% of them are attributed to a lack of access to water, sanitation and hygiene (WASH). The significant decrease in the last 15 years is a major achievement largely due to improvements in access to better quality drinking water, toilets, and better hygiene and care practices. These changes prevent young children being infected with harmful microbes that come from drinking dirty water and living in dirty environments, and contracting severe diarrheal diseases, which without sufficient treatment or in vulnerable children ultimately leads to death. 

Of course diarrhea is not the only threat to infant and young children. Ongoing research indicates that the same WASH factors that lead to diarrhea, also lead to stunting and malnutrition in young children. This is because low level of exposure to harmful microbes damages the intestinal tract and prevents proper absorption of nutrients in children. Infants and children under five are more vulnerable to being infected by microbes and get ill far quicker. From a health perspective, the targeting of effective WASH infrastructure is crucial to reach the most vulnerable groups.

Provision of WASH programs for vulnerable children whilst at nurseries or child care centers could be the most efficient way to protect their health. In Naivasha whilst researching risks of diarrheal disease for my PhD case study, I was shown Vision Nursery. The nursery cares for on average around 40 children in one small room. There is no drinking water provision, only water stored in containers from a tap stand. The nursery has access to a child adapted toilet (a container based toilet, provided by Sanivation), a positive step in WASH provision, however, without handwashing or regular cleaning the use of the toilet carries its own risks. Moreover, the nursery is also host to resident chickens, which are major carriers of harmful bacteria and co-habitation with people is linked to malnutrition and stunting in children according to recent research. The mud and rough concrete floor means cleaning and hygiene is difficult to maintain. There is inadequate space and utensils to safely prepare the childrens’ meals, and food cannot be re-heated or stored in secure containers.

Despite all of these shortcomings, the nursery provides an essential service. The female entrepreneur who started Vision Nursery has been running it for almost seven years and rents the small space. She is constrained by small margins, high rents, and lack of borrowing power. Her operation is linked to the Kenyan flower industry- a global success story of export growth. Naivasha is an epicenter of this booming export center for flowers, and it is driven overwhelmingly by a female workforce.  The associated employment opportunities allow women to gain a regular income with positive consequences of independence, empowerment, and rising equality for women in Kenyan society. An unintended consequence of female empowerment is the growth in a secondary industry of local nurseries and childcare. There are little to no regulations for nurseries in Kenya, and if they do exist,  they are not enforced. This allows for poor standards to exist, particularly in regard to WASH provision.

Potential baby WASH strategies to combat infection at the nursery level focus on robust barriers to specific exposure pathways that are specific for infant behaviours. For example, ingestion of pathogens occurs indirectly when children place contaminated objects in their mouths. Termed ‘mouthing’ it is responsible for almost 90% of a child’s exposure in one study.

Other direct exposure pathways include placing of hands directly into mouths and touching dirty floors. It’s important to regularly disinfect toys and maintain hygienic floor surfaces—possibly through use of mats or plastic, washable floor covers. Informed WASH strategies should be developed which can identify a broad range of baby-specific exposure routes. Indeed these indirect routes may be far more of consequence for children than direct routes of drinking contaminated water and food, which are traditionally the focus of WASH household campaigns.

The safe disposal of faeces remains the primary barrier to prevent dispersal of pathogenic bacteria in the environment and subsequent exposure routes. Despite a recent systematic review of health impact from sanitation intervention that concludes there is a lack of robust evidence, provision of safe sanitation is ultimately necessary to reduce contaminated environments that occurs as a result of open defecation.

In addition to focusing on specific prevention strategies at the nursery level, it is also crucial to increase integration between WASH, early childhood development (ECD), nutrition, and maternal newborn and child health (MNCH) programming. In addition, it’s important that outcome and impact monitoring is not uniquely focused on reduction in diarrheal disease. Impact monitoring and value for money evaluations should also explore targets that are linked with nutrition, undernutrition, and height and weight. It is notoriously difficult to link specific WASH interventions with impacts, without radnomised controlled trials, due to the huge variety of exposure pathways and variables that exist.

The WASH and sanitation sector might consider moving its focus from mostly household WASH and school sanitation to specialist WASH needs during infant care. If children survive the first year they are less vulnerable to further infection or severe outcomes. Therefore, intentionally focusing on activities at this juncture, as well as better integrating our efforts with other sectors—as the new babywashcoalition.org does—could have an enormous impact on child health.

Editor's Note: In this post, Georges Mikhael, Head of Sanitation at Water & Sanitation for the Urban Poor (WSUP), explores the importance of government buy-in for improving sanitation.

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I think I may have recently witnessed a real toilet revolution! As Water & Sanitation for the Urban Poor’s (WSUP’s) Head of Sanitation, a general poop enthusiast, and having been born on World Toilet Day, I hope you can understand how exciting this is for me.

I recently visited Visakhapatnam (‘Vizag’ for short) for the second time to support the WSUP Advisory India team in their implementation of a USAID project supporting the Greater Visakhapatnam Municipal Corporation (GVMC). Vizag is the largest city in Andhra Pradesh state, found on India’s eastern coast.

The project aims to improve sanitation across the whole city – eliminating open defecation and making sure that all residents have access to a toilet.

Since my first visit, I found an unmistakable urgency and energy in the way sanitation is being tackled in India by different institutions as a result of Prime Minister Modi’s commitment to Swachh Bharat Abhiyan, a national campaign to clean up India in time for Mahatma Gandhi’s 150th birthday on  October 2, 2019.

I had heard reports from my Indian colleagues about the speed at which authorities are making decisions on sanitation issues, and I had seen maps showing the rapid progress being made on the ground - a lot of toilet building!

But this urgency only really hit me once I got out to the Bnr Nagar community in Vizag. Everywhere I looked, literally every few steps I took, there was a toilet at a different stage of construction. I wasn’t taken to this community because it represented a standout example of progress on construction of toilets – there are plenty of other communities just like it around the city.

Of course, constructing toilets is just one part of improving sanitation, but GVMC, supported by WSUP, is already looking at the next steps, including how to deal with the challenge of emptying toilets on the hillsides around Vizag.

At WSUP, we always talk about this so called ‘enabling environment’, and how important it is to making progress in sanitation. It is core to our theory of change; it’s in all of our national business plans. But it can be hard to grasp what it actually is, and how to make it more effective.

It was obvious to me during this trip that an important part of the enabling environment is without a doubt government spending: the Government of India’s 2016 budget for the Swachh Bharat was US$ 1.3 billion. That’s about $1 per person across the country in just one year. As WaterAid’s recent study of East Asian countries has shown, it is obvious that commitment by political leadership is a major factor for improving access to safe sanitation.  

What could be done in Maputo if $1 per resident per year were spent on sanitation by the municipal authority? Lusaka? Freetown? Without a doubt, we could make much more rapid progress on Sustainable Development Goal 6 if this level of government buy-in were replicated around the world.

So if you’re curious what a real toilet revolution looks like, if you want some inspiration, consider a trip to Vizag. Maybe bring an aspiring politician with you.

Editor's Note: In this post, Edson Monteiro, a WASH Project Officer at UNICEF Angola, highlights UNICEF's partnership with Andrex to bring a Community Led Total Sanitation (CLTS) programme to rural villages in Angola. This post originally appeared on UNICEF's site, to view the original post please click here.

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© Karin Schermbrucker. Eugenia, 11, washes her hands after learning about sanitation and hygiene during a ‘triggering’ meeting in Calipanguela Village, Angola.

I recently returned from a trip to visit rural villages in Angola to look at the impact that UNICEF’s sanitation partnership with Andrex is having on children and families there. It’s incredible to think that seven out of ten people living in rural Angola do not have a clean, safe toilet to use. This has a huge impact on the health of Angola’s children and is one of the reasons the country has the highest rate of child mortality in the world.

As I began my journey into the heart of Angola, I visited villages that were in different stages of learning about sanitation. Due to a number of reasons, such as the poor economic climate in Angola and the poverty that the country suffers, many people do not have access to basic sanitation. Without a toilet, the reality is that many people still have to go to the toilet out in the open, often in the bush or a lake and near their homes. This risks faeces contaminating their food and drink, causing sickness to children and families.

The first village I visited was called Calipanguela, located over an hour away from the nearest city, Nharea. The village is incredibly rural, with mud huts, dirt tracks and livestock. The process of educating the community about the importance of using a toilet, washing their hands and sanitation in general had not reached this village yet, but would start with a ‘Triggering’ meeting.

The meeting involves gathering all of the villagers together and sharing food and water between them. Then something shocking happens. To exemplify the danger of open defecation, the facilitators place fresh human faeces, found that day in the village, near the food and water they’d been sharing. The flies become instantly attracted and begin moving between the faeces, food and water. 

The method is deliberately provocative. People immediately understand the danger of going to the toilet outside and realize they may have been eating food contaminated by their faeces. The village then designs an action plan to tackle the reasons why so many people go to the toilet outside, and to improve the health of the community.

I went on to the village of Luwawa, which was triggered a year ago. After being monitored on a monthly basis to ensure the community were using and maintaining their toilets, it was about to be awarded a certificate. Villagers no longer went to the toilet out in the open, and Luwawa had been declared ‘open defecation-free’. This is a huge honour in Angola, and to mark the occasion, there was singing, dancing, and a party.

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© Karin Schermbrucker. Sabina and two of her four children in their home in Waleka, Angola, where newly built toilets have made everyone healthier.

Finally, to complete my journey, I visited a village that had been declared ‘open defecation-free’ for a year. Here I met a wonderful family, with a mother named Sabina, who wanted to share her story. Sabina is 39, is married, has four children, and lives in a village called Waleka.

Sabina told me about life before her village was triggered and her family built a toilet. “Before we had a toilet, we went outside to the bush to defecate, which made me feel uncomfortable. When we went to the toilet outside, I was worried about my family getting sick or being bitten by a snake.

“Defecating outside made my children sick; they were always ill. When they were ill, they didn’t manage to go to school.”

Sabina told me that it always smelt before the village was triggered and the toilets were built. Sometimes there would be faeces all around the village, and it didn’t feel clean. Now that they have all built toilets and been declared open defecation-free, she feels happy, and can see that there has been a reduction in illness for all of the villagers.

Sabina said: “Now there is a real change in the village. Now everything is OK.”

The Andrex partnership raises funds for UNICEF’s Community Led Total Sanitation (CLTS) programme, which empowers communities to build, maintain and take pride in their own hygiene and sanitation. The great work that the partnership has helped to fund was clear to see in all of the villages that we visited, no matter what stage of the journey they were in. 60,000 lives will be impacted this year thanks to the funds raised by Andrex for the UNICEF programme.

As I plan my next trip back to the villages, I feel confident that thanks to this partnership, villagers will continue to feel empowered to use their toilets and benefit from the programme.

Editor's Note: In Part Two of this series on wastewater treatment, Craig Fairbaugh, a Research Fellow at Engineering for Change, highlights technologies that meet the challenge as described in E4C’s Solutions LibraryPart One of this series can be found here.

Designers and engineers have long recognized the need for wastewater treatment in developing communities but often are met with the challenges of no piped sewer system, high capital investment, and limited technical skills necessary for operation and maintenance. Enter decentralized wastewater treatment; a solution that treats waste effectively on site and requires no existing piped infrastructure. Decentralized anaerobic treatment systems have existed since the 1800s as septic tanks, but in order to meet the Sustainable Development Goals with a rapidly growing population in the developing world, engineers are attempting to design solutions that are affordable, scalable, more effective, and easier to maintain.

The Engineering for Change Solutions Library features technology reviews of three solutions for decentralized wastewater treatment: Biopipe, the Biofil Digester, and DEWATS.

Biopipe
Biopipe is a decentralized pipe network that treats domestic wastewater for reuse in irrigation and secondary applications (but not for drinking). The system is comprised of a tank, pipe modules, circulation and water pumps, and a UV filter. Bacteria lining the inside of the pipe remove microbiological pathogens, similar to the treatment processes that occur naturally in river beds. 

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Biopipe uses aerobic treatment, filtration, and UV sterilization to treat domestic wastewater.

Biopipe is making the transition out of the prototype phase with a recent exclusive distribution deal for Asia and Africa with Metito, a water management design and engineering firm in emerging markets.

Biofil Digester
The Biofil Digester mimics the natural world with a process similar to the natural decomposition that occurs in soil on a forest floor. Developed in Ghana, the typical digester is housed in a 2’ x 2’ x 6’ concrete structure. Liquid waste rapidly separates from solid as it filters through a layer of permeable pavement. Macro-organisms in the soil below break down pathogens. The digester can be connected to an existing toilet or septic system, is scalable to meet small or large demands, and produces no waste product. The Biofil Digester can be installed above or below ground in a concrete structure with a “microflush” option which conserves the amount of water needed for flushing. Since 2008, more than 4500 Biofil Digesters have been installed across Africa and South Asia.

The Biofil Digester uses aerobic treatment and macro-organisms in soil to break down and remove harmful pathogens in domestic wastewater.

DEWATS
While the Biopipe and Biofil Digester are manufactured treatment systems, BORDA’s Decentralized Wastewater Treatment System (DEWATS) is a technical design approach to treating wastewater at the household and community level. Founded by the Bremen Overseas Research and Development Association, DEWATS uses physical and biological treatment mechanisms such as sedimentation, floatation, aerobic, and anaerobic treatment to remove pathogens from household wastewater. These treatment stages are commonplace in centralized systems, but what separates the DEWATS design approach is employing a passive system (no power required), low maintenance requirements, and construction from affordable and locally available materials. Hundreds of DEWATS treatment systems have been implemented and are currently operational across Africa, South Asia, and Southeast Asia.

DEWATS

DEWATS design methodology employs a series of baffled chambers and planted horizontal gravel filters to promote removal of pathogens by anaerobic and aerobic processes.

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A DEWATS treatment facility in South Africa serves as an educational treatment system for neighboring communities. A primary treatment vault (top) and horizontal gravel filter (bottom) are constructed and inspected by local officials and tradesmen.

In a recent expansion of our Solutions Library, E4C added these three technologies as examples of decentralized treatment, which has the potential to scale up and meet needs in cities and rural communities. Visitors to this web site know better than most that wastewater treatment is often overlooked in discussions about global development. With these new additions and more sanitation technology planned for the future, we hope to draw attention to the options available to those in need.

For more on wastewater treatment technologies, including the EkoLakay Toilet, the Easy Latrine, the Elephant Toilet and others, please visit E4C’s Solutions Library

Editor's Note: In this post, Sam Drabble, Research and Evaluation Manager at Water & Sanitation for the Urban Poor (WSUP), discusses some best practices for those looking to improve sanitation on a citywide level.

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A waste collector from Clean Team doing his rounds in Kumasi, Ghana. Photo Credit: WSUP

The concept of improving sanitation on a citywide basis, rather than looking at individual communities or projects, is gaining increasing traction in the WASH sector.

World Water Week in Stockholm, in late August, was a clear example. In a specific session on citywide sanitation, Guy Norman from WSUP spoke about our experiences in Kumasi, Ghana’s second largest city. The session drew upon a sector review, led by WaterAid, which has documented successes in Kumasi, as well as Vizag (India), another city where WSUP is playing a key role.

Citywide sanitation is undoubtedly a complex approach, but essential if we are to reach scale in urban contexts. It requires coordination between the many organisations engaged in service provision—local government, regulators, NGOs, donors—and in some cases, the development of a citywide sanitation plan that sets out a roadmap for future service provision and investment.

Here are five insights for those who are attempting to implement citywide sanitation improvements, based on our experiences:

Understand the city before designing the solutions

We say it often, but it can never be said enough: there is no one-size-fits-all solution to urban sanitation! Our experience underlines that every city—and in many cases, individual low-income communities—have their own set of conditions.

Kumasi is a case in point. The sanitation landscape in Kumasi has three interesting features: 1) an unusually high number of pay-per-use public toilets (the leading form of sanitation in urban Ghana, with around 700,000 people using one in Kumasi each day); a high proportion of compound housing in low-income communities, where tenants will often share a living space with more than 20 other people; and 3) the existence of a bylaw, longstanding but not properly enforced, which requires compound landlords to provide an in-house toilet for their tenants.

Our support to Kumasi Metropolitan Assembly (KMA), predominantly funded by USAID and the Bill & Melinda Gates Foundation, evolved as a response to these features. Since 2011 we have worked with KMA to improve the standard of public toilets in Kumasi. This is an interim solution, but a pragmatic one, given these toilets already proliferate throughout the city.

By improving the standard of service, we improve the level of sanitation until the longer term solution gains traction: a five year compound sanitation strategy, targeted at landlords and centred around improve mediation and enforcement of existing bylaws.

Other ongoing activities in Kumasi include continuing to invest in Clean Team, a containerised toilet business that we established in 2013; and strengthening the back end of the sanitation chain by training tanker operators and rehabilitating the sludge dumping site at Dompoase.

Adopt a step-by-step approach

When we imagine a citywide sanitation programme being implemented, we might picture a range of activities being rolled out simultaneously across the city. In reality, as with so much in life, we come unstuck if we try to do too much at once. The task of achieving citwide sanitation coverage is massively daunting, but becomes more manageable if we break it down.

This is how Greater Vizag Municipal Corporation (GVMC), with WSUP’s support, decided to tackle the challenge of achieving open defecation free (ODF) status across the 78 wards that form the city. GVMC’s ongoing ‘ward by ward’ approach began by mapping open defecation levels in every ward to establish the baseline situation.

Those wards with low levels of open defecation (OD) were targeted first to achieve ODF status relatively quickly: this set an example for other wards by demonstrating that ODF status is attainable, and helped to build momentum as the focus moved to areas of the city with progressively higher levels of OD. These latter wards required more time for implementation, reflected in the staggered implementation timeline: one month was allocated to achieve ODF status for 20 of the initial wards and two months for the next group of 28 wards.

Sanitation planning is about the process, not the final document

In a session at World Water Week, Arne Panesar from GIZ emphasised that city sanitation plans should be seen as primarily about a process, not the production of a document. This resonated with our experience: in some cases, a lot of time and resources go into producing a document that sits on the shelf.

However, the process—creating a dialogue between the key institutions, mapping the current sanitation status of the city, and identifying the gaps and bottlenecks in service provision and how these could be addressed—is of enormous value in itself, above all because it engages the institutions who are ultimately responsible for providing the services.

Faecal sludge management (FSM) service provision needs to be made more systematic

One area where we believe citywide sanitation plans do have huge value to add is in promoting the systematic provision of FSM services. As discussed in Stockholm, a problem at the moment is a lack of good tools for estimating the costs of different citywide approaches (sewerage, FSM, or combined sewerage and FSM).

A particular problem is that FSM systems—transfer stations, trucking systems, etc.—tend to just randomly develop; if FSM systems were designed by engineers in the same way that sewerage systems are, they’d presumably be cheaper and more effective. We think the question of how to develop systematic FSM services that cover the full sanitation chain—and how these can be better integrated in citywide sanitation plans —is potentially an interesting area for future research.

There is more to stopping faecal contamination than providing improved toilets

At World Water Week, we were struck by some emerging findings from the Sanipath research team at Emory University, who are analysing faecal contamination pathways in Maputo (this work is linked to the USAID-funded MapSan evaluation of our Japan Social Development Fund-backed communal sanitation programme).

Sanipath’s early analysis of results suggests that a very important source of faecal contamination is salad vegetables produced in the environs of Maputo. This is very relevant for us: it suggests that even if we were able to provide perfect toilets in Maputo’s low-income communities (and convince people to wash their hands after each use), people might still get disease from lettuce and tomatoes because untreated waste is being used for crop irrigation elsewhere.

This final insight acts as a reminder that city sanitation is extremely complicated: the more evidence we have about what is really going on, both in the communities where we work and across the city as a whole, the better. 

Editor's Note: In this post, Marc Gunther, a reporter at Nonprofit Chronicles, discusses approaches to sanitation problems worldwide. This post originally appeared in Nonprofit Chronicles, to view the original post please click here.

It’s easy for most of us to take the simplest things–like flushing a toilet–for granted. Yet almost 2.4 billion people lack access to modern sanitation, and nearly 1 billion practice open defecation, according to the World Health Organization. The problem is worst in rural areas of sub-Saharan Africa and south Asia, particularly India.

What’s to be done?

That’s hard to know, says Seeking Sanitation Success, an excellent report commissioned by Catholic Relief Services:

Very little information on sustained solutions is available, making funders and practitioners in the sector vulnerable to repeating mistakes or investing in unproven approaches.

The report also found:

There has been no NGO-led sanitation approach that leads to success at scale (depending on the definition).

The report was written by Susan Davis, who is the founder of Improve International, a small NGO aimed at improving the quality and sustainability of water and sanitation projects in poor countries. By phone, she explains that most progress in delivering modern sanitation has been led by governments, and not NGOs.

That doesn’t mean that NGOs can’t play a constructive role, she says. They can advocate for government action, they can help spur behavior change around sanitation (which is harder to do than you might think) and, importantly, they can help figure out which of the many approaches to sanitation work best.

This is an all-too-familiar story in global development. We don’t know enough about what works. Programs are under-studied. Results are under-reported, if they are reported at all. Successes are trumpeted. Failures, not so much. Followup is rare.

“People aren’t really paying attention to what happened 10 years ago,” Davis says. “We’re more excited by innovation.”

A NONPROFIT FOCUSED ON EVIDENCE

Helping governments, foundations and nonprofits use evidence to improve their impact is the purpose of IDinsight, a nonprofit that I profiled in the July issue of The Chronicle of Philanthropy. My story, Data at the Speed of Life [subscription required], explains how IDinsight does high-quality, affordable research to enable nonprofits to learn quickly, adjust their programs and make more of a difference.

IDinsight’s work is valuable because too many leaders in global development “lack the evidence they need to make well-informed decisions,” says Neil Buddy Shah, IDinsight’s CEO and founding partner. This isn’t something you’ll read about on the websites of charities that help the global poor, but it’s true.

While reporting on IDinsight, I came across one of its clients, a Colorado-based nonprofit called iDE (it stands for International Development Enterprises) that stands out because it is committed to learning, to measuring its impact, to transparency and to developing market-driven solutions to global poverty. (All my biases!)

Which brings us back to toilets.

Traditional approaches to sanitation have provided free community latrines or toilets to all, driven by the belief that if-you-build it-they-will-come. But absent strong reasons to change behavior, these projects have disappointed. Put bluntly, people continue to crap outside, the way their parents and grandparents did. Numerous other strategies have been deployed to end open defecation which, in case you didn’t know, can spread disease, pollute waterways and contaminate fruits and vegetables growing nearby.

iDE favors an approach known as sanitation marketing, which sets itself apart by treating households as consumers, not as beneficiaries. The NGO has been working in Cambodia since 2009, with the support of US AID, The World Bank, The Bill and Melinda Gates Foundation (which paid for the research with IDinsight), the Stone Family Foundation and the government of Australia.

It is getting results. iDE’s work in Cambodia has grown into “the largest-scaled improved rural sanitation project” led by an NGO anywhere in the world, according to Yi Wei, who directs iDE’s global WASH (Water, Sanitation and Hygiene) initiative.

THE RIGHT PRODUCT AT THE RIGHT PRICE

Sanitation marketing aims to (1) increase the demand for toilets and (2) to strengthen the private sector’s capacity to supply them. This is Econ 101. "Everything we do is market-based,” says Chris Nicoletti, the global IQ director at iDE, who oversees its work on measurement. “It’s very much our ethos.” To succeed, iDE and its local partners need to design and make the right product and sell it at the right price.

Their product, known as the Easy Latrine, was developed in the late 2000s with the help of Jeff Chapin, a designer on leave from the renowned design firm IDEO. It’s been modified since then but remains a simple, low-tech, low-cost concrete latrine that came about using the principles of human-centered design, which is a fancy way of saying that Chapin and iDE  listened to their customers at every step of the process. It’s made by local manufacturers and costs roughly $36, before delivery and installation, which brings the price up to about $50. A growing number of customers add what’s called an Easy Shelter, a cement structure that provides privacy to latrine users and costs another $200 or so. (That’s price-competitive, more than shelters made of sheet metal and less than those made of bricks, I’m told.)

Latrines sold slowly at first. A World Bank Field Note from 2012 found that households bought 10,621 latrines from local private enterprises in the first two years, results it called “promising.” WHO’s most recent estimate, also from 2012, is that 8.6 million Cambodians practice open defecation. How could iDE speed adoption? 

Being a learning organization–seeing what works and what doesn’t–was key.

To improve the sales process, iDE worked with Whitten & Roy Partnership, or WRP, a global consulting firm, to train the Cambodian rural sales agents who go door to door selling toilets. “They get very high-quality training on how to sell,” Nicoletti says. “They are mentored, managed and trained by WRP.” WRP found, among other things, that sales commissions at first weren’t high enough to motivate the agents, so the commissions were increased. Instead of wielding Powerpoint presentations, Cambodian salespeople go door-to-door with flip charts to guide them through their spiel.

IDinsight was brought in to see if offering financing would help, as I wrote in the Chronicle of Philanthropy:

To test the market, IDinsight ran a set of randomized, controlled trials. Nearly 90 percent of Cambodian consumers, they found, were unwilling to pay the market price for a latrine, which ranged from $35 to $55. But when they were offered a 12-month loan, half of these same consumers agreed to pay $50.

Meantime, iDE worked to simplify and consolidate the supply chain and help local government officials promote improved sanitation. “The iterative approach is part of our DNA,” Yi Wei says. “There’s always room for improvement, and the market is always evolving.”

All the tweaks made a difference. Latrine coverage in Cambodia had grown by about 1.5 percent a year from 1992 through 2012. Since then, coverage has increased by 6.4 percent a year in the seven provinces where iDE works. Cumulatively, iDE has sold 238,406 latrines through its network of about 100 latrine producers and 300 sales agents. Program costs per unit have dropped, as volumes grew. Here’s an iDE website with more information.

WHAT HAPPENS NEXT?

That’s the good news, but issues remain. For now, there’s no single strategy for disposing of the waste after the latrines fill up, which takes months or years.

Susan Davis of Improve International says that, without a plan to recycle or dispose of sludge, the program can’t be called a success, yet. “We as a sector have focused on getting people to stop going outside and start using a toilet,” she noted. “What happens next?”

iDE is seeking “a commercially viable fecal sludge management solution,” perhaps by creating businesses to collect the waste and turn it into fertilizer, Nicoletti says. The Stone Family Foundation and the government of Australia continue to support iDE in Cambodia but the Gates Foundation no longer supports the work, unfortunately; it’s been pushing a a buzz-generating challenge to reinvent the toilet.

A couple of closing thoughts: First, solving hard problems like sanitation takes time. To tackle them, grantmakers need to commit for the long term, particularly as nonprofits like iDE demonstrate progress and a willingness to learn. It’s tempting to turn to the next new thing, before we even know whether the last old thing has worked.

Second, iDE’s commitment to research does not appear to be rewarded in the nonprofit “marketplace,” such as it is. Without shared metrics around success and with little transparency in the sector — as I blogged about last year in Water Taps and Information Gaps — the work of one NGO can’t be compared with another. Flashy websites and marketing claims (“every dollar goes directly to clean water projects”) carry the day.

Yi Wei asks: “How are we ever going to use resources more efficiently if we are not going to be more transparent and accountable?”

Fortunately, people at IDinsight tell me there’s more demand for their work than they can handle. That’s a sign that more foundations and charities, like iDE, want to learn how to do what they do better.

Here’s an excellent video about iDE’s work in Cambodia:

Editor's Note: In this post, Jonathan Evans, Mariana Gallo, and Alivia Knol of the Centre for Community Organisation and Development (CCODE), discusses how the EcoSan toilet system has helped to combat Malawi's sanitation crisis. 

With implications in areas as diverse as nutrition, education, and health, the lack of proper sanitation and hygiene is considered one of the greatest barriers to global development. In Southern Africa, Malawi is all too familiar with these far-reaching consequences. Diarrheal disease is currently the fifth cause of death in Malawi and it is estimated that poor sanitation costs the country approximately US$57 million each year.

Malawi’s sanitation crisis is perhaps most evident in the nation’s capital city of Lilongwe, and the industrial center of Blantyre. A combination of factors including a lack of a sewage treatment system, poor access to water, and a lack of space result in a complex sanitation challenge for the cities’ slums.

Currently, the most widespread model of sanitation toilet in these informal settlements is the pit latrine. Pit latrines are often smelly, fragile structures that are unsafe for children and are subject to overflow during the rainy season. Once a pit latrine becomes full, it is common for a completely new pit to be dug, making the system unsustainable. Open defecation is also commonly practiced in urban Malawian slums, with terrible health consequences.

Ecosan toilets1

The Centre for Community Organisation and Development (CCODE), in partnership with the Federation of the Rural and Urban Poor of Malawi, has been installing an alternative system called the Ecological Sanitation (EcoSan) toilet in Malawi since 2005. EcoSan toilets are dry-composting latrines, where the human waste is mixed with soil or sawdust to decompose in anaerobic conditions, producing as a result a compost that is odorless and safe to handle. Though there is a reasonable investment of training, and money required at the installation of an EcoSan toilet, the numerous long-term benefits of this system result in overall savings. This is in sharp contrast to pit latrines, which are quite cheap in the short run, but very costly in the long run. When maintained properly, EcoSan toilets can function with minimal water supply, and will produce a dry compost final product that is not unpleasant or difficult to empty.

When dirt and soot are periodically added to the collection chamber, the EcoSan toilet can turn human waste into manure that is used as fertilizer in gardens and farms. This fertilizer can be used by EcoSan owners in their own fields, or can be sold to other farmers. This capability is not only environmentally friendly, but is a source of great monetary savings (sometimes even earnings) for the EcoSan owner.

One unforeseen benefit that has emerged in the implementation is that the EcoSan toilet has become a status symbol in the community. The sturdy, odor-free design is something that EcoSan owners take great pride in, which in turn motivates their neighbors to seek out a similar toilet for their house.

The primary drawback of the EcoSan system is the cost. The current cost of a unit is around of US $215, which includes materials and labor. This is a significant sum of money for most households in the slum areas of Lilongwe and Blantyre. To overcome this obstacle, CCODE and the Federation work to provide loans to access them, and support village savings and loan groups as a way to increase investment capacity. Other solutions have come from the beneficiaries themselves: some groups have agreed to pool their money together to pay for a toilet to be installed in one house with the understanding that everyone who contributed money will be able to use the toilet. Once they’ve saved enough money, they will pay for a toilet to be installed for the next family, and so on. This solution is not ideal, but it’s nevertheless a way to increase access for a population that would normally never be able to afford such a toilet.

Another challenge with EcoSan toilets is that they are not maintenance-free. When the toilets are not properly taken care of, they can start to smell, get clogged up, or attract flies. These issues are all completely avoidable, but the owner must be committed to the necessary upkeep.  CCODE and the Federation ensure that each and every household that gets an EcoSan toilet also receive the necessary information and training to use and maintain it properly.

Despite these challenges, the EcoSan toilet is proving to be the most adequate solution to the sanitation and hygiene crisis in Malawi. Not only does it save space and money in the long term, but it also contributes to the achievement of one of the UN’s Millennium Development Goals of Ensuring Environmental Sustainability. However, without adequate financing for impoverished households to install EcoSan toilets, they wouldn’t be accessible to the people that need them the most.

With the help of local savings and loans programs like the Federation of the Rural and Urban Poor, and the work of numerous NGOs throughout Malawi, access to improved sanitation will continue to expand, if not as quickly as perhaps it could. Nevertheless, every single toilet that is installed means less danger for children, less exposure to disease, and less damage to the environment. There is certainly a long way to go, but progress is being made every day.

Editor's Note: In this post, Dylan Lunney, Director of Communications for OHorizons, discusses the Low Tech, High Thinking approach to creating affordable, simple solutions that can have a meaningful impact on WASH issues.

Bangladeshi_Women_Stand_Next_to_an_OHorizons_BioSand_Filter

Bangladeshi Women. Photo credit: ohorizons.org

Low-tech, scalable, local solutions present an exciting opportunity to address the water, sanitation, and hygiene (WASH) objectives laid out in goal number six of the United Nation’s Sustainable Development Goals (SDGs).

There is no one-size-fits-all solution to tackling WASH issues, but in order for development projects to be successful and sustainable, communities should not be bystanders in projects that are designed to help them. This belief is underscored within SDG 6 section 6.6b

In addition, solutions addressing the challenges of people living in poverty should be designed by carefully examining and accounting for the needs, practices, and available resources of the end-user. This seems like a basic, self-evident concept, however the history of water development projects demonstrates otherwise.

Take for instance that the cumulative cost of failed water systems in sub-Saharan Africa alone was estimated to be $1.2 billion to $1.5 billion from 1987-2007. The poster child of this development design failure is the PlayPump, an initially highly-touted safe drinking water ‘solution’ that quickly failed when it turned out that kids would have to ‘play’ for 27 hours a day to filter the intended amount of water. Development projects that fail to incorporate the needs, skills, habits, and resources of the end-user don’t produce their intended result—in this instance providing safe drinking water—and they are an enormous waste of money, time, and resources. Instead, beneficiaries should be involved in identifying the technology and approach that will benefit them most and the community should be directly involved in the building and maintaining of their local infrastructure.

OHorizons, where I work, is part of this appropriate design movement in WASH global development. We call our design process Low-Tech, High-Thinking.

A lot of attention is given to the newest app or high-tech gadget. You’ve probably heard of Bill Gate’s highly celebrated machine that turns human waste into water. It’s impressive. It’s also impractical for most poor, rural communities, where the water and sanitation crisis is particularly dire, who likely don’t have the infrastructure or funds to build or maintain this $1.5 million dollar facility that is roughly the size of two school buses.

The core belief behind the Low-Tech, High-Thinking movement is that it takes just as much creativity and ingenuity to create affordable, simple solutions that can have a meaningful impact on a global scale. Understanding the systemic underlying causes along with listening to and learning from the end- user, is a vital part of this design process. Adhering to the following principles can also help guide this process and ensure a solution is truly centered around the beneficiaries and the environment in which they live:

Low-Tech Principles

Simple: Anyone, regardless of education level or expertise, should be able to develop and implement a solution with minimal instruction.

Low-cost: The solution should be affordable to the end-user.

Locally-sourced: 100% of the materials, tools, and labor should be available locally.

Flexible: Every community is different and has different resources available to them; solutions should be flexible enough to adapt to varying local conditions.

Open-source: Solutions should be freely available to anyone who would like to utilize them.

OHorizons has used this approach to engineer a Wood Mold for the production of concrete BioSand Filters (BSFs). BioSand Filters (BSFs) are a low-tech, household appliance that use sand, gravel, and natural biological processes to filter pathogens out of water, making it safe for drinking. We’ve made our step-by-step construction manual open-source so that local organizations can manufacture BSFs for a fraction of the upfront costs of the traditional steel mold. Our Molds make more than 50 concrete filters without an issue due to the use of our patented collapsible inner core and 2” x 2” supports that hold the outer walls of the Mold together with bolts rather than screws, which strip the wood. This innovation allows more people to get safe drinking water at an exponentially faster rate. 

There exist many other fantastic household level solutions that follow similar design parameters. Two of my favorites are the Tippy Tap for hand-washing and the C.R.A.P.P.E.R. for toilets.

TippyTap

The Tippy Tap is a hands free way to wash your hands and is especially appropriate for rural areas where there is no running water. It is operated by a foot lever and thus reduces the chance for bacteria transmission as the user touches only the soap. They’re also very easy to build and can be made with basic, low-cost materials.

The organization Toilets for People (TFP) has designed a high-quality composting toilet that they’ve appropriately named the C.R.A.P.P.E.R. (compact, rotating, aerobic, pollution-prevention, excreta reducer). It’s user-friendly and easy to maintain, can be made from locally available materials for about $100, and is being built around the world by NGOs serving their communities.

Here’s a video of TFP in Peru with their NGO partner Amazon Promise, building 17 CRAPPERS:

 

Toilets for People’s founder Jason Kass, is a passionate ambassador for bridging the gap between the appropriate technologies already out there and creative implementation on the ground.

As we continue to develop solutions for water, sanitation, and hygiene, one area to think seriously about investing in is low-tech, human-centered design projects that transform beneficiaries into local change makers. Harnessing the power of people through Low-Tech, High-Thinking Design can and should play an important role in helping ensure availability and sustainable management of water and sanitation for all by 2030!

Editor's Note: In this post Susan Davis, Founder and Executive Director of Improve International, discusses all of the possible definitions of sanitation success. This post originally appeared on Improve International's website, to view the original post click here

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During a recent desk review, we found there is no one widely accepted definition of sanitation success, even for broadly used approaches like community-led total sanitation.

Some consider long-term success to be the movement of households up the “sanitation ladder,” the idea of incremental progression between service levels of different quality. Success for sanitation marketing efforts can include an increase in local businesses who are investing in sanitation to expand their business, sales to target households, and number of households who are investing their own money into a toilet sold by these partner businesses.  We realize we haven’t captured all possible definitions of sanitation success, but wanted to share what we found.

3iE: Sustained use is defined as the continued practice of a WASH behavior and/or continued use of a WASH technology at least six months after the period during which there was external support to community groups, leaders and volunteers in the form of training, supervision and feedback, distribution of technology, or provision of communication materials.

Global Sanitation Fund (GSF):  The GSF works towards attainment of universal access to improved sanitation, which they measure using these indicators: number of people with access to improved sanitation, number of people living in open-defecation free environments, and the existence, and evidence of use, of a dedicated place for handwashing and availability of soap or ash (as a proxy for people washing their hands at critical times). The GSF includes in its description access to improved sanitation by all members of a community and proper handling, storage and treatment of human waste, but these are not included in their results.

Government of India: ODF is the termination of fecal-oral transmission, defined by a) no visible faces found in the environment/village; and b) every household as well as public/community institutions using a safe technology option for disposal of faces.  A safe technology option means no contamination of surface soil, ground water or surface water; excreta inaccessible to flies or animals; no handling of fresh excreta; and freedom from odor and unsightly condition.

IRC Water and Sanitation Centre: The sanitation service level framework evaluates the services provided by the delivery of safe latrines using four indicators:type and accessibility of latrines to households (in line with national norms); use of sanitation facilities by members of the household;cleanliness, maintenance and pit emptying of the facilities; and environmental safety of fecal waste.

Joint Monitoring Programme (JMP):  A sanitation facility is considered improved if it hygienically separates human excreta from human contact, but this indicator does not address the subsequent management of fecal waste. Safe management comprises several stages along the “fecal waste management chain,” from containment through emptying, transport, treatment, and reuse or disposal.

Netherlands Water Partnership: Sanitation facilities are only sustainable when people make their own choices and own contribution towards obtaining and maintaining them. People have to experience the toilet as an improvement in their daily life. Sanitation systems have to be embedded in the local institutional, financial-economic, social-cultural, legal-political, and environmental context.

Sustainable Sanitation Alliance (SuSanA): The main objective of a sanitation system is to protect and promote human health by providing a clean environment and breaking the cycle of disease. In order to be sustainable a sanitation system has to (1) promote health and hygiene effectively, (2) be financially and economically viable, (3) socially acceptable and institutionally appropriate, (4) technically appropriate including operation and maintenance (O&M), and (5) protect the environment and natural resources.

UN Sustainable Development Goal 6Ensure availability and sustainable management of water and sanitation for all.  Targets include:

6.1 By 2030, achieve universal and equitable access to safe and affordable drinking water for all

6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations

6.3 By 2030, improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally

6.4 By 2030, substantially increase water-use efficiency across all sectors and ensure sustainable withdrawals and supply of freshwater to address water scarcity and substantially reduce the number of people suffering from water scarcity

6.5 By 2030, implement integrated water resources management at all levels, including through transboundary cooperation as appropriate

6.6 By 2020, protect and restore water-related ecosystems, including mountains, forests, wetlands, rivers, aquifers and lakes

6.a By 2030, expand international cooperation and capacity-building support to developing countries in water- and sanitation-related activities and programmes, including water harvesting, desalination, water efficiency, wastewater treatment, recycling and reuse technologies

6.b Support and strengthen the participation of local communities in improving water and sanitation management

WaterAid: Sustainability is about whether or not WASH services and good hygiene practices continue to work and deliver benefits over time. No time limit is set on those continued services, behavior changes and outcomes. In other words, sustainability is about lasting benefits achieved through the continued enjoyment of water supply and sanitation services and hygiene practices.

Water For People:  Water For People envisions sanitation success in steps, summarized as follows:

  • Family forever. “a loved latrine is a used latrine and household defecation behavior will be changed Forever.”
  • Sanitation Business Forever. This moves the focus to sustainable service delivery.
  • Forever sanitation services at scale.  Any person with a pit latrine in any part of a city or district should be able to easily access the sanitation service they require, not just the ones in the relatively limited geographical area covered by the entrepreneurs supported as part of step 2. (Sugden, 2013).

WSP: The World Bank Water and Sanitation Program used the following performance indicators to rate relative success of sanitation case studies:

  • Prevalence of open defecation
  • Hygiene behavior
  • Access to sanitation by the poor
  • Environmental sanitation improvements
  • Extent of self-financing
  • Program cost per household
  • Range of toilet components and designs utilized
  • Local availability of sanitation wares and services
  • Regular support and monitoring
  • Implementation at scale

What’s your organization’s definition of sanitation success?  Let us know in the comments section below or contact us.

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