Before this post gets ahead of itself, a small disclaimer:
This post is about sanitation and all things related.
Still reading? Good.
According to the World Health Organization (WHO) sanitation is defined as “the provision of facilities and services for the safe disposal of human urine and feces”. In term of raw numbers, the crisis is appalling: about 2.4 billion individuals are deprived of adequate sanitation facilities. Compare this to data on access to water issues and it is evident that sanitation is the biggest contributor to the Global Water Crisis.
In a 2008 press release, UNICEF and the WHO insist that “sanitation is the cornerstone of public health”. Inadequate human disposal systems are breeding grounds for diarrhea and other diseases. According to WHO data, diarrheal diseases cost about 2 million deaths per year. WHO Director-General Margaret Chan has argued that: “[i]mproved sanitation contributes enormously to human health and well-being, especially for girls and women. We know that simple, achievable interventions can reduce the risk of contracting diarrheal disease by a third”.
But what does it mean to ‘improve’ sanitation facilities? The United Nations has stated that improved sanitation facilities should have a connection to public sewers or septic systems. Pour-flush latrines, simple latrines and ventilated improved pit latrines also qualify as “improved”. Practices deemed inadequate refer to “bucket latrines (where excreta is manually removed), public latrines and open latrines”.
While installing adequate sanitation facilities may be simple and relatively inexpensive (compared to the benefits offered), altering behavior is not. Take the experience of Bangladesh. A heavily impoverished South Asian economy, Bangladesh suffers many water-related hardships. According to a WHO and UNICEF report, in 2006 only 32% of the rural population was using an improved sanitation facility. The urban areas fared better, with 51% access, but even there, only 7% of urban facilities were connected to a sewerage system.
Given poor state of sanitation in the country, Bangladesh has proven to be a testing ground for several approaches to sanitation. In May 1993, CARE-Bangladesh in concert with the International Center for Diarrheal Disease Research implemented the Sanitation and Family Education (SAFE) project to test two competing approaches:
- Model 1 emphasized education ‘sessions’ with child caretakers, where they were exposed to the concept of clean water, waste management, and disease prevention among other things.
- Model 2 included these sessions but also added a myriad of support activities including “school programs, child-to-child approaches, and the involvement of key opinion leaders in the community”.
In a review of the program, CARE established that after one year both models had been very successful, with Model 2 slightly outperforming Model 1. CARE reported “dramatic improvements were seen in all areas of intervention, for all targeted behaviors, and by all measures – knowledge, reported behavior, demonstrated practices, and observations.” Even in light of relative success, CARE was unable to identify whether Model 2’s out-performance merited the additional funds it was allocated. In addition, the projects time horizon may have been insufficient to observe real trends in the use of improved sanitation facilities.
Evaluating a separate set of interventions that ended in 2006, the World Bank’s Water and Sanitation Program solved some of these issues by choosing a longer time horizon. Evaluators returned to Bangladeshi communities in 2011 four and a half years after being declared 100% sanitized The WB reported some evidence of backsliding: four years later only 89.5 of households owned or shared a latrine. The evaluators concluded that that households exposed to follow-up programs “were 1.8 times more likely to have an improved or shared latrine compared to those that did not receive a follow-up program”, evidencing the importance of thinking long-term.
Interestingly, teaching rural communities in Bangladesh about sanitation has created a business opportunity for locals. Since the establishment of sanitation-based initiatives, sanitation providers have become a robust and mature market in Bangladesh—and present evaluators with a nifty way of measuring success.
So what does Bangladesh teach the development community? Well, change is hard. It requires a community-based approach, which is resource- and time-intensive. Moreover, the tactics that work in Bangladeshi communities may not work in neighboring India. The paradox is that while the challenge is universal, the solution is not.