38731 January 2007 Field Note Sanitation and Hygiene Series From Burden to Communal Responsibility A Sanitation Success Story from Southern Region in Ethiopia This is a sanitation success story from the Southern Region of Ethiopia where 20 percent of the country's population reside in 10 percent of a geographic area known for its high population density and ethnic diversity. The story explains how the Regional Health Bureau decided to focus on preventable diseases and how it then facilitated a strong region-wide commitment to high impact, public health interventions through the empowerment of households resulting in a wave of household latrine building. Summary Map of Ethiopia This is a sanitation success story from the Southern Region of Ethiopia where 20 percent of the country's population reside in 10 percent of a geographic area known for its high population density and ethnic diversity. The story explains how the Regional Health Bureau decided to focus on preventable diseases and how it then facilitated a strong region- wide commitment to high-impact, public health interventions through empowering households, resulting in a wave of household latrine building. This sanitation story is distinctive because it was successfully driven by the Health Bureau (working closely with all key stakeholders), using their own funds through a cascading process of advocacy, consensus (and capacity) building, promotion (via Background community volunteers) and supportive supervision. Alongside other gains in public health, pit latrine For a long time, Ethiopia has featured at the bottom of the ownership rose from under 13 percent in September international league table of access to `on-site' sanitation 2003 to over 50 percent in August 2004. By August - estimated at less than 18 percent in 2002/3. This figure 2005, it had reached 78 percent, and a year later, reflects considerable regional as well as rural-urban variation was on-track to reach 88 percent. The Health compounded by the usual difficulties in defining what Bureau is now working with Unicef, the African constitutes an adequate `on-site' sanitation option. Where Development Bank, the European Union, the Water success stories are reported, they have almost exclusively and Sanitation Program-Africa and the World Bank to been facilitated by donor funding or NGO execution. The empower households to upgrade traditional pits with broad impression in Ethiopia is that population demand for permanent platforms and shelters, and to improve `on-site-sanitation' as well as government willingness to overall domestic hygiene. commit resources is low. As Dr Shiferaw Teklemariam, head of the Regional However, a number of regional success stories are emerging and one region in particular has demonstrated Health Bureau, points out: "... none of these how well-placed donor support, combined with committed achievements would have been possible without leadership and innovative low-cost approaches, can bring close inter-sectoral collaboration and strong about a dramatic shift in household latrine construction. leadership, committed to universal Water Supply This field note describes the Southern Region's (Southern and Sanitation (WASH) access. This collaboration Nations, Nationalities and Peoples' Regional State) rise to has been further strengthened by both national and the top of the domestic `on-site' sanitation league table regional memoranda of understanding which will in the span of three years, and how several sanitation formalize sector synergy and build on the universal prejudices were overcome along the way. coverage approach of the health service extension program. This is the positive and sustainable The Southern Region is home to diverse cultures and foundation from which to follow the roadmaps and scores of ethnic groups, with a population of 15 million achieve our MDGs". - much bigger than many African countries. There are 2 From Burden to Communal Responsibility A Sanitation Success Story from Southern Region in Ethiopia 13 zones and eight special woredas1 enthusiasm and talking with the ­ sub-divisions of a zone. In total, there same voice..." are 133 woredas (districts) in the region. Some of the densely populated areas Drivers of Adoption such as Wanago woreda in Gedeo zone are inhabited by 1,100 people per At the household level, women have square kilometre, while peripheral areas been identified as the main drivers such as South Omo and Bench Maji of latrine construction. At public have low population densities. In early consensus-building meetings, they 2003, access to `on-site' sanitation complained about how open field was estimated to be under 13 percent defecation directly affects their lives. - even lower than the estimated national They highlighted the health risks of average of 15 percent. contact with feces in the banana plantations, and in the fields where From under 13 percent to more they collect fodder for cattle. They than 77 percent in two years also complained of the bad smell and embarrassment of seeing people In just two years, the region experienced defecate in the open2. a rapid improvement. As Dr Shiferaw reported to the press in February 2005: At the village level, volunteer community "Walk into any household in Southern Dr. Shiferaw and Kebele (village) Chairman Region and you have a three in four health promoters have led by example chance of finding a pit latrine, and this 80 percent in the space of three years. and gone house to house with health does not include the latrines that haven't He suggested the key to this success extension workers and members of the been counted for quality reasons." was a combination of consensus kebelle3 health committee to persuade and commitment from the household householders to follow suit. At health The Regional Health Bureau head to the regional assembly. As one center and woreda level, environmental explained how they had shifted from environmental health official remarked: health workers, working under the the broad primary health care model "We are all infected with the same supervision of the woreda health to focus on a limited number of `high impact, broad reach, low cost' public health interventions. Recent supervision Figure 1. Latrine Construction 2002/3 to 2005/64 and monitoring has revealed that public interest in and adoption of latrines, On-site Sanitation in Southern Region 100 immunization, and family health, is set 88.8% to rise above the critical threshold of 80 78.8% 60 1Special woredas were created to protect 51.7% the interests of concentrations of distinct ethnic groups providing them with their own 40 administration 2In line with the Southern experience, the esaercnIegatnecreP Community led Total Sanitation approach in 20 Bangladesh identified `self-respect' as one 12.8% of the main motivating forces behind latrine construction (see footnote 4) 0 2002/3 2003/4 2004/5 2005/6 3Kebelle is the Amharic word for sub-district (a collection of villages containing as many as Annual increase in latrines with 2005/6 projection 2000 households) 4The years 2003-2006 are 1995-1998 in the Source: Southern Nation's Regional Health Bureau Ethiopian Calendar 3 office (with inter-sectoral and political has included making a modest but support), provided training, technical dedicated sum of money available for direction and encouragement. the mass mobilization of the entire population as sanitation stakeholders The zonal level has also provided an under the slogan: `Sanitation is important intermediary level in driving Everyone's Problem and Everyone's the process as emphasised by the story Responsibility'. in Box 1, where shame was cited as an important factor in consensus-building An affordable product and a strong motivator for latrine construction. At the regional level, the The Southern Regional Health Bureau Health Bureau has been the prime driver has applied some of the key guiding with the support of the regional cabinet. principles of the highly acclaimed In this context, the official ratification of Community-Led Total Sanitation (CLTS) the Regional Public Health Proclamation approach4 ­ that of `zero subsidy' ­ but in August 2003 and the processes allowing the community to come up followed in the formulation of the Final steps in constructing a latrine with its own innovative and affordable regulation, were key drivers in attracting models. The CLTS approach has analysis of the prevailing situation in political support and commitment. contributed to a similar dramatic latrine Southern Region reveals a high level of coverage improvement in South Asia. fulfilment of these criteria. Determining Factors In Bangladesh, where the approach was pioneered, sanitation coverage In order to achieve a social change of Leadership has improved from around 30 percent in 2004 to over 70 percent today5. In this magnitude, it is widely accepted Throughout the health hierarchy India, Maharashtra State has scaled up that five key factors must be in place: in Ethiopia, there is no shortage of to 3,500 local governments claiming well-informed, well-respected, well- inspired, well-informed and committed `defecation free' status in three years. connected leadership; an affordable leadership but in Southern Region there product; latent demand by a critical has been an exceptional willingness to Latent demand mass of early adopters; the right take risks and challenge conventional context; and the `tipping point'. An primary health care approaches. This In the limited Knowledge, Attitude, Belief and Practice studies6 carried out in Box 1: 'Shame' ­ A Key Driver Ethiopia, women expressed demand for a safe, private, hygienic, smell-free latrine Dr Shiferaw explained that during the cascading advocacy and consensus building while men acknowledged the importance process, a zonal administrator was asked if he would stay in a village overnight. of a latrine, particularly during the rainy His hosts were embarrassed when the administrator asked, "but what happens if I season. However, latrine construction need a latrine?" The zonal administrator noted and reported on the obvious shame has not generally been prioritized. In his question had caused and how rapidly consensus was reached on the need for Southern Region, women volunteer latrine construction. He was later gratified to be invited a second time by the same community health promoters have village, but this time without the faintest hint of embarrassment as the whole village became the influential, early adopters had built latrines. supported by leaders at all levels. Dr Shiferaw added that shame over the prevailing sanitation situation, and dismay at 4Kar K. (2005) Subsidy or self-respect. Community the poor progress of programs and projects to effect change, had been important Led Total Sanitation: an update. IDS Bulletin 257 drivers of change both within his department and the regional cabinet. 5Bangladesh Bureau of Statistics, Unicef Courtesy of WSP Bangladesh (2006) 6 Source: Interview with Dr Shiferaw, 04/05/06 WaterAid (2003) KABP study on defaecation and latrine preference 4 From Burden to Communal Responsibility A Sanitation Success Story from Southern Region in Ethiopia The right context reduce private open defecation options. the long-term partnership with John In addition, girl-child school enrolment Snow International through the USAID- Traditional sanitation wisdom suggests in, and completion of, primary and funded project, Essential Services for that where houses are scattered and secondary schools is significantly above Health in Ethiopia. This partnership gave there is a wide choice of rocks, bushes, the national average. The Health Bureau greater emphasis to `high impact' public trees and gullies to provide privacy, leadership suggest that women in health programs and sponsored the then demand for latrines is limited. In Southern Region have been better able training of community health promoters Southern Region, population expansion to express their sanitation priorities and who not only led by positive example resulting in high household densities, influence their husbands. An additional but went door-to-door, to successfully and deforestation have combined to important contextual factor has been persuade households to follow suit. Table 1. Latrine building by Zone/Special Woreda in Southern Region 2002/3 - 2003/4 No Zone or Special Woreda Latrine Coverage% % Increase Population (2005) Households Zones 2002/3 2003/4 1 Benchi Maji 9 72 63 449,521 89,904 2 Dawro 15 41 26 367,726 73,545 3 Gamo Goffa 16 60 44 1,467,974 293,595 4 Gedeo 15 54 39 773,164 154,633 5 Gurage 14 96 82 1,533,279 306,656 6 Hadiya 13 49 36 1,298,736 259,747 7 Kaffa 11 38 27 789,818 157,964 8 Kembatta-Tembaro 18 72 54 706,525 141,305 9 Shaka 9 60 51 181,508 36,302 10 Sidama 18 62 44 2,775,532 555,106 11 Silti 7 40 33 774,559 154,912 12 Southern Omo 10 36 26 447,084 89,417 13 Welayta 14 57 43 1,582,469 316,494 Special Woredas 14 Alaba 10 48 38 204,254 40,851 15 Amaro 12 65 63 132,326 26,465 16 Basketto 6 16 10 43,324 8,665 17 Burji 12 31 19 53,095 10,619 18 Derhashe 9 75 66 122,272 24,514 19 Konso 11 14 3 212,272 42,454 20 Konta 8 54 46 82,255 16,451 21 Yom 31 46 15 87,009 174,018 Region 12.8% 51.7% 39% 14,084,702 2,973,617 5 A typical traditional village setting The pilot woredas demonstrated what value of improving prevention but the Steps to Sanitation could be achieved; it was now up to the actual trigger for change came from an Improvement in regional government to take it to scale. unlikely source. Southern Region The tipping point It was one of the Bureau drivers who STEP 1: Pilot Referring to the prevailing health overheard a senior health manager state situation prior to 2004, Dr Shiferaw that 80 percent of the disease burden in The high-impact approach was piloted in 20 woredas selected on the basis described a phenomenon known as the region was preventable. The driver of the community's willingness to dig the `leaking bucket' effect: "The rural remarked that the same assertion had latrines. The most successful of these people get sick, they are treated and been repeated for the last ten years and, was Misha woreda located in the more leave, then they get sick again, are with a mixture of guile and ill-concealed densely populated, rolling hills of the treated again....and the cycle continues. skepticism, suggested that surely after North East zone of Southern Region. They spend most of their cash income a decade some of the diseases might It now boasts over 75 percent latrine on health care." actually have been prevented! This story coverage - an increase of more than illustrates another important factor in thefive times the baseline figure (with With support from John Snow success story ­ that of the willingness reported increased handwashing after International, the regional health of senior management to listen to the latrine use); more than 85 percent leadership was starting to recognize the people and to put the people first. immunization and 60 percent family 6 From Burden to Communal Responsibility A Sanitation Success Story from Southern Region in Ethiopia planning use. The pilot process, Box 2: It all started in Misha... although externally supported by USAID funds and with technical input from "It is August, the countryside is greened by the ample rains and the observer, eager John Snow International, was designed for clues to explain the success, notes that this is not the home of the 60 percent of to operate within a framework that could Ethiopians depending on food-aid; market day in Misha woreda suggests good times. be replicated by government. The key The skeptical observer notes that the context is right. The locally-based religious factor was that the framework could be scaled up and implemented within the mission with a strong focus on education has ensured that the majority of farmers regional public health budget. reach level 12 (completing high school but not necessarily passing college entrance exam) and current girl school enrolment is at 89.2 percent, a stark difference from the STEP 2: The ignition documents national average of 50.6 percent. On the basis of results from the pilot Up to 2005, Southern Region had an unusual structure in that both the health and and in line with the new health policy education desks were coordinated by a capacity building cadre at all levels which was in Ethiopia, the Regional Health designed to encourage closer inter-sectoral collaboration, co-ordination and mutual Bureau decided to shift their health reinforcement. The current woreda health team greets us, cheerfully explaining that focus and increase time and money the team's full complement should be 17! The team consists of three members: the spent on preventing morbidity. The health desk head, an environmental health officer responsible for disease prevention regional government produced a and control and a mother-and-child health nurse. Although they are assisted by series of `ignition' documents' (Health Development Popular Mobilisation) in professionals from health posts, health centers and two NGO clinics, they repeatedly 2003/4. The ignition documents were emphasize the importance of community health promoters. The team explain used to stimulate discussion among the morbidity data displayed on the walls of their cramped office, emphasizing a regional, woreda and zonal staff about spectacular epidemiological shift. Reported diarrhea (gastric infections), helminths the prevailing burden of disease and the and eye/skin infections have progressively fallen out of the top five infections during various contributing factors. the last four years. The team is rightly proud of their achievements. A list of 20 causes of outpatient The methods have been diverse. They actually demonstrate active amoebic protozoa morbidity and mortality were identified as an advocacy tool. They engage influential leaders in the laboratory analysis of by the health teams and the underlying stools to demonstrate how bacteria and protozoa could enter the body through poor factors to these problems were found sanitation and hygiene. The team have employed drama and role-playing effectively to be: communities' low awareness at different ceremonies to raise important public health issues, emphasizing over and on health, low coverage of health over again that prevention starts in the home and not at the health post, the woreda services, and the high prevalence of health office or the Regional Health Bureau in Awassa. easily preventable diseases. The ignition documents outlined how to intervene in various high impact health areas by Even though the visiting team is three hours late and it is the end of the day, we are shifting from a curative to a preventive joined by other woreda desk officers who have returned specially for discussions and focus. sit for three hours explaining what they see as keys to their success. They emphasize leadership, teamwork and personal commitment. Even without the benefit of Amharic, The six key interventions were: the observer notes that here is a team, working in concert, eager to complement 1. Household pit latrine construction each other's work and share the burden as well as the spoils of their considerable 2. Vaccinations ­ DPT 3 achievements. As we are waved on our way, the team point to a brand new Toyota 3. Creating health posts Land Cruiser parked outside ­ a collective reward for their efforts. Misha woreda: 4. Maternal and childcare 'Best in Zone' and 'Best in Region'. 5. Family planning 6. Strengthening Outpatient Service Delivery (focus Malaria and HIV/AIDS) Source: The Water and Sanitation Programme team ­ field visit report extract 7 STEP 3: Dedicated finance Table 2. Sample of a Performance Contractual Agreement In 2002/3 pit latrine coverage was Zone/ special woreda ........................................................................................... under 13 percent. The following year Woreda ................................................................................................................... it rose to more than 50 percent, and Latrines Immunisation Health Post MCH Service Family Planning Outpatient Service in 2004/5 reached 78 percent. "The DP3 Construction Coverage Service Coverage Delivery incl. Malaria number of latrines rose from around Target % % % % % % 100,000 to 2 million," says Dr Shiferaw. Achieved % % % % % % People did this at their own expense. Signed Woreda .......................................................................................................................................................... The activities which were funded Signed Zone .......................................................................................................................................................... (detailed in Box 3) did not cost more Signed Region .......................................................................................................................................................... than 500,000 birr (around US$50,000). STEP 5: Appropriate technology 4. Superstructure should consist of roof The target for 2005/6 is to attain 90 and walls percent coverage but with close quality The Regional Health Bureau set minimal 5. Should be provided with diversion assurance to a `minimum safety/hygiene standards for latrine construction, ditch to protect the pit from flooding standard' (this includes being more preferring to follow the Community-Led 6. Should be provided with hand than 20 meters from a water source and Total Sanitation approach where the washing facility `down-wind' of people's dwellings). central objective is to break the culture of open defecation while allowing the Currently, the Regional Health Bureau is STEP 4: Cascading advocacy community to choose how to achieve it. engaged in intensive capacity building and consensus building activities throughout its structures, The Regional Health Bureau set some The ignition documents were discussed with a strong focus on promoting criteria for construction as follows: conformity with sustainable technical by regional experts, zonal health officials1. Site: standards. The Bureau acknowledges and capacity-building staff at zonal · 20m-30m from water source the importance of use as well as access and woreda levels to reach consensus · Wind direction away from dwellings and quality and is currently planning to on the need for the six high-impact · At the back of dwelling conduct a study to assess how many interventions. The regional government 2. Pit design: of the latrines conform to the technical encouraged zonal and woreda officials · Stable soil type ­ rectangular criteria and what behavior change has to talk to the kebelle ­ smaller, local · Unstable soil type - circular taken place in terms of family latrine use administrations ­ on ways to involve 3. Platform (floor slab): and hand washing frequency. the community and ensure there was · Should cover the pit political will to back their actions. · Should slant towards the hole STEP 6: Performance-related agreements While politicians and civil servants spoke with one voice, leaders at all Box 3: Funded Activities Southern Region government officials levels were rallying their people to 1. Preparation of community have introduced a performance create a positive social epidemic. "We mobilization document contractual agreement that covers all six wanted to involve the people," says Dr 2. Per diem for meetings to discuss of the high-impact interventions. It is a Shiferaw, "because in the past people the prepared document method to encourage results-oriented thought sanitation should be done by 3. Trainer of Trainers for health management and make sure that the government and NGOs. One had to professionals officials (politicians and civil servants) be a health official to get involved in 4. Training for health promoters and at various levels agree to achieve and such things. What we have achieved supportive supervision actually deliver key public health targets. could only have been done with the The agreement has a simple format participation of the people." Source: Regional Health Bureau which details the `high impact' targets 8 From Burden to Communal Responsibility A Sanitation Success Story from Southern Region in Ethiopia for the woreda, zone and region. At the village level, community-based leaders sign similar agreements with woreda officials to facilitate implementation of agreed targets at the kebelle level. This is part of the on-going Civil Service Reform for results-oriented performance appraisal. The contract sets a minimum acceptable level of delivery with incentives for the three best performing woredas - the top prize being a vehicle. STEP 7: Training (community health promoters) with supportive supervision During the pilot phase, with assistance from John Snow International, woreda Health extension worker training community health promoters Trainers of Trainers were selected and trained on the `minimum health of small doable actions. It is these STEP 8: Monitoring and package.' They in turn facilitated the volunteers with minimal training who evaluation selection and training of community have provided the essential health link health promoters on the `minimum between woreda, kebelle, sub-kebelle, The Region is currently working to health package'. This process has now village and household. They have been develop cascading monitoring and been replicated in all other woredas. well supported by elected leaders, as evaluation systems to link with the well as traditional and religious leaders, national health information management One community health promoter and personnel from health and other system but the cascading performance- has been chosen for every 30/40 sectors. The essence of success here related contracts have provided an households and charged with mobilizing can be attributed to teamwork. important means of monitoring as the people towards fulfilling the high well as ensuring accountability. In impact objectives. They are unpaid Community Health Promoters addition, an independent household although the community is expected to demonstrate latrine construction in survey (conducted by the Kale Hiwot assist them with farming activities. They their own households and offer advice Church7) as well as routine monitoring are expected to volunteer in their spare to their selected 30/40 households by other bilateral organisations8, confirm time, when collecting wood and water on construction. Those unable to dig the reported 2004/5 latrine coverage with other village members and during their own pits, such as the sick and figures. events such as coffee ceremonies, elderly, receive help from others. A weddings and funerals. clear hierarchy of responsibility ­ from the region, to the zone, to the woreda, 7 In 2005, the Kale Hiwot Church carried out an independent household study covering a number There is general agreement that to the health unit, to the kebelle, to of woredas to submit a funding proposal to volunteer community health promoters the health extension worker, to the UNICEF. The woreda latrine coverage (complying have been one of the most important community health promoter, and with a minimum standard) ranged from 17 percent - 59 percent. factors in encouraging latrine ultimately to the household ­ have been 8 Unicef has been working in 43 woredas and their construction and use. They have crucial elements in the overall success assessment of those households with latrines mobilized the community to change of the high-impact public health fulfilling a minimum standard up to 2005 is 50 percent Source: Therese Dooley ­ Unicef Hygiene behavior by encouraging the adoption interventions. and Sanitation specialist 9 An important strength of the Southern Anecdotal reports from women during Box 4: Community Health Region's approach has been the field visits indicate reduced smell and Promoters consensus-building framework and reduced contamination of the `false' the willingness of cabinet members banana plantations and the fields where Selection criteria for community health to participate in the annual situation they collect animal fodder. However, promoters: analysis process leading to the besides the actual use of latrines, other preparation of strategic plans. In this · Volunteer, committed and motivated factors such as safety, durability, privacy · Acceptable by the community way, politicians experience first hand and hygiene of already-constructed · Able to read and write what the problems are and whether latrines present real challenges for · Shows exemplary behavior the planned activities are having the future. In addition, comprehensive any impact. They play an important approaches to improve handwashing Their only incentives are: motivating and monitoring role. and the safe drinking water chain are · Can join Health Extension Worker only just beginning. training (upgrading skills) As the Regional Health Bureau · Are paid per diems during suggests, it is too early to expect The Way Forward campaigns ( e.g. national substantive changes in morbidity vaccination campaigns) and patterns, although the pilot woredas While Dr Shiferaw and his colleagues receive T-shirts ­ with their advanced broader hygiene are recognized for facilitating the · In some cases they are provided success ­ report reduced diarrhea sanitation epidemic, the regional staff support for their farming activities and worm infestation at health centers. are under no illusions about the uphill during the time they are doing In addition, while construction figures struggle they face. The majority of voluntary work have been rigorously collected and households have dug traditional latrine · Recognition from the community as cross-checked (with some construction pits with a wide variety of platforms 'health information resource person' discounted due to poor quality), they and super-structures of an essentially Source: Regional health bureau suggest that only half the latrines temporary nature. Children or animals constructed are actually used9. falling into pits, pits overflowing, roofs caving in and bad smells, all combine to give traditional pit latrines a bad name, the private sector and the people ­ to resulting in low usage. make a range of affordable technical options and hygiene consumables The first challenge is to build on the more available at the local level. existing momentum and turn these pits Through national government programs into durable, appropriate and affordable supported by the World Bank, the latrines that can be used by the whole African Development Bank and Unicef, family. The second will be to focus on all 133 woredas in the region will have urban areas that are lagging behind. additional resources. Bridging the The third challenge is to improve technology gap is recognized as a major hygiene, particularly handwashing at challenge and the Water and Sanitation critical times but also water safety and Program will expand its regional support food hygiene. to include a study to assess the local sanitation market. The regional government recognizes that it cannot take sanitation to the next 9In baseline health surveys conducted in 2003 by level without additional support. They the Health Bureau, latrine ownership and use was have therefore been developing further reported to be 35 percent Source: MoH, USAID, ESHE(2005) - Twelve Improved hygiene through handwashing partnerships ­ with donors, NGOs, Baseline Health Surveys 10 From Burden to Communal Responsibility A Sanitation Success Story from Southern Region in Ethiopia Health extension worker visiting a household The Region, as an important contributor the regional team acknowledge the facilitating role, such a rapid social and supporter of the National Hygiene challenge of ensuring that all latrines, change could only have been achieved and Sanitation Strategy and Protocol, whether household, communal or with the participation of the people. will not provide individual household institutional, have hand washing "Sanitation is not something you give subsidies (with exceptions for groups stations. To achieve such important away as a commodity," he points out. with special needs) but will invest in behavior change functions, 15 NGOs creating an enabling environment. have been charged with responsibility Dr Shiferaw and his team are now for facilitating participatory hygiene and engaged with the challenge of making Activities already identified will sanitation transformation skills learning sure latrines are safely used by all include extensive software (including by woreda health staff, health extension members of the family, and that participatory hygiene and sanitation workers and community health handwashing is done at the four10 critical transformation skills and tools), promoters. times so that, like latrine ownership, the artisan training (and equipping), the practise becomes the rule rather than establishment of sanitary outlets, In summing up this success story, the exception. demonstration units (at the homes of Dr Shiferaw is quick to re-emphasize community health promoters and food the central role played by the people. distributors) and institutional latrine He suggests that the Region has construction, particularly at schools. experienced a cultural revolution which has made latrine ownership the rule, not While some of the new latrines have the exception. While he accepts that he 10The four critical times are: after defaecation, after cleaning a child's bottom, before preparing food some form of hand washing facility, and his team have played an important and before eating food. 11 About the Sanitation and Hygiene Series WSP Field Notes describe and analyze projects and activities in water and sanitation that provide lessons for sector leaders, administrators, and individuals tackling the water and sanitation challenges in urban and rural areas. The criteria for selection of stories included in this series are large-scale impact, demonstrable sustainability, good Water and Sanitation Program cost recovery, replicable conditions, and leadership. - Africa World Bank Hill Park Building Upper Hill Road PO Box 30577 Nairobi Kenya Phone: +254 20 322-6306 Fax: +254 20 322-6386 E-mail: wspaf@worldbank.org Website: www.wsp.org January 2007 WSP MISSION: To help the poor gain sustained access to improved water and sanitation services. WSP FUNDING PARTNERS: The Governments of Australia, Austria, Belgium, Canada, Denmark, France, Ireland, Luxembourg, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, the United States of America, the Bill and Melinda Gates Foundation, the United Nations Development Programme and the World Bank. ACKNOWLEDGMENTS This field note was prepared by Simon Bibby (Consultant, WSP-Africa) and Andreas Knapp (Water and Sanitation Specialist, WSP-Africa) who was also the overall task manager of this knowledge product. The field note is based on consultations, field missions and interviews with Dr Shiferaw Teklemariam (Head of Regional Health Bureau, Southern Region), Demissie Bubamo (Hygiene and Environmental Health Team Leader, Southern Region), Dereje Mamo (Hygiene and Environmental Health Expert, Southern Region), as well as with many other health staff and community leaders at zonal and woreda levels in Southern Region. Peer reviewers: Julia Rosenbaum (USAID-HIP), Therese Dooley (Unicef), Daniel Gelan (Unicef), Katherine Tulenko (WSP) and Barry Jackson (Development Bank of Southern Africa). Detailed feedback was also provided by Piers Cross (WSP- Africa) and Belete Muluneh (WSP-Africa). Editorial supervision: Toni Sittoni Editorial assistance: Sylvia Maina Photo credits: Andreas Knapp.