Report No: ACS17727 Socialist Republic of Vietnam Scaling Up Rural Sanitation - Strengthening Demand Creation and Supply Chain Synthesis Report {25 Apr 2016} GWASE EAST ASIA AND PACIFIC Document of the World Bank Standard Disclaimer: This volume is a product of the staff of the International Bank for Reconstruction and Development/ The World Bank. The findings, interpretations, and conclusions expressed in this paper do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Copyright Statement: The material in this publication is copyrighted. 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Table of Contents Executive Summary...................................................................................................................... 6 1 Introduction ................................................................................................................... 13 2 Background .................................................................................................................... 13 2.1 WASH sector context ................................................................................................................ 13 2.2 Rationale for the TAs................................................................................................................. 14 2.3 Sector developments since 2011 .............................................................................................. 14 3 Objectives of the TA ........................................................................................................ 16 3.1 Implementation approach ........................................................................................................ 16 4 Results and Key Achievements ........................................................................................ 22 4.1 Government strategy for NTP3 implementation is informed................................................... 22 4.2 Innovative approaches generated for demand generation and supply strengthening ............ 22 4.3 Increased government capacity to deliver the sanitation component of NTP3 ....................... 39 4.4 Knowledge deepened on the enabling environment and programmatic approaches............. 45 5 Lessons learned and recommendations ........................................................................... 50 5.1 Lessons learned ......................................................................................................................... 51 5.2 Recommendations .................................................................................................................... 55 Annexes..................................................................................................................................... 58 One: Provincial Rural Sanitation Behavior Change and Market Strengthening Strategy, Period 2015- 2020 for Hoa Binh province ..................................................................... Error! Bookmark not defined. Two: Capacity Building Strategy for Rural Sanitation Sector 2015-2020 and Orientation 2025 .... Error! Bookmark not defined. List of Figures Figure 1 National Sanitation Budget 2012-15 (USD) Figure 2 TA timeline and main activities Figure 3 Process to develop BCC campaigns Figure 4 National sanitation campaign logo Figure 5 The SANCON model Figure 6 Capacity Building Process for Health Staff Figure 7 Overview of Capacity Building Strategy for Rural Sanitation Figure 8 Mapping rural poverty and sanitation List of Tables Table 1 Estimates on the use of sanitation facilities in Vietnam, 1990-2015 Table 2 Combined Results Framework for enabling environment support (P132287), demand and supply side strengthening (P133773) Table 3 Communes with rural sanitation intervention in Hoa Binh under NTP3 2015 Table 4 Promotional drivers and messages. Table 5 SANCON profit in initial implementation period (from May to Dec 2015) Table 6 For adopters: Where did you get the money to build your toilet? Table 7 Hoa Binh NTP Sanitation Budget, 2012-15 Table 8 Personnel trained Table 9 Knowledge products developed under the TA Table 10 Comparison of Hoa Binh and Mekong Delta campaigns Table 11 Summary of TA impact to the rural sanitation sub-sector List of Boxes Box 1 Behavior change messages Box 2 Hoa Binh post-intervention assessment: topline findings and recommendations Box 3 Guideline for the Planning and Implementation of Rural Sanitation Programs (2014) Box 4 Capacity building needs assessment Abbreviations and Acronyms BCC Behavior Change Communication CPM Center for Preventive Medicine DANIDA Danish International Development Agency DFAT Department of Foreign Affairs and Trade (Australia) DFID Department for International Development (UK) IEC Information, Education and Communication JMP Joint Monitoring Program MARD Ministry of Agriculture and Rural Development MDG Millennium Development Goals M+E Monitoring and evaluation MOH Ministry of Health NTP National Target Program NVCARD North Vietnam College of Agriculture and Rural Development ODF Open Defecation-Free PCN Project Concept Note PforR Program for Results RWSS Rural water supply and sanitation TA Technical assistance UNICEF United Nations Children’s Fund VBSP Vietnam Bank for Social Policy VIHEMA Vietnam Health Management Agency WASH Water, Sanitation and Hygiene WSP Water and Sanitation Program (World Bank) Executive Summary Introduction This report concerns two streams of Technical Assistance provided by the World Bank Water and Sanitation Program (WSP) to help the Government of Vietnam scale up sanitation promotion in rural areas: 1. Strengthening the Enabling Environment, Capacity Building Systems and Evidence-Based Learning and Lesson Sharing (P132287) 2. Strengthening Demand Creation and Supply Chain Development (P133773) The Joint Monitoring Program (JMP) estimated that access to improved rural sanitation was 67% in 2012 when the TA was formulated but for the Government of Vietnam’s higher standard of ‘hygienic latrine’, it stood at just 55% in 2011. Furthermore, there were significant inequalities in access; JMP data showed that by 2011, 36% of the poorest quintile had access while for the richest quintile it was 99%. The framework WSP support was the third phase of the National Target Program for Rural Water Supply and Sanitation (NTP3). Under this programme, lead responsibility for rural sanitation and hygiene promotion lies with the Vietnam Health Environment Management Agency (VIHEMA) within the Ministry of Health (MOH). When NTP3 began, VIHEMA did not have a comprehensive approach for scaling up rural sanitation and therefore requested WSP support in delivering on their NTP3 commitments. Objectives and scope of the TA In order to scale up access, particularly among the hard-to-reach, it was critical to improve both the demand- and supply-side components of NTP3. When the TA began in 2013, an early priority was to conduct a situation analysis to clarify exactly where and how WSP could best add value to the sanitation sub-sector. Lessons learned from previous and ongoing interventions were documented and then applied via operational guidance and other capacity building support, while targeted research and piloting was undertaken to fill critical knowledge gaps. Among the various initiatives launched, research and piloting in Hoa Binh province was particularly significant as it generated much learning on both demand- and supply-side activities, and provided the basis for developing a range of guidelines, manuals and strategy documents. It was also a focal point of reference for supporting the design and strengthening of other World Bank programs. Results and Key Achievements These are structured around four Intermediate Outcomes: 1. Government strategy for NTP3 implementation is informed NTP3 was already designed and underway when the TA started, but WSP was able to influence operational strategy through dialogue with MOH and other key stakeholders at all levels. An initiative was to review the policy and legal framework for scaling up rural sanitation. This confirmed that existing arrangements were essentially sound, but were not understood well by government stakeholders, especially at sub-national level. Progress was further hampered by insufficient funding and the absence of mechanisms for prioritising support to locations most in need; a lack of political will; and inadequate operational guidance on how to use resources for effective software support. A related initiative was the production of maps cross-referencing access to sanitation with poverty. This prompted VIHEMA to rank and prioritise provinces for support under NTP3. The TA also supported a government-led advocacy initiative: introduction of an annual ‘Patriotic Sanitation Day’ and associated ‘Patriotic Sanitation Movement.’ High level government officers have participated in the event including (on one occasion) Vietnam’s Prime Minister. 2. Innovative approaches generated for demand generation and supply strengthening Demand generation. At sub-national level the focus of the TA has been on Hoa Binh province, in the north. Hoa Binh has a high ethnic minority population and many communities that are physically hard to reach, making it challenging to achieve the ‘last mile’ of sanitation access. In the nine selected pilot communes, baseline sanitation access was already very high (more than 90%), but most toilets were of a very poor quality - typically simple pit latrines without slabs. The key challenge was not so much ending open defecation as encouraging and enabling households to upgrade to a more hygienic toilet (as per VIHEMA definition). WSP contracted the NGOs SNV and CODESPA to conduct formative research and, based on the findings, develop a strategy and tools for behavior change communication (BCC) and supply chain (SC) strengthening that was affordable to government given the limited IEC budget available. Once the strategy and tools were ready, Hoa Binh government took responsibility for implementation, with technical support from WSP. The strategy promoted toilets not only on the basis of health benefits but also in terms of the privacy, status and convenience that they offer. Messages also tapped into the drivers that could motivate households to invest in latrines without the incentive of a hardware subsidy. Promotional activities included a series of communal events, each attended by hundreds of people from across the commune and included comedy, dance, songs and presentations. The TA also developed an evidence-based BCC strategy for the Mekong River Delta provinces where the use of fish pond and battlefield latrines is common (the latter discharge directly into the river). The campaign used disgust and concern for family well-being to challenge the acceptability of such toilets. Supply chain strengthening. In both Hoa Binh and Mekong, obstacles to the construction of hygienic latrines included limited awareness of low-cost options; the absence of suppliers who could offer both materials and skilled labor; a lack of information on costs, and a mistaken view that hygienic latrines were unaffordable; a perception among suppliers that sanitation offered little business potential; and limited access to hardware in remote and mountainous areas. The business model developed in response to these challenges is known as a Sanitation Convenience Shop or ‘SANCON’ and has the following features: 1. Suppliers’ sales agents offer information and advice to help customers choose an appropriate model. 2. All construction materials (sub-structure and superstructure) plus skilled labor for construction are included in a single ‘package’ price. 3. Some suppliers offer payment by instalment, with terms of typically three to six months. As of February 2016, ten SANCONS are in operation across two districts of Hoa Binh. Latrine design options In Hoa Binh, WSP worked with VIHEMA and a local consulting firm to develop new options including septic tanks and soakage pits made from prefabricated concrete rings. These can halve the cost of the latrine sub-structure, which would normally be made from brick (detail cost mentioned clearly in the catalogue of latrine options). They also save up to 80% of the construction cost, since installation is easy. Providers normally prefabricate the rings offsite, but on-site production using light molds is another option for remote locations. Another innovation was to use cement bricks instead of fired bricks, thereby reducing the cost of a latrine by around 25%. Further cost reductions were made by reducing the size of septic tanks. Additional options were developed for situations where the use of pits was not viable, for example floodplains and other places with a high water table, or locations with rocky or collapsing soil. All of the options developed are relatively simple, enabling households to participate in construction, helping to reduce costs. Each one features in a catalogue provided to each SANCON and sales agent. The TA explored a number of financing options for households including revolving funds operated by the Women’s Union; payment by instalment; and loans from the Vietnam Bank for Social Policy. In the event, the main sources of funding used were personal savings (80%) and VBSP loans (19%) (detail information is in session 4.2.2) Results of the Hoa Binh pilot While no hardware subsidies were offered, nearly 1,200 hygienic latrines were built in the nine pilot communes in 2015, an increase of 21% in coverage. SANCONS faced challenges, however, as they tended to promote only concrete ring systems for which there was low demand. Furthermore, government health staff had limited understanding of what they could and should do to help the SANCONS become viable businesses. Though the pilot was fairly small, it provided ‘proof of concept’ for the promotional strategy and tools and revealed that because the traditional brick-based septic tanks are preferred but more expensive, a more tailored marketing strategy is needed for the concrete ring option At a higher institutional level, WSP encouraged government decision makers to give sanitation higher priority and with WSP support, the Hoa Binh Department of Health adopted a new three-year plan with realistic targets that could potentially be met using available NTP3 funds. Furthermore, the provincial government used their resources differently; instead of funding hardware subsidies for demonstration toilets the budget was used for ‘soft‘ activities: behavior change communication, supply chain development and capacity building for staff. By 2014, more than 70% of the total provincial NTP3 budget was allocated for such activities, and in 2015 this rose to 100%, Replication through World Bank operations and other partners The TA developed a Rural Sanitation Behavior Change and Market Strengthening Strategy 2015-20 in the expectation that it could be adapted for use in other places in Vietnam with similar conditions. Lessons and outputs from Hoa Binh were in fact adopted by a number of World Bank projects: (i) Mekong Delta Water Resources Management for Rural Development Project The TA helped this project to align its sanitation component with NTP3, using lessons from Hoa Binh. Formative research informed the design of locally-appropriate tools and messages; project staff were then provided with, and trained, in the use of the BCC and SC strategy and associated tool kits. (ii) Result-based Scaling up Rural Sanitation and Water Supply in the Northern Mountains and Central Highlands Program (SupRSWS PforR). The TA supported the design of the sanitation component of the SupRSWS PforR, which will operate in rural areas of 21 provinces. The Hoa Binh model has been adapted for use by the program, especially for the Central Highlands region where culture, conditions and lifestyle are somewhat different. (iii) Second Northern Mountains Poverty Reduction Project (NMPRP-2) – Additional Financing and Central Highlands Poverty Reduction Project (CHPRP). The project targets some of the most isolated ethnic minorities in Vietnam. The TA is supporting the piloting of promotional interventions in selected locations with a focus on community-wide sanitation using a community-driven development approach. (iv) Rural Water Supply and Sanitation Project, Red River Delta (PforR): The TA indirectly contributed to the project where the Hoa Binh BCC toolkit was adapted for use in eight provinces of the PforR. 3. Increased government capacity to deliver the sanitation component of NTP3 Short term capacity building initiatives included: 1. Introduction, and adoption by VIHEMA, of the theory of change for scaling up rural sanitation (including enabling environment, demand creation and supply chain strengthening) developed by WSP at global level, based on experience from several countries. 2. Production of the Guideline for the Planning and Implementation of Rural Sanitation Programs, based largely on experience from Hoa Binh. This was a very significant output of the TA in 2014. 3. Development, and initial implementation of, a set of training packages for health staff at various levels, based on the Guideline and associated tools. 4. A number of south-south learning events for government partners including study tours to Thailand (2013) and Indonesia (2014) and learning exchanges between Hoa Binh and Kon Tum, in An Giang Province. WSP also enabled government officers and political leaders to attend regional events such as the EASAN Conference in Bali in 2011 and a regional sanitation learning event in Bangkok in 2012. For the longer term, the TA developed a Capacity Building Plan for Rural Sanitation Sector 2015-2020, which was formally adopted by VIHEMA in May 2015. Associated training packages were developed for managers and operational staff at all levels. Amongst other things, the curricula will be used under the SupRSWS PforR project in 21 provinces from April 2016 onwards. 4. Knowledge deepened on the enabling environment and programmatic approaches The many studies and reports produced under the TA have informed planning and resource allocation processes at national and sub-national levels and informed the design of ongoing and new lending operations. VIHEMA now recognise the importance of an enabling environment for scaling up sanitation and appreciate the importance of ending open defecation rather than just building toilets, though there is so far no formal recognition of ODF status. Lessons learned During the past three years much has been learned about challenges to scale up rural sanitation and the rather fundamental shift in mind-set required among policy makers, political leaders at provincial, district and even commune level, as well as among health system implementers. The environment in which such changes have happened and hence results were achieved, has benefited from intense technical support and hand-holding through this TA. The next generation of TA for Vietnam, given the at-scale Program-for-Results on rural sanitation, would have to leverage these lessons on how to best create buy-in of both high level decision makers, who need to approve and allocate funds in a different manner as in the past, and of government staff at the local level, who will need to apply new approaches on the ground. The real challenge is how in the next years this can be done in more provinces, with less intense external support, thus relying more on internal government mechanisms and platforms, harnessing and fostering a new generation of sanitation champions. To achieve sanitation results, both lessons on the operational and policy level are thus critical to not be lost while scaling up implementation. Fine tuning last mile delivery aspects is essential for achieving results on the ground - especially under a Program-for-Results – where government is in the driving seat to determine how they are going to deliver rural sanitations services. It is the operationalization of the rural service delivery approach - that emphasizes demand creation, supply chain strengthening and putting in place the capacities at local level using the Vietnamese government system - that will contribute to future success. At policy level, a number of critical dimensions in the enabling environment remain unaddressed, although some progress was made during the TA-period. Operational level Creating demand for rural sanitation 1. Using evidence-based sanitation behaviour change communications - not based on health motivators - requires intense effort to be accepted by national and senior provincial implementers 2. Adapting behaviour change communication toolkits for different regions is doable through rapid qualitative spot-research, but should not lead to short-cuts in field testing with target audiences 3. At-scale demand creation needs to elicit maximum household self-investments; the use of public funds needs to shift towards promotion and BCC, combined with smart incentives for the poor 4. Planning and budgeting support for demand creation is essential, adopting a multi-year timescale for campaigns and adequate support for capacity building. 5. Effective village-level delivery and commune leadership is critical for broad campaign outreach and social mobilization 6. Self-understanding of sanitation mandate may need clarification and articulation of district level role is required for more effective support to implementation of commune and village activities; Strengthening supply chain for rural sanitation 7. Role and practical tasks for government in facilitating the sanitation market needs to be clearly articulated and may need to be outsourced due to internal capacity constraints. 8. Newly introduced latrine options need to respond to perceived consumer benefits, be accompanied with aspirational marketing and limit the number of product options 9. The SANCON model has demonstrated potential, but requires modification especially for remote areas with dispersed villages and weakly developed supply chains. 10. Effective sales agents can be from various backgrounds and be recruited among existing local volunteer cadres; especially in remote areas these roles could be combined with village level sanitation promoter roles. Policy level 11. Strengthening government ownership and leadership is vital for progress in rural sanitation and advocacy activities are necessary down to the commune level 12. Government funding for sanitation and hygiene promotion remains inadequate and omits the financing of essential supply chain and promotion activities 13. Monitoring systems are inadequate; a simplification of the hygienic latrine definition would help to resolve some ambiguities. 14. Institutional capacity building could leverage the existence of regional MoH institutes rather than one-off ToT approaches at central level; in the medium term a financing approach is required, preferably combining national core funding for capacity development, with provincial allocations for training provinces and district implementers on a demand-basis. 15. A Strategic Guideline is also very important for management level Recommendations Given the phasing out of the National Target Program for Rural Water Supply and Sanitation, recommendations focus on potential new vehicles that could be used to address sanitation issues in the future. Several of the lessons learned articulated above are already reflected in the new multi-year TA that has been designed to strengthen the implementation of the Program for Results in 21 lagging provinces in the Northern Mountains and Central Highland regions. The below recommendations thus focus on complementary areas, where the Government of Vietnam, or in particular VIHEMA and provincial governments, would need to strengthen its policies or guidance. MoH / VIHEMA and provinces Effective strategies and tools that were developed and tested under the TA should be advocated for wider use in other districts and provinces – especially those where funding is already available under World Bank-assisted programs. But with NTP3 ending shortly, sanitation risks being marginalised both by government and development partners within the forthcoming ‘New Countryside Development’ NTP. Advocacy among senior policy makers at national level (right up to the Prime Minister) should be intensified to further raise the profile of sanitation on the national development agenda and secure increased funding. Once the contours of the new Country Side Development are more clearly articulated, it will be important for VIHEMA to establish: ï‚· A templated advocacy package for provincial governments, not just regarding the need to invest in sanitation, but also with clear guidance on how to spend differently on sanitation so that limited funds can be used more effectively as under NTP3. ï‚· Dedicated national sanitation planning and budget exercises, emphasizing demand generation, supply chain support and capacity building and monitoring. ï‚· A revised costing circular that recognizes and allows all necessary elements of the rural sanitation service delivery approach to be financed through provincial funds, including support to the supply chain, BCC community events for sanitation, rewards incentives for sanitation promoters and ways to deliver smarter partial subsidies to the poor. ï‚· A clearer articulation of roles and responsibilities of various levels, especially a more pronounced role for district government’s roles in sanitation service delivery, and strengthen the facilitation role of health workers. ï‚· An institutionalized capacity building strategy and action plan, including a financing strategy, and business plans for MoH regional institutes to cover core curriculum for sanitation; this action plan could also include the introduction of online courses to expand access to training for health workers in order to achieve efficiency gains. ï‚· A policy guideline for achieving commune total sanitation status, especially as efforts to enact Open Defecation Free guidelines have not yet materialized, and process to track progress in provinces. ï‚· Guidance document that articulates how other service delivery platform for rural development, such as under the New Country Site development (but also under existing Community-Driven Development projects financed by the World Bank) can be leveraged to introduce sanitation promotion and local business straining for sanitation, making optimal use of existing human resources, financing mechanism, and capabilities at village and commune level of such platforms. ï‚· A closer collaboration with the Ministry of Education for promoting better sanitation in schools. ï‚· More effective and accurate monitoring functions for rural sanitation. The issue of ambiguous and inaccurate monitoring for sanitation usage has remained unresolved over the past years and needs to be carefully looked at based on the M&E initiative under the Red River Delta PforR. ï‚· Assessment of the current septage management for promoting and developing guidance on proper septage collection and treatment. World Bank/WSP Future support from the Water Practice will be directed to support implementation of the PforR in 21 lagging provinces in the Northern Mountains and Central Highlands, and already includes specific support for advocacy, BCC campaign development and implementation, market facilitation support and capacity building. In addition to the ongoing program, the following three recommendations for future TA are provided that would help to sustain, deepen and further scale the results to support the achievement of the SDGs i. Support the development of a financing plan for institutionalizing capacity development under the Capacity Development Strategy and Action plan, in a post-NTP3 environment (and potential on-line course content) ii. Given the investments in the adaptation of the toolkit for the Mekong Delta, and the institutional limitations of the World Bank Water Resources for Rural Development project (WB6) to fully adopt the toolkit and rural sanitations service delivery approach at scale, a future TA program for the strategic Mekong delta could be explored, aligned with a relevant WB operation. Of all the households in Vietnam that do not have hygienic latrines, more than half live in the delta, where climate change and pollution are having an increasingly negative effect on socio-economic development and public health. iii. Strengthen the monitoring and evaluation system. Given the considerable investments of the government in external auditing functions for sanitation verification under the ongoing PforRs, additional TA could further explore how administrative systems could routinely be strengthened, including third party verification. This TA would have to further build on the results of DFAT TA to Red River Delta, which already aimed to improve systematic M&E functions of the government./. 1 Introduction This report concerns two streams of Technical Assistance provided by the World Bank Water and Sanitation Program (WSP) to the Government of Vietnam. They are: 3. Strengthening the Enabling Environment, Capacity Building Systems and Evidence-Based Learning and Lesson Sharing (P132287) 4. Strengthening Demand Creation and Supply Chain Development (P133773) Together these TAs make up a support program to assist the Government of Vietnam, particularly the Ministry of Health (MOH) in accelerating progress on sanitation under the third National Target Program on Rural Water Supply and Sanitation (NTP3). WSP has supported the government to improve the enabling environment for sanitation service delivery; strengthen rural sanitation supply chains; generate demand for improved sanitation; and inform service delivery models through knowledge and learning. The TAs began in Dec 2012 and are due to end in Jun 2016. This report documents the results and lessons learned from the TA, and makes recommendations for future activities in support of rural sanitation. 2 Background 2.1 WASH sector context Vietnam met the Millennium Development Goal (MDG) target for rural water supply some years ago. While the sanitation target has also been met (see section 2.3), rural sanitation and hygiene promotion have made slower progress and until recently received much less attention in government programs. The Joint Monitoring Program (JMP) estimated that access to improved rural sanitation was 67% in 2012 when the TA was formulated but for the Government of Vietnam’s higher standard of ‘hygienic latrine’, it stood at just 55% in 2011. Furthermore, there were significant inequalities in access; JMP data showed that by 2011, 36% of the poorest quintile had access while for the richest quintile it was 99%. The National Target Program for Rural Water Supply and Sanitation (NTP) is the government’s primary instrument for implementing Vietnam’s rural water supply and sanitation (RWSS) Strategy to 2020. NTP had a first phase from 2000 to 2005 (NTP1) and a second phase from 2006 to 2011 (NTP2). Though largely responsible for rural water supply coverage increases over that period, NTP1 and NTP2 did not devote sufficient attention and funding to household sanitation. Furthermore, while MOH was officially responsible for rural sanitation promotion, in practice it played only a supporting role. In 2012, NTP entered its third phase (2012-15). Like its predecessor, NTP3 involved a number of ministries under the overall leadership of the Ministry of Agriculture and Rural Development (MARD). In a departure from the previous phase, however, it was divided into three discrete sub- projects: Project 1: Rural Domestic Water Supply and Environment Project 2: Rural Sanitation Project 3: Capacity building; communication and supervision; monitoring and evaluation. The establishment of a dedicated sanitation project was designed to ensure that this subject received greater attention than it had before, under the leadership of MOH. MARD remained the designated lead agency for Project 3, however, which covered all recurrent, non-investment activities including monitoring and evaluation, capacity building and communication. Good co-ordination between the health and agriculture sectors was therefore essential. 2.2 Rationale for the TAs The promotion of household sanitation under NTP2 had been undermined by constraints both in terms of the policy and institutional framework and operational approaches. Critical challenges included the following: ï‚· heavy reliance on a traditional Information, Education and Communication (IEC) approach and the use of hardware subsidies without accompanying measures to target the poorest households; ï‚· a lack of systems and resources for capacity building in sanitation, at scale; ï‚· latrine subsidies, and loans via the Vietnam Bank for Social Policy (VBSP), tended to benefit better off households who could afford higher end facilities that met strict government standards1 as there was no pro-poor focus to program support; ï‚· a nationwide RWSS monitoring system was in place but was inadequate for sanitation and hygiene, with a lack of disaggregation to show poor and vulnerable households or latrine type, and no monitoring of ODF status or latrine use after construction; and ï‚· learning and knowledge sharing on sanitation was patchy, with most projects inadequately evaluated and documented. The focal government partner for the TAs was the Vietnam Health Environment Management Agency (VIHEMA) within MOH. VIHEMA has lead responsibility for sanitation and hygiene promotion at national level and provides direction to sub-national offices responsible for health: the provincial and district Centers for Preventive Medicine (pCPM and dCPM). These in turn oversee Commune Health Stations, which are the key operational unit for health extension work. When NTP3 began, government health agencies did not have a comprehensive approach for scaling up rural sanitation. VIHEMA therefore requested WSP support in delivering on their NTP3 commitments. Beyond government, smaller pilots, often supported by international NGOs, tended to be more progressive in their approaches to sanitation promotion but lacked viable strategies or resources for going to scale sustainably. Much the same applied to NGO-led initiatives to strengthen the supply of affordable sanitation products and services, especially in remote and flood-prone areas. 2.3 Sector developments since 2011 The sector has not been static since 2011 and the TAs have been responsive to changes that have occurred over the last four years. One of these concerns the sector funding landscape. In recent years Vietnam has undergone a transition from low- to middle-income status and, recognising this, a number of bilateral donors to the WASH sector, including DANIDA, DFAT and DFID, have ended or scaled down their financial and technical support. World Bank operations have, however, expanded and over the course of NTP3 the Program for Results (PforR) was initiated in the Red River Delta while a second PforR program has been approved for the Northern and Central Highlands regions. The Bank also supports a number of poverty reduction programs that can potentially address WASH components2. These programs have benefitted from innovations and lessons learned from the TAs, and some have received direct assistance from the TAs on operational approaches. Meanwhile, government funding for sanitation increased from 2012-2014 for both hardware and ‘soft’ (promotional) activities, dropping only in 2015, the final year of implementation due to the recent Government decision of reduction of public expenditure, especially operational cost; see Table 1. 1 Folkard, A., and Thanh, V. 2009. Financing Household Water and Sanitation: Study on Water and Sanitation lending of the Vietnam Bank for Social Policy in support of National Target Program No.2. Report prepared for the Danish Embassy to Vietnam and the Vietnam Bank for Social Policy. 2 Northern Mountains Poverty Reduction Program Phase Two – Additional Financing, and the Central Highlands Poverty Reduction Project Figure 1. National Sanitation Budget 2012-15 (USD) 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2012 2013 2014 2015 Hardware Subsidies Promotional Activities Total Source: VIHEMA NTP3 implementation report, January 2016 Access to sanitation nationwide has increased over the course of NTP3; see Table 1. It is estimated that just over two-thirds of the rural population now use improved sanitation as per the JMP definition, while open defecation has dropped to just 1%. Access to unimproved sanitation stands at 29% in rural areas. Table 1: Estimates on the use of sanitation facilities in Vietnam, 1990-2015 RURAL SANITATION Estimated coverage 2015 update Other Open Year Improved Shared unimproved defecation 1990 29% 2% 26% 43% 1995 37% 2% 27% 34% 2000 45% 3% 27% 25% 2005 53% 3% 28% 16% 2010 62% 4% 27% 7% 2015 70% 4% 25% 1% TOTAL (RURAL AND URBAN) SANITATION Estimated coverage 2015 update Other Open Year Improved Shared unimproved defecation 1990 36% 2% 23% 39% 1995 45% 3% 22% 30% 2000 53% 3% 23% 21% 2005 61% 4% 22% 13% 2010 70% 4% 21% 5% 2015 78% 5% 16% 1% Source: JMP 2015 The Government of Vietnam measures access based on its own standard of a ‘hygienic’ latrine and the NTP3 target for 2015 of 65% is reported as met (having reached 64% by June of that year). While this is encouraging, there are still many provinces that have not yet met the target. Examples include Ha Giang, Lai Chau, Son La and Dien Bien in the Northern Mountain Region, where access to hygienic latrines is reported to be below 40%; and many locations in the Central Highland and Mekong River Delta Regions have also not met the target.3 Furthermore, the Government of Vietnam has adopted a new vision, to achieve nationwide Open Defecation Free (ODF) status by 2025 and 100% access to hygienic latrines by 2030. The ODF verification process is now being piloted, including a different definition and higher-level criteria: 100% of households having a latrine, and at least 70% of households having a hygienic latrine. MOH will need to consolidate and expand sanitation promotion at scale if these targets are to be achieved. It should be noted here that there will be no NTP4 for rural WASH; government is in the process of merging its 16 current NTPs and for period of 2016-2020 there will be only two: New Rural Development and Sustainable Poverty Reduction. Sanitation and hygiene will be a component of the former. 3 Objectives of the TA In 2013 WSP began implementing a multi-year program of capacity building support to government entitled ‘Scaling up Rural Sanitation in Vietnam’. The TA aims to strengthen government capacity for scaling up sanitation promotion within and beyond NTP3, with a particular focus on poor households in low access areas.4 The support was structured as two TAs with the following development objectives: 1. To improve the implementation capacity of the government’s NTP3 through strengthening policy and regulation, developing the capacity of implementing agencies, lesson learning and sharing (P132287). 2. To strengthen the implementation capacity of the Government’s NTP3 to include more effective demand generation for sanitation, as well as supply chain development in hard-to-reach areas with low sanitation access (P133773). The TAs were designed to apply to the Vietnamese rural sanitation context the theory of change for rural sanitation developed and implemented by governments with WSP support in a total of 16 countries including Indonesia and other East Asian countries; India; Tanzania; and Ethiopia. 3.1 Implementation approach WSP activity under these two TAs has been guided by the following principles: ï‚· to work with, and add value to, government systems and, in the process strengthen government ownership of efforts to scale up sanitation and hygiene promotion; ï‚· to focus on technical and upstream support rather than direct implementation since a funded national program is already in place; and ï‚· to undertake focused pieces of research, training and piloting to address specific priority needs in the sub-sector. In addition, the TAs operated in a way that was complementary to other World Bank initiatives and to the work of other development partners, so as to avoid the duplication of efforts. In 2012, World Bank had not yet introduced the Programmatic Approach instrument for TA, hence two complementary, but separate, TAs were adopted to address these two objectives. There were inevitably 3 Due to inconsistent application of a very comprehensive set of criteria, , actual data from baseline surveys of the TA and the Bank-funded project (Red River Delta PforR) shows much lower percentage in comparison with the reported data. 4 WSP Vietnam. 2012. Scaling Up Rural Sanitation in Vietnam: Project Implementation Plan, FY13-FY17 areas of overlap between the two streams of work and for this reason the results frameworks for the TAs have been merged in Table 3. The sequencing of activity under the two TAs is represented in Figure 1. To scale up sanitation access, particularly among the hard-to-reach, it was critical to improve both the demand- and supply-side components of NTP3. When the TA was designed there had not been a systematic attempt to learn from the experiences of earlier projects and initiatives in sanitation promotion, to inform the implementation of NTP3. An early priority, therefore, was to conduct a situation analysis to review both the policy and legal framework for rural sanitation and the operational approaches and tools for sanitation promotion and the supply of goods and services that had been used in recent years. This helped to clarify exactly where and how WSP could best add value to the sanitation sub-sector. Lessons learned from previous and ongoing interventions were documented and then applied via operational guidance and other capacity building support, while targeted research and piloting was undertaken to fill critical knowledge gaps. Table 7 summarises the key studies and other knowledge products produced under the TA. Figure 2. TA timeline and main activities • Situation analysis • Review policy and legal framework • Review BCC materials used to date • Review of supply chain studies • Review programmatic approaches to sanitation used in Vietnam • Advocacy 2013 • Introduce Theory of Change for sanitation promotion at scale • Support sanitation events at national and provinvial level (Hoa Binh) • Develop guidelines for Patriotic Sanitation Movement • Research and piloting of demand- and supply-side interventions • Begin work in pilot province, Hoa Binh • Advocacy • Support sanitation events and dialogue in Hoa Binh • Support in identifing post 2015 agenda • Capacity building • Develop guidelines on rural sanitation planning and implementation • Capacity needs assessment in all eight regions in Vietnam 2014 • Develop national capacity building strategy and action plan for rural sanitation • Research and piloting of demand- and supply-side interventions • Produce Hoa Binh strategy, implementation plan and toolkit • Undertake formative research in Mekong region, support WB6 sanitation component • Capacity building • Finalise training modules for incorporation into health sector curricula • Research and piloting of demand- and supply-side interventions • Implement Hoa Binh BCC strategy and toolkit • Rapid assement of Hoa Binh results • Support to other sanitation programs 2015 • Finalize BCC and SC strategy and tools for Mekong, support WB6's sanitation component • Support design of sanitation component of new PforR program • Support incorporation of sanitation component into World Bank CDD programs Among the various initiatives launched, the research and piloting in Hoa Binh was particularly significant as it generated a considerable amount of learning on both demand- and supply-side activities, and provided the basis for developing a range of guidelines, manuals and strategy documents. It was also a focal point of reference for supporting the design and strengthening of other World Bank programs, as explained in the following sections. The TA built upon, and in some cases developed, strategic partnerships with key sector players at national and sub-national level. At national level, partnership with VIHEMA (MOH), UNICEF and Plan International helped to revitalise the existing Sanitation Technical Working Group, which has become a useful forum for sub-sector policy debate and lesson sharing. At operational level, WSP contracted the NGOs SNV and CODESPA to design a comprehensive toolkit for demand creation and supply chain strengthening in Hoa Binh, and later to adapt the toolkit for use in the Mekong delta. WSP also collaborated informally with the NGOs Child Fund and World Vision on training, workshops and the sharing of promotional materials. They also entered into a contractual agreement with the North Vietnam College of Agriculture and Rural Development (NVCARD) for capacity building activities. Apart from this, many STCs were hired for specific tasks, including field-based support to the application of newly designed approaches and tools. Table 2: Combined Results Framework for enabling environment support (P132287), demand and supply side strengthening (P133773) Intermediate Indicator(s) Results Outcome(s) Government Achieved strategy for NTP3 ï‚· By 2013, policy note has been ï‚· In lieu of a policy note, a review was carried out of implementation developed to inform government the policy and legal framework for scaling up rural is informed targeting process to improve equity sanitation. This plus sanitation–poverty mapping focus of NTP3 implementation for (see below) were used in dialogue with VIHEMA areas with low sanitation access to prioritise provinces for support under NTP3 and then over the period 2015-2020. ï‚· A guidance note on the ‘Patriotic Sanitation Movement’ (which involves an annual sanitation day) prepared with WSP support and disseminated to all line ministries and provinces. ï‚· The movement provides the basis for government agencies at all levels to make plans and allocate resources for sanitation promotion. Innovative Achieved approaches and ï‚· By 2014, evidence-based behavior ï‚· Innovative BCC strategy developed and solutions for change communication strategy implemented with WSP support in a rural area demand developed, with focus on selected with very low access: Hoa Binh (typical of the generation and low access areas Northern Mountain Region). Promotional supply messages aim to trigger an emotional response strengthening from the target audience, not just to provide generated information. Community events aim to stimulate a sanitation movement in the commune. ï‚· The promotional tools is being also adapted for use in the Result-based Scaling up Rural Sanitation and Water Supply in the Northern Mountains and Central Highlands Program (SupRSWS PforR). ï‚· The approach was adapted for the Mekong Region. In this case visual materials stimulated disgust and embarrassment at the problems caused by poor sanitation. The strategy is now being applied in eight provinces under the Intermediate Indicator(s) Results Outcome(s) Mekong Water Resources for Rural Development Project (WB6). ï‚· Sanitation promotion has also been integrated into other initiatives such as the World Bank poverty reduction projects. Achieved ï‚· By 2014, business models for ï‚· The ‘Convenience Shop’ business model for affordable and marketable sanitation promoting and supplying hygienic toilets was products and services for selected, developed in Hoa Binh and included in the challenging, low-access areas provincial strategy. developed ï‚· The same approach is being adopted under new World Bank ‘Scaling Up Rural Water supply and Sanitation’ program in 21 provinces ï‚· A modified model has been developed for the Mekong Region and is being used in seven provinces under the Mekong Water Resources for Rural Development Project (WB6). ï‚· New financial options introduced including payment by instalments to the “Convenience Shopâ€? ï‚· Technological innovations included concrete rings and cement bricks to reduce costs and ensure quality; plastic septic tanks for flood-prone areas; and plastic rings for pit lining in remote mountainous areas. Government Achieved capacity to ï‚· By 2013, guidelines and tools have ï‚· Guideline for the Planning and Implementation of deliver sanitation been developed for provincial level Sanitation Programs produced in 2013 and issued component under planning, programming, coordination by VIHEMA to all 63 provinces for NTP3 has been and monitoring of sanitation implementation. Associated training to nearly 100 increased key and senior health staff was provided in early 2014. ï‚· Manuals and BCC and supply chain toolkits for Rural Sanitation Behavior Change and Market Strengthening 2015-20 developed and implemented in Hoa Binh Province. Approximately 1,100 health staff and motivators trained on implementation in Hoa Binh. ï‚· Manual and toolkits also developed for Mekong Region. Training provided for more than 50 senior health staff and Women’s Union members in Mekong and WB6 project. ï‚· Manual and toolkits developed for integration of human and animal waste management into the Second Northern Mountains Poverty Reduction Project (NMPRP-2) – Additional Financing Achieved ï‚· By 2013, VIHEMA has adopted a ï‚· Rural Sanitation Sector Capacity Assessment capacity building plan based on a Report completed in 2014. Based on the findings needs assessment. a Capacity Building Strategy 2015-2020 developed and endorsed by VIHEMA in 2015. Intermediate Indicator(s) Results Outcome(s) Achieved ï‚· By June 2015, behavior change ï‚· Six training curricula developed in collaboration communication and supply chain with MOH for implementation of the national development have been integrated in capacity building strategy. Amongst other things national at-scale capacity building they will be used in the new PforR project (21 program. provinces) from April 2016 onwards. Not achieved ï‚· By 2014, a performance ï‚· Not done, to avoid duplication - similar work was benchmarking system is being due to be carried out under TA for the World developed in selected provinces, Bank-supported PforR Program. based on an improved sector M&E system. Knowledge Achieved deepened on ï‚· By 2013, equity analysis of rural ï‚· Poverty and sanitation map developed and strengthening sanitation access completed and disseminated; see the enabling widely disseminated ï‚· http://sdvmd1.worldbank.org/climateportal/util/ environment for global_map.html rural sanitation and programmatic approaches for hard to reach areas. Achieved ï‚· By 2013, systematic evaluation of ï‚· Two relevant studies completed in 2013: different demand creation Qualitative Assessment of Programmatic approaches disseminated, and gaps Approaches to Sanitation in Vietnam; and for further research identified Behavioral Determinants of Sanitation and Handwashing with Soap in Vietnam: a Review of Current Studies and Behavior Change Communication Materials since 2006. ï‚· Two formative research studies carried out: Report on Sanitation Consumer Demand and Supply Chain Assessment for the Rural Sanitation in Hoa Binh Province (2013); and Sanitation Consumer Demand and Supply Chain Assessment for the Rural Sanitation Mekong River Delta (2014). Achieved ï‚· By 2013, assessment of sanitation ï‚· Review of current studies on Rural Sanitation products and supply chain Supply Chain in Vietnam produced in May 2013 disseminated, and gaps for further ï‚· Sanitation Consumer Demand and Supply Chain research identified Assessments carried out for Hoa Binh Province and Mekong Region to identify gaps in the sanitation market and potential business models. ï‚· Support also provided to the assessment for the Result-based Scaling up Rural Sanitation and Water Supply in the Northern Mountains and Central Highlands Program (SupRSWS PforR). Intermediate Indicator(s) Results Outcome(s) Achieved ï‚· Emerging learning on enabling ï‚· Technical support provided in 2015 to environment (M&E, capacity implementation of Hoa Binh pilot (nine development at scale, institutional communes) which provided practical experience arrangements etc.) documented and and lessons in scaling up disseminated ï‚· Range of knowledge products produced, for example ‘Investing in the Next Generation: Children grow taller, and smarter, in rural, mountainous villages of Vietnam where community members use improved sanitation’ (Research Brief). Field Note also under development on the process by which relevant BCC campaigns and supply chain models were developed for the three most difficult areas in Vietnam: Northern Mountain, Central Highland and Mekong Regions. ï‚· A number of relevant products from other WSP initiatives in Vietnam and beyond were translated and disseminated, for example on sanitation marketing. Not achieved ï‚· By 2014, evaluation of effectiveness ï‚· Due to methodological challenges and the of NTP3 subsidy completed sensitive nature of the issue, this could not be done. Instead, VIHEMA and WSP conducted an evaluation in 2015 of the intervention in Hoa Binh, where efforts focussed on BCC and supply chain strengthening without hardware subsidies. Report due January 2016. Achieved ï‚· Exchange of best practices facilitated ï‚· Inter-province exposure visits (An Giang, Daklak, through regular peer learning with Hoa Binh) provided for about 100 provincial government and other development officers in collaboration with development partners12 agencies (for example UNICEF, PLAN International). ï‚· 50 key senior officers from Central and Provincial agencies facilitated to attend international advocacy and regional learning events including study tours to Indonesia and Thailand. ï‚· More regular meetings of Sanitation Working Group chaired by VIHEMA supplemented by learning events with visitors from other countries. 4 Results and Key Achievements This section provides some further detail on the achievements of the TA in delivering the Intermediate Outcomes as summarised in Table 2. 4.1 Government strategy for NTP3 implementation is informed When the TA started, a number of NTP3 decrees had already been issued and there was limited scope to influence the design of the national program. Informally however, WSP provided substantial technical assistance and training to strengthen program implementation, and through its dialogue with MOH had significant influence on operational strategy as explained in 4.3 below. The PCN envisaged that a policy note would be produced to inform the targeting of government resources, with a view to improving equity, specifically to ensure that NTP3 prioritised support to under- served and hard to reach locations. This task was approached slightly differently and in lieu of a policy note, a review was carried out of the policy and legal framework for scaling up rural sanitation. This confirmed that existing arrangements were essentially sound, but were not properly understood by government stakeholders, especially at the provincial and lower levels. Progress in rural sanitation was further hampered by insufficient funding and the absence of mechanisms for prioritising support to locations most in need; a lack of political will; and inadequate operational guidance on how to use resources for effective software support. This resulted in many provinces simply using NTP funds for hardware, building so-called ‘demonstration’ latrines scattered across districts and communes, without a coherent strategy to encourage household investments. A related initiative was production of poverty and sanitation maps; see below. Based on the review findings and the mapping exercises, VIHEMA ranked and prioritised provinces for support under NTP3. The TA also supported new government initiatives to raise the profile of sanitation nationwide including the introduction of a ‘Patriotic Sanitation Day’ (July 2nd) and associated ‘Patriotic Sanitation Movement’ with high level Government officers participating including Vietnam’s Prime Minister. WSP helped MOH to develop a Directive encouraging health sector agencies to participate in sanitation day, plus a guideline advising them on what to do, thereby helping to establishing a formal platform for activity planning and implementation. The day was successfully celebrated in 2014 and 2015 with much publicity both in national and local newspapers. 4.2 Innovative approaches generated for demand generation and supply strengthening 4.2.1 Demand generation At sub-national level the focus of the TA has been on Hoa Binh province, in the north, where operational research and piloting facilitated by the NGOs SNV and CODESPA in 2014 led to the development of the Provincial Rural Sanitation, Behavior Change and Market Strengthening Strategy 2014-20, plus associated manual and guideline. Hoa Binh was selected as it is typical representative for the Northern Mountainous Region, a poor province and characterised by having a high ethnic minority population and communities that are physically hard to reach, making it challenging to increase of sanitation access. Hoa Binh has a population of 820,400 and 195,809 households. Of this total, roughly 83% of the population lives in rural areas. The province is divided into 1 city and 10 districts, with a total of 214 communes, wards and towns. Agriculture is the principle source of income. As of December 2011, the per capita income was about 730 USD (15,300,000 VND to 1 USD). Roughly 37% of the households are poor and near poor (Action plan in 2014 – Sanitation component, Hoa Binh PPC – NTP3). Figure 1 Map of Hoa Binh province with hygienic latrine coverage situation (2013 data) There are six ethnic groups inhabiting the province. The Muong is the major ethnic group (61.8%) followed by the Kinh (28.7%), Thai (4.04%); Dao (1.8%); Tay (3.2%) and Mong (0.4%). Hoa Binh’s terrain characterizes for being mountainous, with two different sub-regions: the northwest of the province, which is highly mountainous, between 600-700 meters above sea level, and the southeast region is less mountainous, with an elevation of between 100 - 200 meters. Despite being a mountainous province, Hoa Binh’s population density is high, about 171 persons/ km2 (2009), although there are big variations in population densities between urban and rural areas and between the low and up land. The provincial rate for hygienic latrine coverage is much lower at 44% when compared to the national average of 60% (2013 data). There are also considerable variations in hygienic coverage between rural districts, ranging from 26.1% to 55.1% with the lowest hygienic coverage in Mai Chau district. Almost households has a very poor quality, however, meeting neither the JMP improved standard nor government criteria for ‘hygienic’ facilities; typically they were simple pit latrines without slabs. WSP contracted SNV and CODESPA to conduct formative research in Hoa Binh, included observations of 801 household revealed substantially lower hygienic latrine rates (7.5% of all surveyed households compared to 44% of the official data average), mainly due to many deficiencies observed in latrine construction as well as with use and maintenance, with most latrines not complying with the MoH criteria on hygienic latrines (criteria for hygienic latrines include both standards of construction similar to the JMP criteria for improved latrines but also include use and maintenance) . These results suggest that the actual hygienic coverage could be lower than the official data. Based on the findings, develop a strategy and tools for behavior change communication and supply chain strengthening. The process to develop the BCC strategy followed 6 steps (see Figure 3). The first step was formative research as detailed above. The second was to distil key research findings and, based on that, develop a creative brief (a document that defines the parameters for the BCC campaign) – this was used to help ensure that stakeholders and the advertising agency hired to develop the campaign shared the same vision for the campaign. Based on the brief, several creative ideas were developed and underwent multiples rounds of pretesting (step 4). Multimedia, print materials and interpersonal communication (IPC) tools were then developed for use by outreach workers (step 5). The IPC tools were tested with outreach workers to ensure that they were easy to understand and apply in the field (step 6). Feedback from stakeholders, particularly the Ministry of Health, was obtained throughout. Figure 3. Process to develop BCC campaigns 4. Pre-test 5. Develop 1. Audience 2. Creative 3. Concept 6. Pretest 7. Finalize concepts, Strategy,tool research Brief ideation IPC tools materials messages ,materials Stakeholder feedback The output included a campaign concept along with materials, messages and other IPC tools for outreach workers. Research revealed that interpersonal communication was the most effective channel of communication for these communities, so all of the tools were designed for use at village or household level. Both basic and extended packages were developed: Basic package: this included guidelines for both village and household level meetings including messages for broadcast by loudspeaker and display on banners. This package was designed for provinces with limited IEC budgets. Extended package: this had additional guidelines for ‘Clean Games’ events, outdoor media including mural paintings, newspaper articles and suggestions for broadcast media. The extended package was developed for provinces with more funding for promotional activities. Once the strategy and tools were ready, Hoa Binh government took responsibility for implementation under NTP3 budget, with technical support from WSP. The focal operational unit was the Commune Health Station, which has its own staff (but only one staff responsible for rural sanitation activities) and also supports a network of village health promoters (typically one per village) who have basic health training and receive a small stipend. Table 3: Communes with Rural Sanitation Intervention in Hoa Binh under NTP3 2015 District Selected commune Total HHs Total villages Chiá»?ng Châu 867 6 Ä?ồngBảng 360 6 Mai Châu Bao La 559 7 Tân Mai 337 6 Sum 25 BìnhSÆ¡n 624 5 SàoBáy 930 9 Nam Thượng 1098 7 Kim Bôi ThượngBì 537 5 VÄ©nhTiến 1575 17 Sum 43 Total 9 68 The strategy promoted toilets not only on the basis of their health benefits but also in terms of the privacy, status and convenience that they offer. In addition, communication messages were designed not just to deliver information but also to tap into the emotional, social and physical drivers that can motivate households to invest in latrines without the incentive of a hardware subsidy; see Box 1. Box 1. Behavior change messages Promotional messages were developed at multiple levels for three target audiences: A. Benefits for the community ï‚· Do you want to feel proud of your village? ï‚· Act for solidarity ï‚· Make your community a better place to live B. Benefits for the family ï‚· Do you want your children to be healthier and taller? ï‚· More comfort for your family ï‚· Choose a modern lifestyle C. The benefit of gaining respect ï‚· Do your guests feel comfortable at your house? ï‚· Be a better neighbor ï‚· Be a pioneer, be a bright example A national sanitation campaign logo (see below) was also developed and the colour green used for all printed materials to provide consistency and unity to the campaign. The logo and associated tagline were selected through three rounds of testing with a focus group of some 100 people including potential service users, relevant partners (all levels) and health workers. The logo was designed to convey a sense of freshness (no latrine odor), cleanliness, comfort and durability - attributes that encourage latrine construction. Figure 4. National sanitation campaign logo “Chung tay vì làng quê sạch đẹpâ€? “Join hands for a clean and beautiful villageâ€? A further significant output from this part of the TA was a set of eye-catching posters highlighting the benefits of hygienic latrines at both individual and community levels. The underlying principle for design of the posters was ‘show, don’t tell’, and each one presented situations with which the audience could identify with. They were designed both as a visual aid for village health workers to use in village meetings and as standalone posters for display in public places such as health stations, schools and other community buildings. Examples of promotional posters Communication activities were designed so that the health workers could implement them. The basic package included familiar activities such as village/group meetings and household visits, but with the addition of well-crafted visual tools to make these activities more interesting to the households. Another powerful tool was village mapping, whereby households with hygienic or unhygienic latrines were identified in different colours; this encouraged peer pressure for people to reach the same level as their neighbours. Village sanitation maps Village meetings are enlivened by the use of engaging Attractive murals help to give the campaign visibility and visual materials a positive image Promotional activities at commune and provincial level included participatory events with a sanitation focus. Commune Chairmen and senior officers played a lead role in such events which were typically attended by 500 – 700 people from all villages in the commune. The program would include promotional messages and information, comedy, dance, songs and presentations. They were also an opportunity for Sanitation Convenience Store (SANCON) operators to showcase their products and services. An event could be staged for less than $1,000. Commune sanitation events BCC campaign for the Mekong Region The TA also developed an evidence-based BCC strategy for the Mekong River Delta provinces where the use of fish pond and battlefield latrines is common. (The latter have a concrete superstructure but discharge directly into the river). A campaign similar to the one in Hoa Binh was developed, but with some adaptations responding to specific drivers and barriers identified there. Drivers included, for example, the fear that children or elderly people could fall from fishpond latrines, and distress (particularly for women) at being seen by others when using it; increasing pressure to build a hygienic latrine when neighbours have one; and the desire to comply with rules and regulations. Barriers, meanwhile, included beliefs that fish raised in fishpond latrines were tastier; that swimming in a river contaminated with human faeces is safe because the water washes the faeces away; and long standing social norms that make battlefield latrines and fishpond latrines, in particular, acceptable. The campaign was designed to counter these misconceptions. Based on the theme ‘it’s not what you think it is,’ the campaign used disgust and concern for family well-being to dispel beliefs about the acceptability of unhygienic toilets. Pretesting among rural households revealed that strong, realistic pictures had the highest impact on audiences. The visuals also reminded households of the regulation banning fishpond latrines. Table 3 presents a few of the messages adopted. The full set of materials can be found at www.wsp.org Table 4. Promotional drivers and messages. Driver Key message Belief that fishpond fish are safe to Don’t feed your children fish bred in ponds conta minated eat with feces, it’s disgusting and they might get diseases. The government has banned fishpond latrines. Fear that children and the elderly will Don’t put the elderly and children at risk. They can fall in fall into fishpond latrines and be injured or drown. Good neighbour Be a good example and a good neighbour. Help each other to build a hygienic latrine now The logo adopted was the same as in Hoa Binh but with a new tagline, which was ‘Have a hygienic latrine for your family’s peace of mind.’ (Nha tieu hop ve sinh, an tam cho gia dinh). In contrast to Hoa Binh, which adopted an encouraging, aspirational tone, the Mekong campaign uses simple, sharp messages to get people’s attention then uses positive messages to promote the benefits of latrines. The posters depict realistic situations in front of fishpond latrines whereas in Hoa Binh latrines are shown in campaign posters. Examples of posters developed for the Mekong Delta 4.2.2 Supply chain strengthening In both Hoa Binh and Mekong, common obstacles to the construction and use of hygienic latrines included the following: ï‚· Limited awareness of low-cost technology options among masons and sanitation businesses. Most masons had not received any formal training. ï‚· The need to buy materials and services for building latrines from different places, adding to the cost and inconvenience for rural households. All-inclusive services were not generally available. ï‚· A lack of clear and accessible information on the cost of installing different latrine types, since hardware suppliers and masons rarely carried out any marketing activities. Most households with a toilet had built it themselves, neighbors and relatives being the main source of information on options and costs. There was a widely held, but mistaken, view that hygienic latrines are not affordable. ï‚· Private hardware suppliers and masons believed that latrine construction offered little potential for profit due to the current low volumes of sales and small margins on products. Most providers were retailers selling a variety of construction materials, sanitation being only a small part of their businesses. ï‚· Limited availability of sanitation hardware in remote and mountainous areas, adding to the cost and inconvenience of latrine construction. The business model developed to address these challenges is known as “Cá»­ a hàng Tiện íchâ€? (Sanitation Convenience Shop or SANCON). Originally, these are very small businesses (in many cases even the business license is not necessary) of wastewater concrete ring producers, or brick producers, or retailors; and they have few employees. Based on selection criteria for both SANCON and sales agents, commune health staff screened and proposed potential candidates. Conversations started by district and commune health officers with technical support from WSP and VIHEMA. Follow up trainings were then organized by district CPM for SANCON and sale agents. The characteristics and potential advantages for customers wishing to build a latrine are set out in Figure 5. The two most experienced district CPMs in Hoa Binh now plan to set up more SANCONs to cover the whole district market in 2016. Figure 5. The SANCON model A. All-inclusive latrine installation service B. Standardized products and services C. Affordable latrines The service offers a range of benefits to customers: 4. Suppliers’ sale agents provide information and advice on technology and design options and associated operation and maintenance requirements, to help customers choose an appropriate model. 5. All materials required for latrine construction are included in the price paid, both sub-structure and superstructure. 6. The package also includes the services of a mason to build the latrine, one of a network of specially trained and certified artisans. (Certification was another pilot initiative, the intention being to scale it up nationwide in due course). 7. The supplier delivers all construction materials and components to the household. 8. Some suppliers offered their customers payment by instalment, with terms typically three to six months. With some technical support from the TA, District CPM were able to select suppliers who were entrepreneurs with relevant existing businesses, were willing to work with new technology options, and had sufficient capital to participate in the marketing initiative without external support. Each supplier had one or more sales agents, some operating independently and others being members of mass organisations such as the Vietnam Women’s Union. These were paid a commission for each sale generated. At first only Women’s Union members were encouraged to be sales agents but it became clear that belonging to a particular organisation was not very important – what mattered was that the agents had the necessary skills, expertise and motivation. Thereafter people were recruited from diverse backgrounds, some being health workers or village leaders. Sample pages from the of product catalogue As of February 2016, there are ten SANCONS in operation across two districts of Hoa Binh, eight of which were established with technical support from WSP and the Center for Preventive Medicine (CPM) while two set up independently. In Kim Boi, three SANCONs are now expanding to reach other communes and covering the cost of village meetings from their own resources. Thus a positive working relationship has been established between government and private sector players and looks set to continue beyond the TA. Since Hoa Binh is one of the provinces included in the new SupRSWS PforR program, further support to market development is foreseen beyond the two districts and enterprises. The SANCONs can help with cheaper but qualified latrines in comparison with current self- built latrines, which tend to be constructed larger than needed and take more time (7-10 days compared to about 1-2 days of SANCON services) and often lead to superfluous construction material (i.e. bricks, cement, connection pipes). The table below summarizes profits for SANCON derived from sanitation services – this is in addition to their usual businesses. Given the average income of VND 2,000,000/person-month in rural areas in Vietnam (about $90), this is quite an attractive benefit for these very small businesses. Table 5: SANCON profit in initial implementation period (from May to Dec 2015) No of Benefit per Total Location No. SANCON name latrine Unit cost latrine sold benefit (Commune-District) sold (VND) (VND) 1 Bùi Văn Lả VÄ©nh Ä?ồng - Kim Bôi 45 2,300,000 600,000 27,000,000 2 Trần Ngá»?c San VÄ©nh Tiến - Kim Bôi 61 2,100,000 500,000 30,500,000 3 Bùi Văn Bé Thượng Bì - Kim Bôi 16 2,100,000 500,000 8,000,000 4 Ä?oàn Trá»?ng Kế Nam Thượng - Kim Bôi 35 2,300,000 600,000 21,000,000 5 Bùi Văn Thức Nam Thượng - Kim Bôi 12 2,100,000 350,000 4,200,000 6 Bùi Văn Lanh Sào Báy - Kim Bôi 25 2,000,000 300,000 7,500,000 Nguyá»…n Quốc 7 Lập Bao La - Mai Châu 34 1,200,000 450,000 15,300,000 8 Phạm Tuấn Anh Chiá»?ng Châu - Mai Châu 30 2,400,000 650,000 19,500,000 Total 258 133,000,000 Latrine design options In Hoa Binh, WSP worked with VIHEMA and a local consulting firm to develop a new option for consumers: septic tanks and soakage pits made from prefabricated concrete rings. These can halve the cost of the underground components of the latrine, which are normally made from brick. This can also save up to 80% of the labour cost, since no specialist labour is required for installation - households can assist the mason themselves. Prefabricated rings Providers can produce prefabricated rings offsite in bulk and so achieve economies of scale, but for remote areas where the transportation of rings would be difficult and expensive, on-site production using light molds is another option. This was earlier done in Kontum province under a project supported by Plan International and later tested successfully in Hoa Binh. A further option introduced in Hoa Binh was the use of cement bricks instead of fired bricks, thereby reducing the cost of a latrine by around 25%. Cement bricks can be used both for underground components and superstructures. Cost reductions were also achieved by introducing the suitable size of septic tanks, from the fact that masons tended to make septic tanks and pits much larger than was technically necessary. With almost the same using volume of 1.3m3, the total cost of a septic made using concrete ring components was around $82 as compared to $141 for a typical fired brick structure. A third option developed using concrete rings was a raised twin-vault latrine model (dry pit latrine) for use in places where soil conditions or a high water table prevented the use of pits. WSP and Hoa Binh CPM have worked closely with SANCONS to introduce this product in Mai Chau and Kim Boi. Uptake has been modest to date, with just four household facilities built by November 2015. This is not unexpected given the overwhelming local preference for flush latrines. Raised twin-vault dry latrine For households living on floodplains or river banks in Mekong region, WSP has worked with ROTO (a plastics manufacturer) to help expand promotion of the plastic septic tank in the Mekong region, with approval from MOH. The tank can be installed in water top of a wooden platform or under the concrete structure of a hanging house. If the household already has a latrine discharging directly into the water, the waste can be diverted into the septic tank while retaining the existing latrine compartment. The testing period showed that this is a very good technical option. The guarantee from the producer also adds more confidence to this option. The only issue is relatively higher costs of investment (VND3,700,000, about $168), thus requiring more BCC effort. Plastic septic tank WSP also collaborated with Roto plastic company on the development of a light plastic pit lining for mountainous areas where the transportation of materials is difficult. This option is currently under review by MOH. The cost estimation is about $80-90. When the technical is approved and promoted, its application will be very promising for remote areas in the Northern Mountainous region. Plastic pit lining All of the options described above are relatively simple and enable households to participate in the construction process, thereby helping to reduce costs. Each one features in the product catalogue provided to each SANCON and sales agent for distribution to households to help them choose an appropriate option. Financing options for households The TA explored a number of financing options for households including: ï‚· Revolving funds operated by the Vietnam Women’s Union. A large number of these had already been set up via a national Women’s Union campaign called ‘5 numbers, 3 Cleans,’ meaning: - no poverty, law breaking, third child, family violence, stunting or early drop-out from school; and - clean house (including toilet), clean kitchen and clean lanes. WSP and CPM worked with the Women’s Union in Kim Boi and Mai Chau to extend the fund purpose relating to the funds so that they could be used for building latrines. WSP and Hoa Binh CPM provided training for more than 100 heads/deputy heads of Women’s Unions from 51 communes in Mai Chau and Kim Boi districts. The training provided practical experience and covered the importance of sanitation, latrine types, promotional tools and how to inform and motivate households to build hygienic latrines and make us of the SANCON network. By the end of 2015, in Mai Chau, there are some 54 revolving fund groups established across eight communes, four of them are the NTP3 intervention communes. And from a total of Women’s Union members in Mai Chau, 231 latrines were built. Each member received VND 1- 2.5 million in turns depending on members’ monthly contributions to the fund. In Kim Boi, the revolving funds have been set up earlier, some 105 groups changed the purpose of the fund from supporting farming to latrine building. Due to the small monthly contributions from households (20-50,000 VND, about $1- 2 per month) to a fund of 10-20 households, the current contribution to latrine construction is modest but is still a good option for further support and monitoring for lessons. ï‚· Payment by instalment. In 2015, some 200 latrines (around one fifth of the total built in Hoa Binh) were purchased from SANCONS. Some SANCONs allowed customers to pay off their bills over 3-6 months, interest-free. Uptake of this option was limited, however and subject to the financing capacity of each SANCON. The SANCONs usually have profit of about 30% of the total cost per latrines.. Information on profit from latrine services in the table above is addition to their normal work ï‚· Loans from the Vietnam Bank for Social Policy. WSP and Hoa Binh CPM worked closely with VBSP to promote loans for latrine construction in the province, and especially in the nine focus communes. Health stations distributed loan information and helped VBSP to compile lists of households wishing to borrow for latrine construction, and made follow-up visits after disbursement to ensure that the latrines were built. From January to October 2015, VBSP granted loans for clean water and sanitation to 30,400 households, just over 17% of the total households living in the targeted area. This amounted to a credit growth rate of 177% compared to the previous year. In total, 9,222 hygienic latrines were built in the province, and 9,580 small water supplies. However, VBSP is unable to cope with the demand for loans, and only a small portion of applications is successful. In the end, savings and VBSP loans were the main sources of funds for building latrines, as shown in Table 4 below. Table 6. For adopters: Where did you get the money to build your toilet? Overall Kim Boi Mai Chau N=479 N=283 N=196 % % % Savings 80.2 79.9 80.6 Loan from Vietnam Bank for Social Policy (VBSP) 18.8 13.4 26.5 Sale of assets 11.9 12.0 11.7 Borrowings from friends, relatives, neighbors 5.2 7.4 2.0 Money granted from local program or project 4.2 6.7 0.5 4.2.3 Results of the Hoa Binh pilot At a high institutional level, WSP encouraged government decision makers to give sanitation higher priority and supported strategic planning. In the past, cPCM had set very ambitious sanitation targets but did not back up their plans with the necessary resources and, not surprisingly, the targets were not reached. With WSP support, the Hoa Binh Department of Health adopted a new three-year plan with realistic targets that could potentially be met using available NTP3 funds. Furthermore, the provincial government used their resources differently; instead of funding hardware subsidies for demonstration toilets the budget was used for ‘soft‘ activities: behavior change communication, supply chain development and capacity building for staff. By 2014, more than 80% of the total provincial NTP3 budget was allocated for such activities, and in 2015 this rose to 100%; see Table 5. A further breakthrough came in early 2015, when the Hoa Binh government passed a resolution which for the first time incorporated a sanitation target into its Social and Economic Development Plan. Adoption of this target should ensure that funds continue to be allocated for sanitation promotion, and that officials at a lower level (District and Commune People’s Committees, plus village leaders) give sanitation higher priority and support their health workers. Table 7. Hoa Binh NTP Sanitation Budget, 2012-15 Hardware subsidy for Soft activities (capacity building, Year Sub-total household latrines promotion, M&E) (VND) % (VND) % 2012 800,000,000 61 520,000,000 39 1,320,000,000 2013 585,600,000 37 1,014,400,000 63 1,600,000,000 2014 224,000,000 18 1,001,000,000 82 1,225,000,000 2015 0 0 500,000,000 100 500,000,000 Total 1,609,600,000 3,035,400,000 4,645,000,000 Source: Hoa Binh CPM In the nine target communes, the Hoa Binh pilot had a significant impact on house hold sanitation. While no hardware subsidies were offered, nearly 1,200 hygienic latrines were built in 2015 alone. It is approved that BCC messages have come deeply to households in villages and motivate them much for effectively. This aid, SANCONS faced some challenges since they tended to promote only concrete ring systems for which there was low demand. They therefore had to compete with other technology options, plus their masons, who worked for them part-time, preferred to build the more expensive brick- type septic tank with which they were familiar. After some time it became clear that concrete rings are only appropriate for accessible, lowland communities - not for remote and mountainous settings where populations are sparse and transportation problematic and expensive. Among those who built a hygienic toilet, more households in Mai Chau (21.4% of total) bought components from a SANCON than households in Kim Boi (13.1%). To a large extent this reflected the different geographical settings; in Mai Chau people live far from shops and transportation costs are high, therefore some people did not opt for a ‘full package’ latrine and instead bought just concrete rings from the SANCON, in bulk (4-5 households together) to reduce delivery costs. They then bought other materials from local retailers. Though the pilot was fairly small, it provided ‘proof of concept’ for the promotional strategy and tools and was large enough to reveal which design options were most suitable for households in different geographical locations. Within the targeted communities, access to hygienic latrines rose by 21% and the promotional tools were evaluated very positively both by promoters and the target audience, being relevant, engaging and easy to use; see Box 3. The SANCON model was also tested thoroughly by the pilot, and some 17% of households who built a new latrine used SANCON products and services. This was achieved despite an established preference for self-built toilets made using (more expensive) fired bricks rather than concrete rings, and the challenges of applying the model in remote mountainous areas. A further constraint was that government health staff had limited understanding of what they could and should do to help the SANCONS become viable businesses. Box 2. Hoa Binh post-intervention assessment: topline findings and recommendations In December 2015, VIHEMA and WSP commissioned a post intervention rapid assessment in the nine intervention communes in Hoa Binh, funded by NTP3 budget in Hoa Binh province. The assessment reviewed the impact on coverage of hygienic sanitation; the effectiveness of BCC and OSS interventions; and the potential sustainability and replicability of the promotional approach in similar contexts – particularly limited government budgets and local capacity. The assessment used both qualitative and quantitative methods including pre-and post-intervention sample surveys (Feb 2014 and Dec 2015). A total of 801 households were selected for the post-intervention survey in 50% of the targeted villages across all nine communes. Hygienic sanitation coverage in Hoa Binh in the 9 intervention communes 60% 48.4% 50% 40% 33.7% 34.4% 27.7% 30.7% 30% 29.6% 31.5% 20% 10% 0% 2013 2014 2015 Post-intervention survey results (for nine communes in Hoa Binh) NTP3 (Hoa Binh) JMP (Hoa Binh) Topline findings 1. Hygienic latrine coverage increased for all income groups, but especially for the non-poor. Access by the poor rose 6% (from 18% to 24%) while for the non-poor it almost doubled (from 34% to 60%). The increase in hygienic toilets was associated with a decrease in unhygienic facilities, as most of these households already had some form of toilet at baseline. Most of the new facilities had septic tanks. Coverage of hygienic sanitation facilities - Hoa Binh Province Baseline (February 2014; N=801) Endline (December 2015; N=801) 60 55.9 48.4 50 Percentage 40 31.2 27.7 30 17.7 20 12.6 10 0 Hygienic sanitation facilities Unhygienic sanitation No facility/bush/field (i.e. facilities open defecation) 2. Hygienic latrine coverage increased for all ethnic groups: by a factor of 3.5 for the Thai (27.8% of respondents), 2.4 for the Dao – the poorest ethnic (6.1% of respondents), 1.7 for the Muong (59.1% of respondents) and 1.4 for the Kinh (6.7% of respondents). 3. 72% of all respondents said they had received information about sanitation in 2015; of these, 87% had attended sanitation village meetings, 29% sanitation festivals and 13% had received a household visit. 83% of respondents without a toilet said they were now planning to construct one, 44% of them within the next year (compared to 7% at baseline). 4. 43% of respondents were aware of the existence of SANCONS. 10 were set up via the pilot, one of which dropped out, while another set up under their own initiative. 5. There is potential demand for hygienic sanitation, and for SANCON services, though up to now the option of a septic tank made using concrete rings is not popular and most people prefer the larger (and more expensive) septic made from fired bricks. Recommendations If the intervention is to be extended or replicated: 1. Hygienic sanitation targets should be included in each commune socio-economic development plan, with the roles and responsibilities of key actors clearly defined. 2. Hygienic household toilets should be included in the criteria for ‘cultural family’ and ‘cultural village’ and a system of rewards introduced for achievement of this status village-wide. 3. Health staff should encourage the active participation of local leaders in promotional campaigns. 4. Clear roles and responsibilities should be identified for the health department in facilitating private sector participation in sanitation marketing (provide technical support and link to community events such as village meetings). 5. Explore ways of making the SANCON service more attractive to customers, for example by offering a wider range of desirable products and offering post-installation services such as guarantees and/or repairs and upgrading. 6. Strengthen the links between sales agents and SANCONs. Each commune should have more then two sales agents, working at commune level, and at village level. Even each village should have a village based sale agent. 7. Extend marketing into other communes, building on the links between health structures and SANCONs. 4.2.4 Replication through World Bank operations and other partners The Rural Sanitation Behavior Change and Market Strengthening Strategy 2015-20 was developed in the expectation that it could be adapted for use in other places in Vietnam with similar conditions. Lessons and outputs from Hoa Binh were in fact adopted by a number of World Bank projects as outlined below. 1. Mekong Delta Water Resources Management for Rural Development Project The TA has supported this project to align its sanitation component with the NTP3 structure, using lessons from Hoa Binh as outlined earlier. The project has a budget of $3.4 million for sanitation (including school sanitation). Rapid formative research was conducted in the Mekong region and informed the design of locally-appropriate tools and messages. Project staff were then provided with, and trained in the use of the BCC and Supply Chain Strategy and associated tool kits to enable roll out from December 2015 onwards. The PMU has now recruited TA to support provincial government adoption of the approach over the remaining 1.5 years of implementation on the proviso that that pCPM are motivated to adopt a market-based approach, albeit with some hardware support for the poorest households. 2. Result-based Scaling up Rural Sanitation and Water Supply in the Northern Mountains and Central Highlands Program (SupRSWS PforR). The TA has supported the rapid formative research in the two regions (together with UNICEF and London School of Hygiene and Tropical Medicines). Its findings re-confirmed that the comprehensive approach in Hoa Binh can be applied in these regions with small adaptation for very remote areas. As a result, all main activities derived from the TA for the sanitation component are clearly identified in Program documents. Amongst other things, capacity building curricula developed under the TA (see section 4.3 below) will be used for training government staff working on the program. Parallel to the PforR, a new TA has been designed to build provincial capacity for program implementation using the tools developed elsewhere5. 3. Second Northern Mountains Poverty Reduction Project (NMPRP-2) – Additional Financing and Central Highlands Poverty Reduction Project (CHPRP). These projects target ethnic minorities in some of the most remote and isolated areas of Vietnam. The TA is supporting the pilot testing of sanitation and hygiene interventions in selected provinces and communes with a focus on community-wide sanitation using a Community Driven Development 5 P155162 - Capacity Building for Rural Sanitation Service Delivery in Northern Mountainous and Central Highland regions of Vietnam approach, and specifically targeting behaviors that focus on reducing the exposure of children to both human and animal waste. WASH-nutrition linkages re also emphasised in the case of CHPRP. The first phase of piloting involved 25 villages across 4 communes. Commune Development Boards (CDBs) have a key role in the projects and facilitate the development of commune–wide WASH action plans using CLTS methodology; financial linkages with Women’s Unions; and supply chain linkages via trained masons and local suppliers. CDBs also co-ordinate with Commune Health Centers (CHCs), leveraging Common Interest Groups (CIGs) and Women’s Groups for BCC campaigns. Amongst other things, WSP has supported: ï‚· ongoing discussion among stakeholders to facilitate learning; ï‚· exposure visits for PMU staff to provincial health centers; ï‚· development of BCC materials based on the Hoa Binh tools, with the addition of IEC materials on animal waste management, as requested by the project; ï‚· training of trainers in promotional approaches and use of the BCC tools; and ï‚· design of pilot interventions. IEC materials on livestock waste 4. Rural Water Supply and Sanitation Project, Red River Delta (PforR) Learning has happened through the same client (VIHEMA). The TA contributed indirectly to the Project and its achievement of Commune Wide Sanitation target. Under VIHEMA instruction, the Hoa Binh strategy and BCC toolkit were adapted for use in the Red River Delta by PforR, which operates in eight provinces. 5. Other development agencies. As the work in Hoa Binh developed it received increasing attention from other development agencies, some of whom made visits to learn about the approaches developed. Child Fund and World Vision, for example (both of which work in Hoa Binh) funded their staff and counterparts to attend a training program organised by Hoa Binh pCPM using WSP-supported tools, and subsequently incorporated the materials into their own promotional activities. WSP and VIHEMA have also worked closely with UNICEF on concepts and tools development. WSP and UNICEF also co-organized several learning events for provinces, including horizontal learnings and study tours for senior officers from provinces. The collaboration has been further developed when both WSP and VIHEMA supported the formative research in Northern Mountain and Central Highland provinces for the new PforR. In addition, PSI has taken up further work with the Roto Company based on recommendations arising from the TA; this will focus on developing a cadre of sales agents for the promotion of plastic septic tanks in rural areas. Lastly at national level, behavior change communication and supply chain development training was incorporated into the Capacity Building Strategy for Rural Sanitation Sector 2015-2020; see 4.3 below+. 4.3 Increased government capacity to deliver the sanitation component of NTP3 There were two dimensions to capacity building support under the TA: operational guidance and training to enhance the implementation of NTP3 in the short term; and longer term initiatives to develop sector capacity in sanitation and hygiene promotion, and sanitation marketing, nationwide. 4.3.1 Short term initiatives 1. Introduction of the theory of change An early priority for the TA was to introduce the comprehensive Theory of Change (TOC) for scaling up rural sanitation that WSP had adopted at global level based on experience from several countries. This was accepted by VIHEMA and considerable efforts were made to generate a common understanding of it among relevant stakeholders and to support harmonisation across all four components: enabling environment; behavior change communication; strengthening the supply of sanitation goods and services; and learning. This is reflected in the guideline issued by VIHEMA discussed in following section. 2. Guideline for the Planning and Implementation of Rural Sanitation Programs This was a very significant output of the TA in 2014. The Guideline was based largely on experience various assessments carried out early in the TA as discussed above and Hoa Binh. Box 3 outlines the essential content of the Guideline. Prior to this there had been no comprehensive operational guidance for the rural sanitation component of NTP3 and interventions tended to be quite limited in scope, typically including some element of hygiene promotion but also relying heavily on the use of subsidies, and rarely addressing supply-side challenges or measures to create a more enabling environment. The Guideline is detailed and much of its content is in the form of best practice principles and options rather than a detailed and prescriptive process for village-level interventions. This was a deliberate choice as a critical challenge in the sub-sector was the need to introduce a more holistic approach to sanitation that addressed not just demand generation but also supply side strengthening and creation of an enabling environment. The Guideline is pitched at a strategic level, for managers at province and district level rather than for implementers such as commune cadres and field sanitation volunteers. It spans a wide range of issues including, for example, local financing options, targeting strategy and the design of monitoring systems, as further elaborated in Box 3. VIHEMA then organized training for key senior health staff in all provincial Centers for Preventive Medicine for application Box 3. Guideline for the Planning and Implementation of Rural Sanitation Programs under NTP3 (2014) The Guideline begins by highlighting the economic and health impacts of sanitation, as evidence of the case for prioritising rural sanitation. It introduces a Theory of Change for scaling up, and associated concepts, then sets out how these can be applied by provincial governments within the framework of NTP3. The guidance then follows a series of steps in the development of a provincial sanitation program including: 1. Baseline data collection and analysis. This encompasses trends in household latrine use; commitment of local authorities; financing; government capacity at district level and below; ongoing programs; and the availability of goods and services. 2. Priority and targets identification. Data from step 1 is used to identify segments of the sanitation market in the province in terms of their current level of access to sanitation and geographical setting, with special reference to challenging environment such as coastal, mountainous and flood-prone areas. From this, priority target groups are identified and program objectives and targets set. 3. Design and Development of the rural sanitation program. This covers mobilising the support of local authorities; selection of household latrine options; development of local sanitation markets; demand creation and BCC; and capacity development at province, district and commune level. 4. Monitoring, evaluation and reporting. This covers not only village-level results but also progress in mobilising local government support; capacity building; and activities to improve the supply of sanitation goods and services. The guidance includes not only what to do but why, and how, and includes a range of templates for planning, monitoring and reporting. In March 2014, VIHEMA organised two ‘training of trainers’ courses for all pCPMs on how to use the Guideline. 3. Training documents associated with the toolkits for Hoa Binh and Mekong Region WSP worked with VIHEMA and a private firm to develop a set of training packages based on the Guideline and associated tools. Each package was appropriate for health staff at a particular level and initially the TA supported the training of trainers (around 1000 senior pCPM staff), which enabled the training to be rolled out at scale for commune health staff, motivators, sales agents and SANCON operators; see Table 6. For field staff, practical training was provided on the ground while for managers the objective was to develop an understanding of the various steps to be taken to promote sanitation effectively. At all levels, a ‘learner-centered approach’ to training was adopted; amongst other thing this meant that it was designed to inspire learners and make them proactive in learning; provided many opportunities to practice what was being learned; and involved multiple methodologies. Table 8. Personnel trained National guideline : Over 100 provincial health staff from 59 provinces Hoa Binh tools : Over 1,000 health staff and village promoters 108 masons Mekong tools : 60 key senior staff from CPM, Women’s Union and NCERWASS in 13 Mekong provinces Health staff training In addition to training the TA organised a number of south-south learning events. For example, some 50 senior health officers and relevant partners from agriculture and local authorities attended study tours to Thailand (2013) and Indonesia (2014) to learn about government programs, supportive policies and supply chain strengthening (amongst other things), while 50 others participated in learning exchanges between Hoa Binh and Kon Tum, in An Giang Province. WSP also enabled government officers and political leaders to attend regional events such as the EASAN Conference in Bali in 2011 and a regional rural sanitation learning event in Bangkok in 2012. The purpose here was both to expose decision makers to new concepts and ideas and also to strengthen their commitment to sanitation. Apart from these initiatives the TA envisaged that by 2014, a performance benchmarking system would be under development in selected provinces, based on an improved sector monitoring and evaluation system. This was not taken forward, however, primarily because TA in this area was provided under the first PforR program, with DFAT support. 4.3.2 Longer term capacity development In order to support Vietnam in developing capacity for sanitation in a more systematic way, the TA identified milestones along a longer time horizon to support the development of a capacity building strategy and associated training packages for relevant managers and operational staff at all levels. The key output here was the Capacity Building Strategy for Rural Sanitation Sector 2015-2020 and Orientation 2025, adopted by VIHEMA along with a Vision to 2030. The strategy is a comprehensive document and there was extensive discussion with VIHEMA about its scope and content before formal adoption in May 2015. The strategy and plan are underpinned by a number of key principles: enhance co-ordination between the health sector and other stakeholders; utilise a participatory approach; combine relevant forms of capacity building (on-the-job experience, informal training and formal training); prioritise capacity building for remote areas, ethnic minorities, women; integrate the plan into national target programs; and address all three levels (enabling environment, institutional level and individual level). The full document is provided in Annex 2. The document includes a roadmap for provincial level implementation. The associated budget is aligned with the NTP3 capacity building budget and is expected to help mobilize development partner support. VIHEMA are currently waiting for the Health Sector Plan 2016-2020 to be approved, after which implementation of the strategy can begin. However, responsibility for implementation rests with provincial governments and much depends on whether they prioritise it and allocate resources accordingly. Box 4. Capacity building needs assessment The capacity building plan was developed in response to a 2014 capacity needs assessment which investigated the gap between current and desired capacities for planning and implementing rural sanitation interventions in line with the MOH 2014 Guideline for Rural Water Supply and Sanitation Programs. The assessment was based on primary and secondary data collected from central level and eight provinces that had some of the lowest levels of access to sanitary latrines and high levels of poverty. Key findings were that: ï‚· rural sanitation is not a priority with provincial governments and gets little or no provincial budget; ï‚· capacity for sanitation and hygiene promotion is limited at all levels of government both in terms of personnel available (one provincial staff per 178 communes and one district staff per 36 communes in the eight research provinces) and expertise; ï‚· roles and responsibilities for sanitation and hygiene promotion (particularly at commune level) are not clearly defined and understood, plus co-ordination is poor between health sector agencies and between health agencies and other stakeholders; ï‚· CLTS training for government staff often proved unproductive because no plans or funding were in place for application of the acquired skills; ï‚· there was a lack of affordable technology options and promotional models that could be applied at scale; ï‚· monitoring systems were inadequate and unreliable; and ï‚· VIHEMA, the lead health institution for rural sanitation, has insufficient staff to guide and manage rural sanitation programs. Drawing on lessons from Hoa Binh and Mekong, a series of six training packages has already been developed, each for a different target group involved in rural sanitation planning or implementation: 1. Document for advocacy workshops with leaders at central level to raise the priority of rural sanitation and attract increased funding. 2. Document for advocacy workshops with leaders at provincial level to raise the priority of rural sanitation and attract increased funding. 3. Curriculum for managers of provincial and district CPMs on BCC and supply chain strategy, planning, management and advocacy, etc. 4. Curriculum for provincial and district implementers such as CPM or Women’s Union staff on all aspects the activities, so that they can plan, guide and supervise lower level health workers. 5. Curriculum for commune and village health workers on their specific tasks. 6. Curriculum for TOT for commune and village health workers. Each training package includes some field-based experience. Amongst other things, the curricula will be used under the forthcoming SupRSWS PforR project in 21 provinces, from April 2016 onwards. The packages were reviewed and approved by VIHEMA in 2015 and will now be adopted as formal curricula by four MOH training institutes. It is envisaged that, under the new TA, these institutes will either run the courses at their headquarters or in the provinces on a demand-responsive basis, provided provinces have the necessary funding, Alternatively, national allocations (if available) could be used to supplement provincial funds. In the longer term, the curricula may also be developed into online training courses to facilitate self-study for prospective sanitation promotion staff, while also reducing training costs. Such courses would, however, need to be supplemented by some field-based training. The document is now published on the VIHEMA website: http://vihema.gov.vn/tai-lieu-goi-dao-tao-nang- cao-nang-luc-ve-sinh.html. VIHEMA is also processing procedures for a national training code for the document, so that it can be applied formally in all universities in Vietnam for relevant courses on sanitation. Figure 6. Figure 7. Overview of Capacity Building Strategy for Rural Sanitation Rural Vietnam reaches ODF goal in 2025 and Universal Access Sanitation Vision to Sanitation Goal in 2030 Rural 2015 2020 2025 2030 Sanitation 1% ODF 30% ODF 100% ODF 80% ODF 100% HH with latrine 90% HH with latrine 95% HH with latrine Goal (75% HH with hygienic 100% HH with latrine (100% HH with hygienic (65% HH with hygienic (90% HH with hygienic latrine) latrine) latrine) latrine) Enabling To create an enabling environment of policies, mechanism and capacity to Environment overcome challenges in changing individual hygiene and community Goal environment sanitation behavior for a rural living environment free of fecally contamination Objective 1: To build commune level institutions as the key implementers of RS interventions Institutional Objective 2: VIHEMA and Health institutions at all levels, RS training providers are Capacity Goal capable of implementing RS programs effectively. All the institutions sustain in terms of organizational structure, human resources, financial resources and a learning culture Objective1. To create a shared vision of ODF and national RS goals and build commitment to supporting staff with Health managers at all levels. Objective 2. To build commitment for achieving ODF goal with RS implementers at all Individual levels by building commune level as the key implementers of RS interventions Capacity Goal Objective 3. To build implementation capacity with key trainers at central, provincial and district levels to be able to provide RS training courses and guidance as requested. Objective 4. To create a shared vision and build capacity with private sector for rural sanitation service delivery as a profitable business opportunity 4.4 Knowledge deepened on the enabling environment and programmatic approaches The TA generated a considerable number of knowledge products at both national and provincial level and for specific programs. This began with reviews of existing sector knowledge and experience, and of the policy and institutional framework, to establish to what extent the sector was ready for scaling up and identify critical knowledge gaps. This prepared the ground for formative research which in turn led to the documentation of guidelines and lessons learned. In the course of the TA, numerous events and exchanges / study tours were also organised. A list of the principal knowledge products developed under the TA is provided in Table 7. Some - including those relating to field-based pilots - were discussed in 4.1 - 4.3 above. This section focuses on those outputs not covered elsewhere in the report. Table 9. Knowledge products developed under the TA # Product Type Title Date 1 Report Research on Policies and Legislation on Rural Sanitation 2013 2 Report Qualitative Assessment of Programmatic Approaches to Sanitation 2013 in Vietnam 3 Report Behavioral Determinants of Sanitation and Handwashing with Soap 2013 in Vietnam: a Review of Current Studies and Behavior Change Communication Materials since 2006. 4 Report Review of current studies on Rural Sanitation Supply Chain in 2013 Vietnam produced in May 2013 5 Report Sanitation Consumer Demand and Supply Chain Assessment for the 2013 Hoa Binh province 6 Report Rural Sanitation Sector Capacity Assessment Report 2014 7 Report Report on Post Intervention Assessment in Hoa Binh province 2016 8 Maps Poverty and Sanitation maps 2013 http://sdvmd1.worldbank.org/poverty_and_sanitation/ 9 Guideline Guidelines for Patriotic Sanitation Movement Implementation 2013 10 Guideline Guideline for the Planning and Implementation of Rural Sanitation 2014 Program under NTP3 11 Strategy Provincial Rural Sanitation Behavior Change and Market 2014 Strengthening Strategy, Period 2015-2020 for Hoa Binh province 12 Strategy Rural Sanitation Behavior Change and Market Strengthening 2014 Strategy, Period 2015-2020 for Mekong River Delta provinces 13 Strategy Capacity Building Strategy for Rural Sanitation Sector 2015-2020 2015 and Orientation 2025 14 Training Six Training Packages for Rural Sanitation Planning and 2015 document Implementation http://vihema.gov.vn/tai-lieu-goi-dao-tao-nang-cao-nang-luc-ve- sinh.html 15 Learning Note Investing in the Next Generation: Children grow taller, and smarter, 2014 in rural, mountainous villages of Vietnam where community members use improved sanitation (Research Brief) 16 Learning Note Learning Note on Understanding Determinants of Assess to 2016 Hygienic latrines for Rural Households Across Vietnam: From Research Findings and to Campaign Development 17 Promotion Hoa Binh BCC and Marketing toolkit: 2014 tools ï‚· Manuals: provincial and district, commune health staff, and motivators ï‚· Manuals for Sanitation Convenience Shop Owners and Sale Agents ï‚· Training documents specifically on how to use the tool for different health office levels: provincial, district, commune trainers ï‚· Posters (promotional, O&M) ï‚· Catalogue including technical options and costs ï‚· Sticker for latrine O&M ï‚· Video clip of activities to support the training 18 Promotion Mekong River Delta BCC and Marketing toolkit: 2015 tools ï‚· Manuals for provincial, district, commune health staff and motivators ï‚· Manuals for Sanitation Convenience Shop Owners and Sale Agents ï‚· Training documents : provincial, district, commune trainers ï‚· Posters ï‚· Flipchart including emotional pictures, O&M guidance, technical options and cost ï‚· Sticker for latrine O&M 1. Equity analysis WSP supported MOH in developing national poverty and sanitation maps; these show sanitation coverage up to district level and cross-reference it with poverty data, thereby highlighting inequities in access. Examples are shown in Figure 8. This exercise enabled VIHEMA to rank provinces according to need and 24 were prioritised for training and financial support from NTP3 and other external sources. The ranking was later reflected in the national Capacity Building 2015-2020. The maps are online and were recently updated using data from the 2014 CENSUS. See http://sdvmd1.worldbank.org/poverty_and_sanitation 2. Study on sanitation and stunting A desk-based study on the links between sanitation and stunting found that not only open defecation, but also the use of unimproved latrines in mountainous areas is significantly associated with child stunting6. This evidence informed the design of the SupRSWS PforR, which seeks to go beyond ending open defecation and to promote the use of improved sanitation. See http://www.wsp.org/sites/wsp.org/files/publications/WSP-Vietnam-Stunting-Research-Brief.pdf 3. Assessment of Programmatic approaches to sanitation This qualitative research reviewed seven approaches to sanitation promotion that had been applied in Vietnam in recent years: Community Health Clubs, CLTS; CLTS plus supply-side strengthening; Output- based Aid; Participatory Action-Oriented Training, Participatory Hygiene and Sanitation Transformation (PHAST); and Sanitation Marketing. The study found that an effective approach to the promotion of rural sanitation needs to combine supply- and demand-site interventions, with the applicability of CLTS being limited to areas with high levels of open defecation. It also found that that targeting the poor has - except in programs using results-based financing - been largely ineffective. 6 Investing in the Next Generation: Children grow taller, and smarter, in rural, mountainous villages of Vietnam where community members use improved sanitation (Research Brief) www.wsp.org The study recommended that further research be carried out to address critical knowledge gaps in the following areas: increasing access to hygienic sanitation among the poorest of the poor; increasing access among certain ethnic groups; strengthening sanitation supply chains; cost-effectiveness of programmatic approaches; and closely monitoring the impact of CLTS on sanitation behavior and latrine building. 4. Dissemination of other WSP knowledge products The TA also translated and disseminated a number of relevant knowledge products developed under other WSP initiatives, for example on the SANIFOAM approach to formative research in sanitation marketing, using these as entry points for discussion with government. Figure 8. Mapping rural poverty and sanitation % Rural Poverty Rate % Rural HHs with our latrine Source: 2009 Census for Sanitation Maps; Poverty Map based on 2009 Census and 2010 VHLSS 5. Study tours Another strand to this work was peer learning through meetings, study tours and exchange visits as described earlier. Horizontal learnings were highly appreciated by provincial officers as they can exchange a lot of issues created under similar conditions, while abroad study tour were highly appreciated by high level senior officers as they could learn more advance experience on the development forward. 6. Review of NTP3 subsidy One activity envisaged in the PCN which did not go ahead was an evaluation of the effectiveness of the NTP3 subsidy. There is in fact no standard NTP3 subsidy; each province sets their own and it was deemed that a comparison of one provincial subsidy versus another would not be a productive exercise, especially since the subsidies are normally only provided to a limited number of ‘demonstration latrines’ spread out over numerous districts and communes within a province, and hence have low promotional impact. As an alternative, a study was initiated in December 2015 to review the initial results of the Hoa Binh pilot in nine intervention communes, where no hardware subsidies were provided for household latrines. VIHEMA has contributed to the study by undertaking quantitative analysis while WSP funded the qualitative research. A Learning Note is also being developed on lessons from the formative research in Hoa Binh (Northern Mountains region) and the Mekong and Central Highland regions; see Box 3. The note summarizes how this evidence has been used to develop context-specific BCC tools and business models that address those barriers. This will highlight the key study findings, including similarities and differences between geographic regions and ethnic groups. The aim of the document is to provide insights to inform the design of future market research studies as well as the development and adaptation of BCC and sanitation market-development programs in other regions of Vietnam. The many studies and reports produced under the TA have enabled VIHEMA to carry out more evidence- based advocacy and have informed planning and resource allocation processes at national and sub- national levels, including the effective sharing of the resources. They have also informed the design of ongoing and new lending operations. VIHEMA now recognises the importance of an enabling environment for scaling up sanitation and this features routinely in their dialogue within MOH and with partners. A significant early step forward was their adoption of the overall Theory of Change used by WSP and its operationalization in the Vietnamese context. VIHEMA also appreciates the importance of ending open defecation rather than just building toilets, though there is so far no formal recognition of ODF status within government policy and legislation. WSP has been collaborating with UNICEF and VIHEMA on the development of ODF criteria and a verification process, but this has not yet led to formal adoption of guidelines due to differing opinions among government and development partners on how many levels of ODF to recognise7. It is increasingly common in the sector globally to promote sanitation as a communal issue requiring collective action rather than a purely private issue for which households need to be convinced one-by-one. The adoption of a commune-wide sanitation definition within the PforR is a reflection of this emphasis (70% houshold hygienic sanitation, + all schools and clinics). 7. Learning note : “Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam: From Research Findings to Campaign Developmentâ€? This Learning Note summarizes key findings and insights from the research and design process used for the BCC campaigns and supply chain strengthening programs for Hoa Binh Province –selected as a representative province for Northern Mountain region as a ‘laboratory’ for developing and implementing strategies and tools in BCC and SC strengthening and the Mekong Delta region, in order to contribute to the delivery of ongoing and future rural sanitation programs in Vietnam. Using the same approach, table 10 below shows a comparison of the BCC design differences for the two regions, extracted from the learning note. Table 10: Comparison of Hoa Binh and Mekong Delta campaigns Hoa Binh campaign Mekong Delta campaign Drivers: Drivers: ï‚· pride and recognition ï‚· belief that feces does not contaminate fish and ï‚· belonging and social cohesion water quality ï‚· cleanliness, comfort ï‚· safety for children and the elderly ï‚· better health for children ï‚· privacy ï‚· status and affordability ï‚· being a good neighbour 7 Government is considering a proposal to adopt two levels: ODF 1 (basic ODF with 100% improved sanitation), and ODF2 (with higher levels of service). ODF definitions for use at village and commune level would also be adopted under proposed guidelines. Campaign concept: “Join hands for a clean Campaign concept: “It’s not what you think it isâ€? villageâ€? The campaign was developed based on changing Given the strong sense of community in misperceptions about the risks (or lack of) of using communes in Hoa Binh, the campaign unhygienic latrines. The four key risks include food highlights the personal, family, and safety (fish that is contaminated by eating feces), community benefits of having a hygienic swimming in contaminated water, falling into a latrine. It does this by emphasizing the fishpond and being seen while defecating. There were collective effort to create a cleaner also two key positive messages about collective action environment by all households. to build latrines and a message about how even poor families can afford a latrine. Messages: Nine key messages were Messages: Six key messages were developed that developed that included, among others: included, among others: ï‚· Be a better neighbor. ï‚· Don’t feed your children fish feces - stop defecating ï‚· Be a pioneer, be a bright example. in the water! ï‚· Provide comfort for your family ï‚· Don’t put the elderly and children at risk - stop ï‚· Act for solidarity. using hanging latrines! ï‚· Make your community a better place to ï‚· Don’t let women be embarrassed - stop using a live. hanging latrine! ï‚· Be a good example and good neighbor - help each other build a hygienic latrine now! ï‚· Even poor families can build a hygienic latrine! Tone: The tone is positive and aspirational Tone: The tone is sharp, direct and shocking, with crisp, clean visuals that capture the combining disgust and fear. There are, however, two beauty of Hoa Binh Province. The motivational and aspirational messages to promote the encouraging and suggestive tone reflects a benefits of latrines. The tone reflects the preference preference for a more roundabout, indirect amongst southern Vietnamese for more style of communication among northern straightforward communication style. Vietnamese. The visuals depict realistic situations in front of The color green was chosen for its association fishpond latrines, unlike in Hoa Binh where latrines are with being fresh, clean and healthy and the not featured in any of the key visuals. flower depicts households that are connected together in a community. 5 Lessons learned and recommendations The TAs have influenced the sector in many ways as summarized in table 11. Table 11: Summary of TA Influence in the rural sanitation sub-sector # Issues Before the TAs During/After the TAs <2013 2014-2015 and afterwards 1 Political Political support for rural sanitation The profile of rural sanitation has increased support was limited, especially at provincial among provincial decision makers in Hoa Binh level. province resulting in rural sanitation being included in the Provincial Economical and Social Development Plan. 2 Technical Some technical capacities exist for - Technical capacity at central level in Capacity rural sanitation at different level of delivering rural sanitation has improved. the government. However, - Capacity development plan for rural implementation experience and sanitation with focus on sustainable delivery knowledge have been scattered and of capacity building for health staff has been have not addressed the systematic developed, including comprehensive capacity gaps. curriculum. - Technical capacity of health staff at provincial level has improved in conducting rural sanitation intervention using strategic approach. 3 Budget Provincial budget allocated for rural Through VIHEMA and provincial CPMs, more planning and sanitation has predominantly been rural sanitation budget have been allocated use used for latrine construction, which to support soft activities in NTP3 in many was called “demonstration latrinesâ€?. provinces (such as Hoa Binh, Gia Lai, Ha Nam, Limited budget has been allocated for Lao Cai, Nam Dinh and Yen Bai). In many conducting soft activities such as provinces, the proportion of NTP3 sanitation behaviour change communications. budget allocated for soft activities amounted to 20% of total rural sanitation budget at early years of NTP3, and has increased to 60% - 100% in 2015. 4 Approach for The approach for scaling up rural A clear approach to rural sanitation has been scaling up rural sanitation has been unclear. Variety developed based on evidence from the pilot sanitation of approaches have been introduced experience in Hoa Binh province. The level of in NTP3 for pilot implementation, confidence at central level in the rural including CLTS, Community Health sanitation approach is high and is being Club, Sanitation Marketing, etc. introduced by VIHEMA to 21 provinces participating in the new PforR 5 Demand The demand creation for sanitation Evidence-based BCC strategy and tools for creation has been historically based on rural sanitation focusing on socio-emotional generation traditional IEC materials which drivers are now available for use in two predominantly carry health-based regions in Vietnam, Mekong and Northern messages. Mountains. 6 Supply chain Although there have been some Sanitation business model that could capture development works supported by different the majority in the market has been organizations on engaging with developed and proven. For the model to be private sector in rural sanitation, application in remote areas, some adaptation clear business model has not been will be needed. well documented making replicability difficult. 5.1 Lessons learned During the past three years much has been learned about challenges to scale up rural sanitation and the rather fundamental shift in mind-set required among policy makers, political leaders at provincial, district and even commune level, as well as among health system implementers. The environment in which such changes have happened and hence results were achieved, has benefited from intense technical support and hand-holding through this TA. The next generation of TA for Vietnam, given the at-scale Program-for-Results on rural sanitation, would have to leverage these lessons on how to best create buy-in of both high level decision makers, who need to approve and allocate funds in a different manner as in the past, and of government staff at the local level, who will need to apply new approaches on the ground. The real challenge is how in the next years this can be done in more provinces, with less intense external support, thus relying more on internal government mechanisms and platforms, harnessing and fostering a new generation of sanitation champions. To achieve sanitation results, both lessons on the operational and policy level are thus critical to not be lost while scaling up implementation. Fine tuning last mile delivery aspects is essential for achieving results on the ground - especially under a Program-for-Results – where government is in the driving seat to determine how they are going to deliver rural sanitations services. It is the operationalization of the rural service delivery approach - that emphasizes demand creation, supply chain strengthening and putting in place the capacities at local level using the Vietnamese government system - that will contribute to future success. At policy level, a number of critical dimensions in the enabling environment remain unaddressed, although some progress was made during the TA-period. Operational level Creating demand for rural sanitation 1. Using evidence-based sanitation behaviour change communications - not based on health motivators - requires intense effort to be accepted by national and senior provincial implementers Senior government health leaders, especially at provincial level, may be quite comfortable with their established approaches to hygiene promotion, emphasizing education and information (and often health- based messaging) rather than socio-emotional drivers and addressing normative barriers for behaviour change. Hence, involving them from the start in the development of innovative BBC campaigns, providing orientation and training and allowing time for them to adapt and appreciate new tools and methodologies is a critical step. VIHEMA’s team, who has benefited from international exposure and exchange visits over the course of the TA, has been able to exert strong leadership in this process, however, provincial level acceptance is equally important. While grass-root level implementers at commune level often are more open to try out “new waysâ€?, getting the full support from provincial health systems for adopting a new BCC campaign is essential and difficult, as at that level resistance to deviate from established practices may be highest. Well-designed study tours and exchange visits - both within the country and internationally - can be particularly useful in demonstrating to government staff and other stakeholders the potential of new approaches to BCC and sanitation promotion generally. 2. Adapting behaviour change communication toolkits for different regions is doable through rapid qualitative spot-research, but should not lead to short-cuts in field testing with target audiences Typically the development of evidence-based behaviour change communications toolkits takes a minimum of 1.5 years, especially if broad quantitative research is being proposed to inform the BCC strategy. However, this TA has demonstrated that, building on an existing toolkit, the application of qualitative rapid sport research, and building on the skills and capacities of the VIHEMA team, these development lead times can be considerably shortened (to around 9-12 months). Adaptation processes can align with overall sanitation campaign logo, but do require different motivators, drivers, as well as overall concept and tone of the campaign to achieve the desired behaviours. It is important that any adaptation of a toolkit does not compromise on user testing. Field-testing of concept, visuals, and messaging remains essential to ensure that BCC materials are persuasive, engaging and well understood by target audiences as well as easy to implement by local cadres. 3. At-scale demand creation needs to elicit maximum household self-investments; the use of public funds needs to shift towards promotion and BCC, combined with smart incentives for the poor The TA demonstrated that households do have some level of willingness to pay for hygienic toilets even in the poorest and most underserved locations. Using public funds for a few ‘demonstration’ latrines is unlikely to have much impact, especially when designs are unattainable for poor households without substantial external support. Shifting the use of public funds towards promotion and BCC activities has shown to stimulate demand and lead to much faster changes in sanitation access (see Hoa Binh evaluation results). While the TA learned that 80% of the households used savings as the main source of funds for building latrines, poor household did not see the same change in access. Hence, a balanced approach may be sought in which carefully designed and targeted assistance to the poorest families, for example via voucher schemes or output-based subsidies, could be introduced alongside intense promotion activities at commune level, and efforts to strengthen local supply chains. This area needs to further explore. 4. Planning and budgeting support for demand creation is essential, adopting a multi-year timescale for campaigns and adequate support for capacity building. It is normal practice among provincial health departments to divide limited funding over all districts in a province and work through the communes in annual turns. Given the need to build sufficient capacity at commune level and the fact that government activities have a short window of implementation due to late budget approvals8, interventions would need at least two years in order to see some significant change in sanitation uptake. The TA has demonstrated that targeted planning (on underserved districts) – based on district and commune data – and simple budget and planning tools for demand creation activities are important to adopt realistic timescales and ensure sufficient time is invested to build necessary capacities. This training proved to be especially important for health centre staff in order to use new promotional tools effectively, as most do not have expertise in behaviour change. 5. Effective village-level delivery and commune leadership is critical for broad campaign outreach and social mobilization During implementation and based on the qualitative results of the Hoa Binh evaluation, several lessons about effective village and commune level engagement were learned: ï‚· Village sanitation maps were found to be effective by both staff and communities, as it helped to create a healthy competition between households. Consistently using village meetings to update these maps and recognize household achievements proved effective, as organizing regular dedicated sanitation meetings is not feasible given villagers’ time constraints. ï‚· Community events with a sanitation theme proved popular (music, dance, drama etc.) and have a dual benefit: delivery of messages to target audience, and rallying for broad support from commune leaders and representatives of other mass organizations (youth and women unions) ï‚· Village-based health motivators are not government staff and if they are to devote significant time and effort to sanitation promotion, it reasonable to offer them incentives for their effort, such as through sales commissions, output-based incentives, and public recognition9. 6. Self-understanding of sanitation mandate may need clarification and articulation of district level role is required for more effective support to implementation of commune and village activities; Though responsibility for sanitation and hygiene promotion in rural areas is clearly assigned to the health department, the self-understanding of these specific tasks at provincial, district and commune level is patchy. Especially in areas, where mandates have been “outsourcedâ€? to for example Vietnam Women Union, such as under various project (including WB) or NGO arrangements in the Mekong delta, 8 Typically budgets are only released 6 months into the fiscal year, leaving short period for implementation 9 East Meets West Foundation will soon publish the results of their research in which village-promoter incentives were given for sanitation. sanitation promotion and behaviour change communications may not be perceived as a core function of provincial CPMs. Furthermore, the role of district PCM in sanitation and hygiene promotion is underdeveloped at present, with provincial CPM taking on much of the responsibility. Identifying clear roles and responsibilities for district level would reduce the workload of pCPM and give responsibility for day-to-day planning and co-ordination to staff who have a closer working relationship with the commune leaders, commune cadres and communities served. Given that on average there is one provincial staff for 178.5 communes, and one district staff for 36.2 communes, developing health cadre capacity closes to implementation level is critical. Strengthening supply chain for rural sanitation 7. Role and practical tasks for government in facilitating the sanitation market needs to be clearly articulated and may need to be outsourced due to internal capacity constraints. One of the implementation challenges that stems from the paradigm shift in rural sanitation service delivery is the changed role of government with respect to the supply chain. In the business as usual scenario, most pCPMs would “procureâ€? a limited number of demonstration latrines - mostly fully paid with provincial funds, and sometimes delivered through local contractors - based on a standardized model approved in their province. However, a supply chain strengthening approach requires that health system staff move away from this direct implementation role to a facilitating, supporting role, in which they would help to identify suitable businesses that could operate as SANCONs or “Sanitation Convenience Shopsâ€?. Due to health actors’ lack of familiarity with such approach, the TA program engaged an external agency to train and coach suppliers and their sales agents in adopting the new business models. Not only are such tasks new to government, there also is not yet a full appreciation of the mutually beneficial relationships and partnership approach between government and local private sector actors in support of rural sanitation outcomes. Going forward, government roles and tasks should be carved out more clearly, such as: i) regulations on “approvedâ€? latrine options and installation procedures, ii) provision of information to all parties, execution of BCC campaigns, including information products and price ranges iii) fostering direct linkages between private sector, sales agents and village-based sanitation promoters. The direct training and continuous support role to businesses and sales agents may not be a natural fit for the capacities and comfort zone of provincial and district health cadres. Provinces may thus decide to engage external consultants or actors to help build the capacity of the local private sector10. 8. Newly introduced latrine options need to respond to perceived consumer benefits, be accompanied with aspirational marketing and limit the number of product options In remote rural areas, people tend to prefer what they know – in the case of Hoa Binh but also the Mekong, this means rather expensive septic tank systems, with sometimes over-dimensioned tanks and a preference for brick11. In Hoa Binh, it has taken time for rural households to get used to an alternative model based on concrete rings and - when too many options are offered – confusion leads to choice paralysis, and not to purchasing decisions. A substantial PR and marketing component is therefore needed when introducing new designs. It is important that the benefits that consumer identify with are clearly communicated for these options (no smell, quality, durability, but also intangible benefits such as status). For example, TA program found that it was counter-productive to promote affordable options as “cheapâ€?, as most people prefer to install a durable, high-quality facility. Hence the positioning of the new product should not only be based on price. 9. The SANCON model has demonstrated potential, but requires modification especially for remote areas with dispersed villages and weakly developed supply chains. 10 Globally, only limited experiences exist in at-scale models where such support functions have been effectively and sustainably delivered through for example national business associations, or through social franchise structures (private-sector model). Given the remote nature of Vietnam’s lagging provinces, the nature of businesses that would become SANCONs and the string role of government, this TA does not propose such national platforms (associations, social franchise), but rather a government-led market facilitation model in which specific capabilities could be outsourced from external consultants/actors. 11 as most septic tanks are sold through masons who have a vested interest in building brick-models Most SANCON operators generated less business than had been anticipated and of those households who built a new hygienic toilet in Hoa Binh, only 20% used a ‘Convenience Shop’ and most built the toilet themselves. SANCONS enabled households to build a good quality toilet for a reasonable price, while problems earlier identified with self-built facilities such as poor quality and odour problems may not have been fully resolved through the product catalogues information provided to households. Although it is commonly found that in most start-up sanitation marketing programs, it takes time for enterprises to penetrate the market, the TA learned that such constraints are even more profound in remote areas12. The limited use of SANCONS thus far, mostly based in accessible district or commune centres, is rooted in the introduction of new products (mostly toilets made using concrete rings), consumer preferences to continue using local labour/masons, as well as the low profit margins in remote, disperse locations with high transportation costs. For such areas a modified approach is proposed, in which linkages between SANCONs and local shop owners could be facilitated, as well as further innovations where mason-led latrine construction would be promoted. 10. Effective sales agents can be from various backgrounds and be recruited among existing local volunteer cadres; especially in remote areas these roles could be combined with village level sanitation promoter roles. Active sales agents are an essential component of the SANCON business model. The TA demonstrated that people from diverse backgrounds can make good agents providing they have the necessary motivation and communication skills, which often can be found among existing village cadres. Combining sanitation promotion sessions and the use of simple and clear catalogues of latrine options and prices, which can be purchased at SANCONs, can help households to access netter quality products and can provide motivation for village volunteers to continue village and household BCC visits. Policy level 11. Strengthening government ownership and leadership is vital for progress in rural sanitation and advocacy activities are necessary down to the commune level One of the biggest achievements of the TA was to secure government ownership and leadership at national and local level. Within Ministry of Health, and VIHEMA, household sanitation is now given a higher priority and is not solely seen as a “private issueâ€?, especially due to evidence-based advocacy around health, economic and nutrition outcomes related to poor sanitation practices (and sanitation is not just understood as solid waste and drainage). The TA learned that targeted advocacy at all levels, from province, district, down to commune, is needed to increase understanding of the ‘public good’ dimension of household sanitation. The inclusion of targets in the Provincial Economic and Economic Plan helps to bring rural sanitation up to priority level and needs to be cascaded down to the District and Commune level Economic and Economic Plan, to make sure the priority is conveyed to all lower levels. For the last mile delivery approach, fostering active support of Commune People’s Committees, which oversee promotional activities at community level is essential, to generate public interest in sanitation and the active engagement of local health staff. 12. Government funding for sanitation and hygiene promotion remains inadequate and omits the financing of essential supply chain and promotion activities In addition to the challenges in amount and timeliness of funds transfers for sanitation 13, a complicating factor is that government budget lines do not include provision for some important activities such as sanitation promotion events or the orientation and training of private sanitation businesses. As a new financial regulation is to be introduced for the New Countryside Development NTP, this may provide the opportunity to change the eligible cost items for rural sanitation promotion (potentially also including incentives for village promoters). 12 Similar low levels of market penetration (20%) were found through early sanitation marketing programs in remote rural areas of Lao PDR, while in Cambodia typically newly established sanitation enterprises were able to capture 30-50% of sales.. 13 These challenges reflect weaknesses in the public financial management system generally, and resolving these is beyond the scope of this TA. 13. Monitoring systems are inadequate; a simplification of the hygienic latrine definition would help to resolve some ambiguities. One of the challenges in tracking progress towards national sanitation targets is the somewhat complicated ‘hygienic’ latrine definition adopted by government. The definition has two components: physical construction and maintenance status. The latter is very difficult to assess and creates a high risk of inconsistency in reporting. Simpler and less ambiguous criteria would help to strengthen sector monitoring14. Current monitoring systems used by MoH and provincial governments vary in quality between provinces and districts and a paper-based system with ambiguous criteria for latrine types complicates the consolidation of data from District Health Centres by the pCPMs. Lessons from of the M&E system in the Red River Delta PforR should be scaled up. 14. Institutional capacity building could leverage the existence of regional MoH institutes rather than one-off ToT approaches at central level; in the medium term a financing approach is required, preferably combining national core funding for capacity development, with provincial allocations for training provinces and district implementers on a demand-basis. While the operational guideline for rural sanitation has defined the service delivery approach in detail, the TA aimed to develop an institutionalized capacity building approach to support its implementation. The current approach is through central and provincial ToTs, lacking anchoring of a systematic curriculum within local organizations. Given that implementation capacity of health staff will remain a critical need in the decade to some, there is an opportunity to use four MoH training institutes as professional training agencies on rural sanitation. Modalities could include provinces sending their staff to training courses organized annually by the Institutes, or on a demand basis invite Institute’s staff to support trainings at provincial and district level, with expenditures covered by provinces (e.g. through allocating resources available from the Program-for-Results financing). 15. A Strategic Guideline is also very important for management level A Guideline is not always very detailed but can be pitched at a strategic level, for managers at province and district level rather than for implementers such as commune cadres and field sanitation volunteers. The Guideline can include content in the form of best practice principles and options rather than a detailed and prescriptive process for village-level interventions. This is very important for the sub-sector to introduce a more holistic approach to sanitation that address not just demand generation but also supply side strengthening and creation of an enabling environment. 5.2 Recommendations Given the phasing out of the National Target Program for Rural Water Supply and Sanitation, recommendations focus on potential new vehicles that could be used to address sanitation issues in the future. Several of the lessons learned articulated above are already reflected in the new multi-year TA that has been designed to strengthen the implementation of the Program for Results in 21 lagging provinces in the Northern Mountains and Central Highland regions. The below recommendations thus focus on complementary areas, where the Government of Vietnam, or in particular VIHEMA and provincial governments, would need to strengthen its policies or guidance. MoH / VIHEMA and provinces Effective strategies and tools that were developed and tested under the TA should be advocated for wider use in other districts and provinces – especially those where funding is already available under World Bank-assisted programs. But with NTP3 ending shortly, sanitation risks being marginalised both by government and development partners within the forthcoming ‘New Countryside Development’ NTP. Advocacy among senior policy makers at national level (right up to the Prime Minister) should be 14 and are already being tested under the ongoing Program-for Results intensified to further raise the profile of sanitation on the national development agenda and secure increased funding. Once the contours of the new Country Side Development are more clearly articulated, it will be important for VIHEMA to establish: ï‚· A templated advocacy package for provincial governments, not just regarding the need to invest in sanitation, but also with clear guidance on how to spend differently on sanitation so that limited funds can be used more effectively as under NTP3; ï‚· Dedicated national sanitation planning and budget exercises, emphasizing demand generation, supply chain support and capacity building and monitoring. ï‚· A revised costing circular that recognizes and allows all necessary elements of the rural sanitation service delivery approach to be financed through provincial funds, including support to the supply chain, BCC community events for sanitation, rewards incentives for sanitation promoters and ways to deliver smarter partial subsidies to the poor ï‚· A clearer articulation of roles and responsibilities of various levels, especially a more pronounced role for district governments roles in sanitation service delivery, ï‚· An institutionalized capacity building strategy and action plan, including a financing strategy, and business plans for MoH regional institutes to cover core curriculum for sanitation; this action plan could also include the introduction of online courses to expand access to training for health workers in order to achieve efficiency gains ï‚· A policy guideline for achieving commune total sanitation status, especially as efforts to enact Open Defecation Free guidelines have not yet materialized, and process to track progress in provinces15. ï‚· Guidance document that articulates how other service delivery platform for rural development, such as under the New Country Site development (but also under existing Community-Driven Development projects financed by the World Bank) can be leveraged to introduce sanitation promotion and local business straining for sanitation, making optimal use of existing human resources, financing mechanism, and capabilities at village and commune level of such platforms. ï‚· Closer collaboration with the Ministry of Education for promoting more sanitation in schools. ï‚· More effective and accurate monitoring functions for rural sanitation. The issue of ambiguous and inaccurate monitoring for sanitation usage has remain unresolved over the past years and needs to be carefully looked at based on the M&E initiative under the Red River Delta PforR. ï‚· Assessment of the current septage management for promoting and developing guidance on proper septage collection and treatment. World Bank/WSP Future support from the Water Practice will be directed to support implementation of the PforR in 21 lagging provinces in the Northern Mountains and Central Highlands, and already includes specific support for advocacy, BCC campaign development and implementation, market facilitation support and capacity building16. In addition to the ongoing program, the following three recommendations for future TA are provided that would help to sustain, deepen and further scale the results to support the achievement of the SDGs 15 This may be aligned with the PforR “commune wide sanitationâ€? definition, however, it could also include a second level of total sanitation commune, that recognizes 100% access to safely managed sanitation, in line with the future SDGs 16 See the PCN for Pxxxx what is this xxxx? (i) Support the development of a financing plan for institutionalizing capacity development under the Capacity Development Strategy and Action plan, in a post-NTP3 environment (and potential on-line course content) (ii) Given the investments in the adaptation of the toolkit for the Mekong Delta, and the institutional limitations of the World Bank Water Resources for Rural Development project (WB6) to fully adopt the toolkit and rural sanitations service delivery approach at scale17, a future TA program for the strategic Mekong delta could be explored, aligned with a relevant WB operation. Of all the households in Vietnam that do not have hygienic latrines, more than half live in the delta, where climate change and pollution are having an increasingly negative effect on socio-economic development and public health. (iii) Strengthen the monitoring functions for rural sanitation. The issue of ambiguous and inaccurate monitoring for sanitation usages has remain unresolved over the last years. Given the considerable investments of the government in external auditing functions for sanitation verification under the ongoing PforRs, additional TA could further explore how administrative systems could routinely be strengthened, including third party verification. This TA would have to further build on the results of DFAT TA to Red River Delta, which already aimed to improve systematic M&E functions of the government. 17 Only 56 (out of 1300 in the entire Mekong Delta) communes would be targeted under this project. Moreover, the siting of the project with MARD, the complicated implementation arrangements and lack of motivation of pCPMs in the project institutional set-up, as well as the “public procurement approachâ€? towards latrines, has hindered the effective implementation of the rural sanitation component thus far. Annexes 1 Research on Policies and Legislation on Rural Sanitation 2 Qualitative Assessment of Programmatic Approaches to Sanitation in Vietnam 3 Behavioral Determinants of Sanitation and Handwashing with Soap in Vietnam: a Review of Current Studies and Behavior Change Communication Materials since 2006. 4 Review of current studies on Rural Sanitation Supply Chain in Vietnam produced in May 2013 5 Sanitation Consumer Demand and Supply Chain Assessment for the Hoa Binh province 6 Rural Sanitation Sector Capacity Assessment Report 7 Report on Post Intervention Assessment in Hoa Binh province 8 Poverty and Sanitation maps http://sdvmd1.worldbank.org/poverty_and_sanitation/ 9 Guidelines for Patriotic Sanitation Movement Implementation 10 Guideline for the Planning and Implementation of Rural Sanitation Program 11 Provincial Rural Sanitation Behavior Change and Market Strengthening Strategy, Period 2015- 2020 for Hoa Binh province 12 Rural Sanitation Behavior Change and Market Strengthening Strategy, Period 2015-2020 for Mekong River Delta provinces 13 Capacity Building Strategy for Rural Sanitation Sector 2015-2020 and Orientation 2025 14 Six Training Packages for Rural Sanitation Planning and Implementation 15 Investing in the Next Generation: Children grow taller, and smarter, in rural, mountainous villages of Vietnam where community members use improved sanitation (Research Brief) 16 Learning Note on Understanding Determinants of Assess to Hygienic latrines for Rural Households Across Vietnam: From Research Findings and to Campaign Development 17 Hoa Binh BCC and Marketing toolkit: ï‚· Manuals: provincial and district, commune health staff, and motivators ï‚· Manuals for Sanitation Convenience Shop Owners and Sale Agents ï‚· Training documents specifically on how to use the tool for different health office levels: provincial, district, commune trainers ï‚· Posters (promotional, O&M) ï‚· Catalogue including technical options and costs ï‚· Sticker for latrine O&M ï‚· Video clip of activities to support the training 18 Mekong River Delta BCC and Marketing toolkit: ï‚· Manuals for provincial, district, commune health staff and motivators ï‚· Manuals for Sanitation Convenience Shop Owners and Sale Agents ï‚· Training documents : provincial, district, commune trainers ï‚· Posters ï‚· Flipchart including emotional pictures, O&M guidance, technical options and cost ï‚· Sticker for latrine O&M