WATER AND SANITATION PROGRAM: RESEARCH BRIEF Scaling Up Rural Sanitation 61296 Long Term Sustainability of Improved Sanitation in Rural Bangladesh October 20111 KEY FINDINGS INTRODUCTION When sanitation sector professionals hear the words ‘sanitation’ • A national focus on sanitation carried out by the Gov- and ‘Bangladesh’ the first thought that may come to mind is that ernment of Bangladesh at all levels likely helped to shift it is the birthplace of the Community-Led Total Sanitation (CLTS) social norms around open defecation and sustain latrine approach. However, there is more to the sanitation story from Ban- use at large-scale. gladesh that needs to be shared. Lessons extracted from the Ban- • Access to local, private sector providers of sanitation gladesh experience could richly inform sanitation strategies in other goods and services helps enable sustained latrine use countries, particularly those struggling to increase access to basic at scale. sanitation in rural areas. • Continued sanitation promotion reinforces latrine use and is positively associated with owning or sharing an Some background may be helpful. From 2003 to 2006, the Govern- improved latrine. ment of Bangladesh (GoB) scaled up efforts to address unsanitary household practices through a national sanitation campaign that engaged multiple levels of government. The government’s goals were to achieve 100% sanitation coverage and stop open defeca- tion in rural areas by 2010. PROBLEM STATEMENT The rapid scale-up of rural sanitation in Bangladesh using the total In a departure from previous efforts, this campaign emphasized the sanitation approach is starting to be adopted by many countries. confinement of feces from the environment rather than the con- Countries in South Asia, Southeast Asia, and Africa are looking for struction of a durable, sanitary latrine. It could be argued that this solutions to address the issue of basic access to rural sanitation, focus helped contribute to and accelerate latrine coverage and and it is important to learn from early pioneers (such as the GoB) cessation of open defecation. Additionally, during this campaign, who have applied the total sanitation approach at scale. One area central, district, and sub-district governments took collective action of particular interest for sector professionals and policy makers and played a lead role in social mobilization. The central govern- is to better understand both positive factors of sustainability and ment also rewarded Union Parishads (the lowest tier of adminis- factors that might work against sustainability of rural sanitation. trative government) that successfully promoted the installation of This knowledge could help inform future programming and policy latrines in all resident households, declaring the Union Parishads decisions. “100% sanitized� or open defecation-free (ODF). While local government took a lead role, various efforts from non- ACTION To learn about the sustainability of rural sanitation in Bangladesh, the governmental organizations (NGOs) helped to bolster and sup- Water and Sanitation Program (WSP) in conjunction with the GoB and port implementation in many areas before, during, and after the NGOs felt it was important to investigate several knowledge gaps: campaign. There were roughly four implementation approaches: 1) local government authorities received limited or no assistance 1) the degree to which sanitation behaviors and facilities are being from NGOs (GOB-only); (2) local governments received some sup- sustained in Union Parishads declared ODF at least four and a half port from international donor organizations (GOB-Donor); (3) local years ago; 2) the level to which sanitation programming has been governments received strong support from NGOs using Commu- sustained in these Union Parishads, and to the degree possible, nity-Led Total Sanitation methods (NGO-CLTS); and (4) local gov- whether this programming is contributing to sustained behaviors; 3) if ernments received strong support from NGOs not dedicated to using Community-Led Total Sanitation (NGO-Non-CLTS). 1 This report updates an earlier version released in May 2011. 2 Long Term Sustainability of Improved Sanitation in Rural Bangladesh Scaling Up Rural Sanitation there are perceived benefits associated with maintaining ODF status Figure 1: Percentage of Rural Household Latrine and if these benefits are contributing to sustained latrine use; 4) the Coverage in ODF-Declared Unions (n=3,000) degree to which private sector sanitation service providers have been sustained, and whether household access to them contributes to Based on GoB Definition Based on JMP Definition sustained latrine use; and 5) identifying other factors that may work in favor of or against sustained sanitation behaviors and facilities. 3% 8% 37% The research team used quantitative and qualitative research meth- ods to analyze the current status of 53 out of a universe of 481 Union Parishads declared ODF before June 2005 (Illustration 1). The study unions represented different geographic areas and the four imple- 52% 37% mentation approaches mentioned above. A household survey cov- ered 3,000 households in 50 of the Union Parishads, and qualitative 52% research was conducted in a sub-sample of 18 Union Parishads.2 8% 3% Unhygienic Improved Illustration 1: Location of Study Districts Hygienic Sharing otherwise improved Shared by > 2 households Unimproved/Hanging/Open pit IBRD 38410 MARCH 2011 No latrine/Open bush No latrine/Open bush BANGLADESH INDIA confining feces should not be neglected as they continue to pose a public health risk. Sylhet RAJSHAHI While access to an improved or shared latrine is high, the picture SYLHET Rajshahi varies depending on which definition is used to classify latrine ac- DHAKA cess. Based on definitions used by the GoB, only 37% of house- INDIA holds sampled met the criteria for a “hygienic� latrine (Figure 1, left); DHAKA based on definitions used by WHO and UNICEF Joint Monitoring Program, 52% met the criteria for an “improved� latrine, which ex- INDIA KHULNA cludes sharing (Figure 1, right). This implies there is more work to be Khulna done to help households improve current facilities. Barisal CHITTANGONG BARISAL Chittagong 70% of sample households have owned their current latrine for at least three years, indicating that the majority of latrines built are fairly durable. STUDY DISTRICTS Bay of Bengal DIVISION CAPITALS All four implementation approaches resulted in high rates MYANMAR NATIONAL CAPITAL DISTRICT BOUNDARIES of sustained latrine use and low rates of open defecation. DIVISION BOUNDARIES 0 20 40 60 80 100 KILOMETERS The use of improved or shared latrines and prevalence of open INTERNATIONAL BOUNDARIES defecation varied slightly across the four approaches. One pos- The 53 Union Parishads studied were located in 36 districts. sible explanation for the similarity in sustained outcomes across approaches could be the GoB’s countrywide commitment to dif- fuse the idea that latrine use is important for household health and development. The government’s commitment may have been the CURRENT STATUS cornerstone for influencing the social norms in favor of improved Four and a half years after the Union Parishads studied were de- sanitation behaviors and facilities, regardless of the specific ap- clared ODF: proach. (Figure 2). 89.5% of sample households own or share a latrine that safely confines feces. Of the remaining 10.5% of households, KEY FINDINGS 2.5% do not have any latrine; 5.5% have a hanging latrine or facility Programmatic and social factors correlated with sustained use of that drains directly into the environment; and 2.5% use an open pit improved latrines: without a slab. While this finding indicates some backsliding, the fact that the Union Parishads sampled in this study are not entirely Female-headed households were more likely to have an im- ODF should not overshadow the large-scale acceptance and use of proved or shared latrine compared to households headed by latrines that has taken place in these Union Parishads. At the same males.3 A possible explanation is related to the concept of purdah time, the 10.5% of households defecating in the open or not properly that exists in Muslim and Hindu cultures. A latrine offers women pri- vacy for defecating, urination, and menstruation management, which allows them to adhere to purdah and avoid the shame of being seen 2 Research was conducted by The Manoff Group, Planning Alternatives for Change and Pathways Consulting Services from October 2009 to April 2010. 3 All odds ratios in full report are statistically significant at p < .05. www.wsp.org Scaling Up Rural Sanitation Long Term Sustainability of Improved Sanitation in Rural Bangladesh 3 Figure 2: Percentage of Rural Household Latrine Other factors that enable the sustained use of improved latrines: Coverage by Approach (n=3,000)4 Social norms around open defecation and latrine use have positively changed, which likely was a result from sanitation 100% and hygiene promotion. Formerly, latrine use had been the norm 90% mostly among upper-income groups or in areas covered by earlier 80% campaigns. Now it is a socially accepted practice at all levels of society, Percentage 70% including the poorest wealth quintile. Those who continue to practice 60% open defecation are socially criticized. Marriage arrangements, village 50% respectability, and village purity for religious events are widely assumed 40% to require use of “hygienic/health-enhancing� latrines. One plausible 30% contributor to this shift in social norms is that the behavior change 20% communication campaign directed toward households was fairly per- vasive: campaign messages were communicated through various 10% channels and settings, including messaging by Union Parishad mem- 0% bers or officers at meetings, rallies, over loudspeaker announcements, CLTS on CLTs NGO GOB-Donor Non-CLTs-NGO GOB Donor GOB only GOB-only and household visits by Union Parishad members or NGO workers. Approach Improved While the average prevalence of open defecation across the study Sharing otherwise improved unions is low, it is important to understand the factors that contrib- ute to the continued behavior of open defecation and use of unim- Unimproved/Hanging/Open pit proved facilities among this segment of the population. No latrine/Open bush Factors correlated with unsustained use of improved latrines: by men at these times. This study suggests that the 2003–2006 campaign possibly tapped into latent demand by millions of females Poverty is a factor that affects sustained use of latrines. to have a latrine for cultural reasons. 89.5% of households own or share an improved latrine; however, those that continued to defecate in the open or did not use an im- Households that reported having been exposed to a follow- proved or shared latrine (10.5%) were largely represented by the up program were more likely to have an improved or shared two lowest wealth quintiles (Figure 3). latrine compared to those that did not receive a follow-up program.5 Additionally, households that were visited by someone Severe natural disasters have an effect on sustained use of who advised them on latrine use were slightly more likely to have latrines. More than 20% of households using unimproved latrines an improved or shared latrine compared to those who did not re- were located in Union Parishads impacted by severe natural disasters port receiving a visit. It was found that two-thirds of Union Parishad (cyclones, floods, or tornados) within the past three years. chairmen still promote sanitation by reminding constituents of the Lack of local leadership may affect sustained use of latrines. In importance of ‘hygienic’ latrine use, providing latrine parts to poor eight Union Parishads there was a higher concentration of households families, declaring local rules against open defecation, and following up on sanitation-related complaints. In-depth research in 18 Union Parishads showed that about half were still using their annual devel- Figure 3: Percentage of Rural Household Latrine opment program funds on sanitation. It was also noted that 26 out of Coverage by Wealth (n=3,000)6 the 53 Union Parishads studied had some form of follow-up program by an organization other than the Union Parishad. This study sug- 100% gests that on-going programming and continued reinforcing mes- 90% sages may be a contributing factor to sustaining sanitation behaviors 80% compared to households that did not receive such messages. 70% Percentage Access to private sector providers is a factor that enables sustained 60% use of improved latrines: 50% At least 95% of households reported an ability to access 40% to latrine materials and skilled masons in a local market. 30% Moreover, 74% of households knew where to find a latrine pit 20% cleaner. The emergence of a mature private sector means that 10% market forces have allowed most households to access afford- 0% able parts and services that can help sustain the use of improved 1st 2nd 3rd 4th 5th and shared latrines. Mass production of latrine parts has made Wealth Quintile latrine ownership a possibility for households of modest means, though not for the very poorest. It is important to note that the Improved businesses that remained operational since the end of the cam- Sharing otherwise improved paign tended to sell a variety of concrete products, and not just Unimproved/Hanging/Open pit latrine parts. No latrine/Open bush 4 Based on JMP definition 5 Ibid. 6 Based on JMP definition www.wsp.org 4 Long Term Sustainability of Improved Sanitation in Rural Bangladesh Scaling Up Rural Sanitation using unimproved facilities (more than 20%). month each year, helping to keep it A common characteristic was that none had on the government’s agenda, and Full report The complete report, Case Study on the a Union Parishad chairman who actively 3) using Annual Development Program Sustainability of Improved Sanitation in Rural worked on sanitation at the time of the study. Allocations issued by the central gov- Bangladesh, is available at www.wsp.org/ Additionally, five of the eight Union Parishads ernment for sanitation. scalingupsanitation. This report includes did not have a sanitation follow-up program. qualitative and quantitative analysis on behavioral outcomes such as latrine use, Financing mechanisms are needed sharing, disposal of children’s feces, operation INSIGHTS FOR FUTURE for households that want to re- and maintenance, and upgrading/repair to PROGRAMMING place or upgrade basic latrines, understand the factors that can lead to—or or move out of shared arrange- inhibit—sustainable sanitation outcomes. Considerations for governments and sec- Information on private sector providers, costs of tor professionals to sustain sanitation pro- ments. This could be accomplished latrine parts and services, institutional factors, gramming and behavior change at scale: by connecting microfinance institutions and perceived benefits of achieving ODF status. with service providers so that provid- Throughout, there is a focus on the poor and ers have the necessary cash flow to how they compare to other households with Government has to have the political more modest means. offer services/products on credit or in will to prioritize sanitation at the cen- installments. Moreover, some form of fi- tral and lower tiers of government. Bangladesh is an excellent example of nancing or subsidy option is needed for Acknowledgements the poorest that still have not achieved This Research Brief was prepared by Craig how sanitation was included in the coun- Kullmann, Task Team Leader for this study, basic sanitation. Subsidies that are tar- try’s poverty reduction strategy, which and Rokeya Ahmed, based on research and geted to the poor through community- a report prepared by Dr. Suzanne Hanchett, provided the road map for all levels of gov- based or self-selection methods may be Dr. Laurie Krieger, Mohidul Hoque Kahn, and ernment and civil society to take and sus- more effective in reaching the poor than additional team members. Technical inputs tain action on sanitation. Advocacy from were provided by Eduardo Perez, Jacqueline means-tested systems.7 the central government down to the local Devine, Jaehyang So, and Christopher Juan governments, led by the Minister of Local Costain. Editorial review was provided by Government, Rural Development and Co- Sanitation marketing can help sec- Amy Grossman. The full report on which operatives, was a factor in unifying the tor professionals better understand this Learning Note is based was produced consumer’s constraints and aspira- by The Manoff Group, Planning Alternatives country around sanitation. for Change, LLC, and Pathways Consulting tions. The barriers and benefits to using Services, Ltd. for WSP. Please see the full a latrine are likely to be different for those report for complete acknowledgements. Sustained sanitation programs are who continue to defecate in the open needed to support behavior change. and those who share a latrine. Market Local government authorities require research can help target an affordable About the program some level of sustained financing for Scaling Up Rural Sanitation is focused on level of service that gives consumers the continued sanitation promotion for an learning how to combine the approaches of most satisfaction, increasing the likeli- CLTS, behavior change communications, undetermined period of time. This study hood of sustained use of latrines. and social marketing of sanitation to generate showed that follow-up and reinforcing mes- sanitation demand and strengthen the supply sages appear to help with sustained use of of sanitation products and services at scale, 7 improved latrines. Bangladesh offers a good Tremolet, Sophie, Pete Kolsky and Eddy leading to improved health for people in rural Perez. 2011. Financing On-Site Sanitation for areas. It is a large-scale effort to meet the basic example of institutionalizing sanitation by the Poor—A Six Country Comparative Review 1) establishing a sanitation secretariat in sanitation needs of the rural poor who do not and Analysis. Available at www.wsp.org/ currently have access to safe and hygienic the government, 2) celebrating sanitation scalingupsanitation. sanitation. The initiative is being implemented by local and national governments with technical support from WSP. For more information, please visit www.wsp.org/scalingupsanitation. WSP is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. Contact us WSP’s donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Gates For more information please visit www.wsp.org or email Craig Kullmann at Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, wsp@worldbank.org. United States, and the World Bank. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. © 2012 Water and Sanitation Program