WATER AND SANITATION PROGRAM: TECHNICAL PAPER 71746 WSP Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Dr. Suzanne Hanchett, Dr. Laurie Krieger, Mohidul Hoque Kahn, Craig Kullmann, and Rokeya Ahmed October 2011 The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. By Dr. Suzanne Hanchett, Dr. Laurie Krieger, Mohidul Hoque Kahn, Craig Kullmann, and Rokeya Ahmed Today, 2.6 billion people live without access to improved sanitation. Of these, 75 percent live in rural communities. To address this challenge, WSP is working with governments and local private sectors to build capacity and strengthen performance monitoring, policy, �nancing, and other components needed to develop and institutionalize large scale, sustainable rural sanitation programs. With a focus on building a rigorous evidence base to support replication, WSP combines Community-Led Total Sanitation, behavior change communication, and sanitation marketing to generate sanitation demand and strengthen the supply of sanitation products and services, leading to improved health for people in rural areas. This Technical Paper is one in a series of knowledge products designed to showcase project �ndings, assessments, and lessons learned in Scaling Up Rural Sanitation. This paper is conceived as a work in progress to encourage the exchange of ideas about development issues. For more information please email Craig Kullmann at wsp@worldbank.org or visit www.wsp.org. This publication updates an earlier version released in June 2011. 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. WSP’s donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. WSP reports are published to communicate the results of WSP’s work to the development community. Some sources cited may be informal documents that are not readily available. The �ndings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its af�liated organizations, or to members of the Board of 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 Group concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh October 2011 Executive Summary Background Sanitation methods (NGO-CLTS); and (4) local govern- When sanitation sector professionals hear the words “sani- ments received strong support from NGOs not dedicated tation� and “Bangladesh� the first thought that may come to using Community-Led Total Sanitation (NGO-Non- to mind is that it is the birthplace of the Community-Led CLTS). The pioneering work and rapid scale-up of rural Total Sanitation (CLTS) approach. However, there is more sanitation in Bangladesh using the total sanitation ap- to the sanitation story from Bangladesh that needs to be proach is starting to be adopted by governments in South shared. Lessons extracted from the Bangladesh experience Asia, Southeast Asia, and Africa as they seek to address the could richly inform sanitation strategies in other countries, issue of basic access to rural sanitation. One area of par- particularly those struggling to increase access to basic sani- ticular interest for sector professionals and policy makers is tation in rural areas. to better understand both positive factors of sustainabil- ity and factors that might work against sustainability of Some background may be helpful. From 2003 to 2006, the rural sanitation. Knowing these could help inform future Government of Bangladesh (GoB) scaled up efforts to address programming and policy decisions. unsanitary household practices through a national sanitation campaign that engaged multiple levels of government. The Methodology government’s goals were to achieve 100 percent sanitation cov- To learn about the sustainability of rural sanitation in Ban- erage and stop open defecation in rural areas by 2010. gladesh, the Water and Sanitation Program (WSP), in con- junction with the Government of Bangladesh and NGOs, In a departure from previous efforts, this campaign empha- felt it was important to investigate: sized the confinement of feces from the environment rather than the construction of a durable, sanitary latrine. It could • First, the degree to which sanitation behaviors and be argued that this focus helped contribute to and accelerate facilities has been sustained in Union Parishads that latrine coverage and cessation of open defecation. Addition- were declared ODF at least four and a half years ago. ally, during this campaign, central, district, and sub-district • Second, the level of sanitation programming that has governments took collective action and played a lead role in been sustained in these Union Parishads, and assess social mobilization. The central government also rewarded to the extent possible whether this programming has Union Parishads (the lowest tier of administrative govern- contributed to sustained behaviors. ment) that successfully promoted the installation of latrines • Third, if there are there perceived benefits of being ODF in all resident households, declaring the Union Parishads and have they contributed to sustained latrine use. “100 percent sanitized� or open defecation-free (ODF). • Fourth, the degree to which private sector sanitation service providers have been sustained, and whether While local government took a lead role, various efforts household access to them contributes to sustained from nongovernmental organizations (NGOs) helped to latrine use; and bolster and support implementation in many areas before, • Lastly, identifying other factors that might work in during, and after the campaign. There were roughly four favor or against sustained sanitation behaviors and implementation approaches: facilities. (1) local government authorities received limited or no as- The research team used quantitative and qualita- sistance from NGOs (GOB-only); (2) local governments tive research methods to analyze the current status of received some support from international donor organi- 53 out of a universe of 481 Union Parishads declared ODF zations (GOB-Donor); (3) local governments received before June 2005 (Illustration 1). The study unions repre- strong support from NGOs using Community-Led Total sented different geographic areas and the four implementation www.wsp.org iii Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Executive Summary ILLUSTRATION 1: LOCATION OF STUDY DISTRICTS households defecating in the open or not properly confin- IBRD 38410 ing feces should not be neglected as they continue to pose MARCH 2011 a public health risk. BANGLADESH While access to an improved or shared latrine is high, the INDIA picture varies depending on which definition is used to clas- sify latrine access. Based on definitions used by the GoB, Sylhet only 37 percent of households sampled met the criteria for RAJSHAHI a “hygienic� latrine (Figure 1, left); based on definitions SYLHET Rajshahi used by WHO and UNICEF Joint Monitoring Program, DHAKA INDIA 52 percent met the criteria for an “improved� latrine, which DHAKA excludes sharing (Figure 1, right). This implies there is more work to be done to help households improve current facilities. INDIA KHULNA Khulna Barisal CHITTANGONG 70 percent of sample households have owned their cur- BARISAL Chittagong rent latrine for at least three years, indicating that the ma- jority of latrines built are fairly durable. STUDY DISTRICTS All four implementation approaches resulted in high Bay of Bengal DIVISION CAPITALS rates of sustained latrine use and low rates of open defeca- MYANMAR NATIONAL CAPITAL DISTRICT BOUNDARIES 0 20 40 60 80 100 KILOMETERS tion. The use of improved or shared latrines and prevalence DIVISION BOUNDARIES INTERNATIONAL BOUNDARIES of open defecation varied slightly across the four approaches. One possible explanation for the similarity in sustained out- comes across approaches could be the GoB’s countrywide commitment to diffuse the idea that latrine use is important approaches mentioned above. A household survey covered for household health and development. The government’s 3,000 households in 50 of the Union Parishads, and quali- commitment may have been the cornerstone for influencing tative research was conducted in a sub-sample of 18 Union Parishads. Survey Results FIGURE 1: PERCENTAGE OF RURAL HOUSEHOLD LATRINE COVERAGE IN ODF DECLARED UNIONS (N = 3,000) Four and a half years after the Union Parishads studied were declared ODF: Based on GoB Definition Based on JMP Definition 3% 8% 89.5 percent of sample households own or share a latrine 37% that safely confines feces. Of the remaining 10.5 percent of households, 2.5 percent do not have any latrine; 5.5 per- 52% cent have a hanging latrine or facility that drains directly 37% into the environment; and 2.5 percent use an open pit 52% without a slab. While this finding indicates some backslid- 8% 3% ing, the fact that the Union Parishads sampled in this study Key Unhygienic Improved are not entirely ODF should not overshadow the large-scale Hygienic Sharing otherwise improved acceptance and use of latrines that has taken place in these Shared by > 2 households Unimproved/Hanging/Open pit Union Parishads. At the same time, the 10.5 percent of No latrine/Open bush No latrine/Open bush iv Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Executive Summary FIGURE 2: PERCENTAGE OF RURAL HOUSEHOLD LATRINE households that were visited by someone who advised COVERAGE BY APPROACH (n = 3,000)1 them on latrine use were slightly more likely to have an 100 improved or shared latrine compared to those who did 90 not report receiving a visit. It was found that two-thirds 80 of Union Parishad chairmen still promote sanitation by 70 reminding constituents of the importance of ‘hygienic’ la- Percentage 60 trine use, providing latrine parts to poor families, declar- 50 40 ing local rules against open defecation, and following up 30 on sanitation-related complaints. In-depth research in 18 20 Union Parishads showed that about half were still using 10 their annual development program funds on sanitation. It 0 was also noted that 26 out of the 53 Union Parishads stud- CLTS Non-CLTS-NGO GoB donor GoB only ied had some form of follow-up program by an organiza- Approach Key tion other than the Union Parishad. This study suggests Improved that on-going programming and continued reinforcing Sharing otherwise improved messages may be a contributing factor to sustaining sani- Unimproved/Hanging/Open pit tation behaviors compared to households that did not re- No latrine/Open bush ceive such messages. Access to private sector providers is a factor that enables the social norms in favor of improved sanitation behaviors sustained use of improved latrines: and facilities, regardless of the specific approach (Figure 2). At least 95 percent of households reported an ability to Key Findings access to latrine materials and skilled masons in a local Programmatic and social factors correlated with sustained market. Moreover, 74 percent of households knew where use of improved latrines: to find a latrine pit cleaner. The emergence of a mature private sector means that market forces have allowed most Female-headed households were more likely to have households to access affordable parts and services that can an improved or shared latrine compared to households help sustain the use of improved and shared latrines. Mass headed by males.2 A possible explanation is related to the production of latrine parts has made latrine ownership a concept of purdah that exists in Muslim and Hindu cul- possibility for households of modest means, though not for tures. A latrine offers women privacy for defecating, urina- the very poorest. It is important to note that the businesses tion, and menstruation management, which allows them that remained operational since the end of the campaign to adhere to purdah and avoid the shame of being seen by tended to sell a variety of concrete products, and not just men at these times. This study suggests that the 2003–2006 latrine parts. campaign possibly tapped into latent demand by millions of females to have a latrine for cultural reasons. Other factors that enable the sustained use of improved latrines: Households that reported having been exposed to a follow-up program were more likely to have an Social norms around open defecation and latrine use improved or shared latrine compared to those that have positively changed, which likely was a result from did not receive a follow-up program.3 Additionally, sanitation and hygiene promotion. Formerly, latrine use had been the norm mostly among upper-income groups 1 Based on the WHO/UNICEF Joint Monitoring Programme for Water and Sanitation. 2 All odds ratios listed in Table 9, page 21 are statistically significant at p<.05. or in areas covered by earlier campaigns. Now it is a so- 3 Ibid. cially accepted practice at all levels of society, including the www.wsp.org v Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Executive Summary poorest wealth quintile. Those who continue to practice Poverty is a factor that affects sustained use of latrines. open defecation are socially criticized. Marriage arrange- 89.5 percent of households own or share an improved la- ments, village respectability, and village purity for religious trine; however, those that continued to defecate in the open events are widely assumed to require use of “hygienic/ or did not use an improved or shared latrine (10.5 percent) health-enhancing� latrines. One plausible contributor to were largely represented by the two lowest wealth quintiles this shift in social norms is that the behavior change com- (Figure 3). munication campaign directed toward households was fairly pervasive: campaign messages were communicated Severe natural disasters have an effect on sustained use of through various channels and settings, including messaging latrines. More than 20 percent of households using unim- by Union Parishad members or officers at meetings, rallies, proved latrines were located in Union Parishads impacted over loudspeaker announcements, and household visits by by severe natural disasters (cyclones, floods, or tornados) Union Parishad members or NGO workers. within the past three years. While the average prevalence of open defecation across Lack of local leadership may affect sustained use of la- the study unions is low, it is important to understand the trines. In eight Union Parishads there was a higher con- factors that contribute to the continued behavior of open centration of households using unimproved facilities (more defecation and use of unimproved facilities among this seg- than 20 percent). A common characteristic was that none ment of the population. had a Union Parishad chairman who actively worked on sanitation at the time of the study. Additionally, five of the Factors correlated with unsustained use of improved latrines: eight Union Parishads did not have a sanitation follow-up program. Insights for Future Programming Considerations for governments and sector professionals to FIGURE 3: PERCENTAGE OF RURAL HOUSEHOLD LATRINE sustain sanitation programming and behavior change at scale: COVERAGE BY WEALTH (N = 3,000)4 100 Government has to have the political will to prioritize 90 sanitation at the central and lower tiers of government. 80 Bangladesh is an excellent example of how sanitation was 70 included in the country’s poverty reduction strategy, which Percentage 60 provided the road map for all levels of government and civil 50 society to take and sustain action on sanitation. Advocacy 40 from the central government down to the local govern- 30 ments, led by the Minister of Local Government, Rural 20 Development and Cooperatives, was a factor in unifying 10 0 the country around sanitation. 1st 2nd 3rd 4th 5th Wealth Quintile Sustained sanitation programs are needed to support Key behavior change. Local government authorities require Improved some level of sustained financing for continued sanitation Sharing otherwise improved promotion for an undetermined period of time. This study Unimproved/Hanging/Open pit showed that follow-up and reinforcing messages appear to help No latrine/Open bush with sustained use of improved latrines. Bangladesh offers a good example of institutionalizing sanitation by (1) establish- 4 Based on the WHO/UNICEF Joint Monitoring Programme definitions of sanitation. ing a sanitation secretariat in the government, (2) celebrating vi Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Executive Summary sanitation month each year, helping to keep it on the government’s agenda, and (3) using Annual Development Program Allocations issued by the central govern- ment for sanitation. Financing mechanisms are needed for households that want to replace or upgrade basic latrines, or move out of shared arrangements. This could be accomplished by connecting microfinance institutions with service providers so that providers have the necessary cash flow to offer services/products on credit or in installments. Moreover, some form of financing or subsidy option is needed for the poorest that still have not achieved basic sanitation. Subsidies that are targeted to the poor through community-based or self-selection methods may be more effective in reaching the poor than means-tested systems.5 Sanitation marketing can help sector professionals better understand con- sumer’s constraints and aspirations. The barriers and benefits to using a latrine are likely to be different for those who continue to defecate in the open and those who share a latrine. Market research can help target an affordable level of service that gives consumers the most satisfaction, increasing the likelihood of sustained use of latrines. 5 Financing On-Site Sanitation for the Poor—A Six Country Comparative Review and Analysis, available at www.wsp. org/wsp/sites/wsp.org/files/publications/financing_analysis.pdf www.wsp.org vii Contents Executive Summary.................................................................. iii Acknowledgements ................................................................. xv Terms and Acronyms .............................................................. xvi I. Introduction ............................................................................... 1 1.1 The Bangladesh Context ...................................................... 1 1.2 The History of Sanitation Promotion in Bangladesh ............ 2 1.3 Study Goals and Objectives...........................................................2 1.4 Implementation Models Used in Union-level ODF Campaigns ...3 1.5 Background Information on Bangladesh Governmental Administration..............................................................................3 1.6 Guiding Concepts ................................................................ 4 1.7 Organization of the Report ................................................... 4 II. Methodology .............................................................................. 6 2.1 Definitions and Terminology ................................................. 6 2.2 Study Union and Village Selection Procedures .................... 7 2.3 Household Survey: Data Collection and Analysis ................ 8 2.4 Qualitative Research in Selected Unions ............................. 9 2.5 Limitations of the Study ..................................................... 10 III. Status of Latrine Facilities and Defecation Arrangements: Latrine Characteristics, Durability, and Changes................... 12 Key Findings ............................................................................. 12 3.1 Status of Household Latrines and Prevalence of Open Defecation ................................................................ 12 3.2 Household Latrine Ownership, Sharing, Maintenance, and Practice ....................................................................... 30 3.3 Summary of Findings for Study Objective No. 1 ................ 41 IV. Perceived Benefits of Being ODF and Using Latrines ........... 43 Key Findings ............................................................................. 43 4.1 Remembering the ODF Campaign ..................................... 43 4.2 Perceived Benefits of Being an ODF Community .............. 44 4.3 Perceived Social and Health Benefits of Latrine Use ......... 46 4.4 Satisfaction with Current Defecation Place ........................ 47 4.5 Pockets of Dissent ............................................................. 48 4.6 Sanitation Experiences of Poor Households ...................... 50 4.7 Purity, Pollution, and Purdah: The Cultural Context of Sanitation Change in Bangladesh ...................................... 52 4.8 Gender Considerations ...................................................... 54 4.9 Summary of Findings for Study Objective No. 2 ................ 55 www.wsp.org Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Contents V. Institutional and Community Support for Sustainability ........ 56 Key Findings ............................................................................. 56 5.1 Local Sanitation Histories and Campaigns ........................ 56 5.2 Approaches Used in the Sanitation Campaign .................. 60 5.3 Current Efforts of Union Parishad Leaders ........................ 61 5.4 Follow-up and Current Sanitation Programs ...................... 65 5.5 The Role of Schools in Maintaining Sanitation Awareness .......................................................................... 65 5.6 Sources of Support for Poor People Wanting to Make Sanitation Improvements ................................................... 66 5.7 Summary of Findings for Study Objective No. 3 ................ 67 VI. Sanitation Products and Services .......................................... 68 Key Findings ............................................................................. 68 6.1 How Households Get Latrines ........................................... 68 6.2 New Latrine Selling Businesses Arose in Response to Demand .............................................................................. 68 6.3 Cost of a Latrine ................................................................. 70 6.4 Sources of Funds to Purchase Latrines ............................. 71 6.5 How Latrine Parts Businesses Were Established ............... 71 6.6 Costs of Raw Materials vs. Prices of Latrine Parts ............ 72 6.7 Product Quality and Injury Risk .......................................... 73 6.8 Pit Emptying Services ........................................................ 73 6.9 Summary of Findings for Study Objective No. 4 ................ 75 VII. Factors Responsible for Sustaining or Not Sustaining Changed Sanitation Behaviors ............................................... 77 Key Findings ............................................................................. 77 7.1 Factors Thought to Contribute to Sustained Sanitation Behaviors............................................................................ 77 7.2 External Enabling Environment Factors ............................. 80 7.3 Factors Thought to Contribute to Not Sustaining Sanitation Behaviors ......................................................... 81 7.4 Negative External Factors ................................................. 82 7.5 Summary of Findings for Study Objective No. 5 ................ 82 VIII. Conclusions and Insights for Sustaining Future Sanitation Programming at Scale ........................................... 84 References ............................................................................... 85 ANNEXES 1: Sanitation Program Approaches ........................................ 88 2: Characteristics of Study Unions ........................................ 92 3: Qualitative Study Activities ................................................ 94 4: Factors Relating to Presence or Absence of Open Defecation in 18 Unions..................................................... 95 5: Maintenance Characteristics Checked of Improved or Shared Latrine During Field Observations. ...................... 100 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Contents Figures 1: Organigram of Governmental Administration in Bangladesh ........................................................................ 3 2: Percentage Rural Household Latrine Coverage in ODF Declared Unions—Government Definition ....................... 13 3: Percentage Rural Household Latrine Coverage in ODF Declared Unions—JMP Definition ........................... 15 4: Open Pit Latrine in Chapai-Nawabganj District ............... 16 5: Two Latrine Examples ...................................................... 17 6: Percentage of Households Responding That at Least One Household Member Practices Open Defecation, by Approach .................................................................... 19 7: An Unclean Latrine in Barisal District............................... 19 8: Percentage of Households by GoB Definition of “Hygienic� and “Unhygienic� Latrine Classified as Clean and Unclean ......20 9: Percentage of Type of Latrine Ownership by Wealth Quintile ............................................................................. 31 10: Percentage of Households That Share by Wealth Quintile...31 11: Percentage of Households That Share, by Approach ..... 33 12: Last Defecation Place of Child Who Does Not Use a Latrine ........................................................................... 35 13: Percentage of Households Satisfied with Current Latrine—“Clean� vs. “Unclean� ....................................... 48 14: Percentage of Households Satisfied with Clean Latrine, by Wealth Quintile ............................................... 49 15: Percentage of Households Satisfied with Unclean Latrine, by Wealth Quintile ............................................... 49 16: Clay Balls (kulub/kuluf) for Cleaning after Elimination ....... 54 17: Award Given to ODF Union Parishads............................. 58 18: Local Business Transporting Slab ................................... 69 19: Local Business Selling a Variety of Products................... 72 20: Hindu Sweeper in Naogaon District................................. 74 21: SaniFOAM Behavior Change Framework ........................ 77 Boxes 1: A New Latrine Protects a Poor Family’s Prestige before Future In-laws ...................................................... 27 2: Key Informants Had Several Observations about the Condition of Public Latrines in Their Unions ................... 29 3: Poor Women Make Their Own Latrine Parts ................... 51 4: A Farmer Is Compelled by Revulsion to Stop Defecating Openly .....................................................................................52 5: A Man Avoids Using the Same Latrine as His Daughters-in-Law ................................................. 53 6: A UP Chairman and Two Women in Bogra District .......... 62 www.wsp.org Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Contents 7: Targeting the Poorest Families in Kurigram District ......... 67 8: Poor-Quality Latrine Parts in Bogra District ..................... 73 9: Some Muslim Pit Emptiers (Cleaners) in Chittagong District Discuss Their New Occupation ........................... 76 Tables 1: Study Unions by Program Approach and Follow-up Programming ..................................................................... 8 2: Household Status According to ODF Definition .............. 13 3: Classification of Latrines Used by Approach and Geographical Area ........................................................... 14 4: Percentage of Latrine Types and Sharing Practices that Meet National and JMP Definitions of “Hygienic� and “Improved� ................................................................ 15 5: Percentage of Latrine Superstructure Types by Household Wealth Quintile .............................................. 17 6: Survey Households Continuing with Open Defecation, by Approach .................................................................... 18 7: Percentage of Improved and Shared Latrines Classified as Clean and Unclean, by JMP group ............ 20 8: Percentage of All Improved and Shared Latrines Classified as Unclean ...................................................... 21 9: Factors Associated with Having an Improved or Shared Latrine ................................................................. 21 10: Factors Associated with a Latrine Being “Clean�............. 23 11: Period of Installation of Improved or Shared Latrines, Percentage by Approach ................................................ 25 12: Top Four Reasons Reported for Changing the Latrine (All Changes Combined), Percentage by Approach ......................................................................... 25 13: Upgrading and Downgrading of Latrine Types or Defecation Places, Percentage for Various Groups ......... 26 14: Percentage of Households Formerly Using an Improved or Shared Latrine (or Not) That Have Downgraded or Slipped Back to Open Defecation ......... 28 15: Percentage of Households That Share, by Wealth Quintile..32 16: Average Number of Persons Using an Improved Latrine, Shared or Not Shared, by Approach, Geographical Area, and Wealth Quintile ......................... 32 17: Percentage of Household Latrines and Cleanliness ........ 33 18: Percentage of Households Reporting Location Where Elderly or Disabled Household Member Most Recently Defecated ........................................................................ 35 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Contents 19: Survey Respondents’ Descriptions of the Characteristics of a “Hygienic� Latrine, by Program Approach, Multiple Responses ....................................................................... 37 20: Percentage Distance Between Clean or Unclean Latrine and Main Living Room ......................................... 37 21: Percentage Distance Between Clean or Unclean Improved or Shared Latrine and Water Source ............... 39 22: Period Before the Pit/Tank Was Emptied Last, by Approach ......................................................................... 39 23: Percentage of Households That Remember Hearing about Their Area or Union Being a Place Where Everyone Uses Latrines ................................................... 45 24: Percentage of Households Recalling Source of Information for ODF Campaign, by Presence/Absence of a Follow-up Sanitation Program .................................. 45 25: Household Survey Responses: Importance of All Households Using Latrines .............................................. 46 26: Top Five Reported Perceived Social Benefits of Latrine Use, Percentages by Approach ....................................... 47 27: Top Five Reported Perceived Health Benefits of Having a Household Latrine, Percentages by Approach ............... 48 28: Percentage of Households Satisfied with Current Defecation Place, by Latrine Type ................................... 48 29: Percentage of the Top Five Forms of Punishment or Fine Recalled, by Approach ............................................. 60 30: Union Parishad Location by Geographic Area and Approach ................................................................. 61 31: Present Activity Level of Union Chairmen to Maintain and Improve Sanitation in 53 Unions ............................... 61 32: Percentage of Respondents Who Are Aware of Free Distribution of Latrine Parts to the Very Poor in the Area by the UP/GoB, by Wealth Quintile ......................... 63 33: Percentage of Respondents Who Have Ever Received Latrine Parts Free from the UP/GoB, by Wealth Quintile ............................................................................. 63 34: Percentage of Households Indicating Whether Anyone Has Visited Them to Discuss Using an Improved Latrine, by Program Follow-up ........................ 65 35: Who Comes to Discuss Sanitation, Percentage by Presence or Absence of Current Sanitation Program...... 65 36: Percentage of Households with Access to Latrine Materials .......................................................................... 69 37: Percentage of Households with Access to Skilled Labor to Install/Repair Latrines........................................ 69 www.wsp.org Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Contents 38: Cost (Materials, Labor, and Other) of the Presently Used Latrine, Percentages ........................................................ 70 39: Median Amount Spent on Latrine, by Wealth Quintile ..... 70 40: Percentage of Households with Access to Financing Latrine Installation/Improvement ..................................... 71 41: A Chittagong District Latrine Seller’s Costs: Past and Present ............................................................................. 72 42: A Chittagong District Latrine Seller’s Prices .................... 72 43: Gopalganj District Latrine Seller’s Prices ......................... 73 44: Percentage of Households with Access to Pit Cleaners .......................................................................... 74 Scaling Up Rural Sanitation Acknowledgements This study was written by Dr. Suzanne Hanchett and Dr. Development and Cooperatives (MoLGRD &C); A. K. M. Laurie Krieger with contributions from Craig Kullmann Ibrahim, Planning Division of DPHE; Md. Ibrahim, Na- and Rokeya Ahmed. The Water and Sanitation Program of tional Sanitation Secretariat of DPHE, Arthur Twembola the World Bank contracted The Manoff Group, Planning and Qumrun Nahar, UNICEF; Waliul Islam, PD, HY- Alternatives for Change, LLC, and Pathways Consulting SAWA Project; Md. Kalim Ullah Koli and Rozena Begum, Services, Ltd. to carry out this research. Dr. Laurie Krieger WaterAid; Yakub Hossain, Deputy Executive Director, (The Manoff Group) was the Project Director, and Dr. Su- VERC; Zillur Rahman, Plan Bangladesh; Ummey Farwa zanne Hanchett (Pathways Consulting Services, Ltd.) was Daisy, Dhaka Ahsania Mission; Milan Kanti Barua, BRAC; the Team Leader. Craig Kullmann (Water and Sanitation Joseph Halder, NGO Forum; Leanne Unicomb, ICDDRB; Program – WSP) managed this research initiative in col- S.G Mahmud, WHO; and Shariful Alam, PD, PSU, Local laboration with Rokeya Ahmed (WSP-Bangladesh). Government Division, Ministry of Local Government, Rural Development and Cooperatives (MoLGRD &C) for The core research team that conducted the field work and helping to guide this study, providing valuable feedback contributed to the report include Mohidul Hoque Khan, and peer review at key points. Deputy Team Leader; Tofazzel Hossain Monju, Qualita- tive Team Coordinator; Shireen Akhter, Field Team Leader; Expert advice and support was provided by Eduardo Perez Kazi Rozana Akhter, Field Team Leader; Anwar Islam, (WSP) who helped to conceptualize the study, and Jacque- Field Team Leader; Farid Uddin Ahmed Mia, Sanitation line Devine (WSP) who provided input at crucial times. Engineer; Ashraul Haque Khan Eitu, Data Analyst; Kazi Peer review of the report was provided by Peter Kolsky Monirul Islam, Field Survey Coordinator; Emdadul Haque, (World Bank), Soma Gosh (World Bank), Nila Mukherjee Research Assistant; Bhuiyan, Farhana Sultana, Research As- (WSP), Eduardo Perez (WSP), Jacqueline Devine (WSP), sistant; Partha Sarathee Ghosh, Research Assistant; F.M. Jaehyang So (WSP), and Christopher Juan Costain (WSP). Zohurul Islam, Research Assistant, and numerous survey Valuable inputs were also provided by Santanu Lahiri, Mark interviewers. Ellery, and Abdul Motaleb from WSP Bangladesh through- out the study. The authors would like to thank the Government of Ban- gladesh and members of the Study Consultative Commit- Most of all we would like to thank the heads of union coun- tee: Khaja Miah, Deputy Secretary (Water Supply), Local cils, NGO staff, masons, pit emptiers, teachers, students, Government Division, Ministry of Local Government, and families in rural Bangladesh who opened their offices, Rural Development and Cooperatives (MoLGRD &C); businesses, schools and homes to the study team, permit- Shams Uddin Ahmed, Deputy Secretary, Local Govern- ted us to engage in the bizarre behavior of inspecting their ment Division, Ministry of Local Government, Rural latrines or businesses, and answered our many questions. www.wsp.org xv Terms and Acronyms Aapobitro Pollution (opposite of purity) Aaraa A local term for open spaces people use for defecation ADP Annual Development Program; in this report, ADP refers only to the annual block allocation to Union Parishad (council) by MLGRDC Almira A polished wooden cabinet for keeping clothes or dishes, often with a glass front Bairar manush “Outside� people; people who are not seen as permanent, native villagers Baire paikhaana-na No outside defecation Bari Residential compound with one or more households Biplob Social revolution Bodna Small pitcher used to hold water for post-defecation cleansing Bon A type of tall, soft grass that can be used for making latrine walls BRAC Bangladesh Rural Advancement Committee (a large Bangladeshi NGO working throughout Bangla- desh, whose activities now include work in other countries) Char/Chari Sand bar island that is vulnerable to extreme erosion Chak, Chaaka Rings Chamars Cobblers Chowkidar Village police Chula Bowl CLTS Community-Led Total Sanitation DC District Commissioner Dhila-kulub/kuluf Clay balls used to clean the anus and genitals after defecation DPHE Department of Public Health Engineering Duli A woven bamboo liner for latrines, used in some CLTS areas Dushon ‘Pollution’ ESHWRA Water and sanitation program run by UNICEF, one of the GoB donor programs GoB Government of Bangladesh Golpata A type of leaf Gorto Pit Gram sharker A village-level government institution, now defunct Gaach paikhaana Tree defecation (defecating on the roots of trees or low branches above a water body) Ghriina Hateful Hang (or Hanging) A latrine that has a superstructure but no pit; the latrine either empties directly onto the ground or Latrine into a body of water Haor Geological depression filled with water three to six months per year xvi Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Terms and Acronyms HH Household HWT High water table IMP/S Improved latrine category with sharing. It is based on the JMP definition, but includes shared as well as unshared facilities Jaati Caste JMP World Health Organization and UNICEF Joint Monitoring Programme Julonto An enclosed space for defecating, without a pit, that is near the home; this would include a hanging latrine and other such arrangements Kaamlaa Day laborer Kacca Crudely made (opposite of pucca) Katha Quilt Khaash Government-owned (as with land) Khola paikhana Open defecation Lakh/Lac The number 100,000 Larki Firewood LGED Local Government Engineering Department LWT Low water table Madrasa Religious school Mela Gathering or village fair; often used in community mobilization in South Asia Methor Pit cleaner MLGRDC Ministry of Local Government, Rural Development, and Cooperatives Mohalla Neighborhood Motka Type of latrine promoted in some old CLTS areas; it has a metal strip in the pan Naapaak ‘Pollution’ (opposite of ‘purity’) NGO Non-governmental organization Norok Hell Noshto kora ‘Pollution’ (similar to Dushon) OD Open defecation ODF Open defecation-free Paak ‘Purity’ Paara or para Section of a village Paathaar A local term for open spaces people use for defecation Paribesh Unnayan Environmental Development [Committee] Pobitro ‘Purity’ (similar to Paak) Poribaar Household Porishkaar Cleanliness Porichhonota Maintaining cleanliness www.wsp.org xvii Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Terms and Acronyms Pourashava Municipality Pucca Permanent or well-made (opposite of kacca) Purdah A behavioral code, widespread in South Asia, that dictates with whom a woman may interact, who may see her, where she may go, how she should dress, speak, and behave, and restricts contact of any sort between certain social categories of males and females PRSP Poverty Reduction Strategy Paper Raj mistri Mason RC Reconnaissance team RDRS Large NGO active in northern Bangladesh RRA Rapid rural appraisal RT Reconnaissance team Salish/Shalish Dispute resolution conducted by local leaders Samiti Committee SCG Study Consultative Group (established by the WSP and GoB) Shorom Modesty Shotho-bhaag kholaa Literally, “Feces-free� paikhaana mukto STUP Special Targeting of the Ultra-Poor, a development program Tk Taka, the currency of Bangladesh (US$1 = Tk 68.5) TNO Former name for UNO (see below) TW Tubewell UNICEF United Nations Children’s Fund Union Lowest tier of government administration UNO Upazila Narbahi Officer (Chief Administrative Officer of the subdistrict) UP Union Parishad (union council made up of an elected union chairman plus nine male and three female ward representatives) Upazila Subdistrict VERC Village Education Resource Center VGF Vulnerable Group Fund VSC Village Sanitation Centers Ward Politico-administrative unit within a union; there are nine wards within each union WES Water and Environmental Sanitation WHO World Health Organization Zila District (an administrative/governmental unit) xviii Scaling Up Rural Sanitation I. Introduction During the liberation war in 1971, people from all corners came together for one platform and worked for one goal to liberate the country. It was just like that dur- ing the ODF campaign: all people came together to eradicate people’s practice of open defecation. We succeeded to make a latrine in each and every household. We did it in a very united and coordinated way, like the war of liberation period. —Female Union Parishad Member It is widely agreed that the Millennium Development Goal (MDG) targeting a 50 percent decrease in the proportion of people who do not have access to safe drinking BANGLADESH water and sanitation (MDG 7, Target 10) has achieved less progress than all other COUNTRY STATISTICS MDGs. At present, one-third of humans lack access to facilities that safely confine • A population of 144 million human feces, which puts them and their neighbors at risk of diarrheal disease. inhabits an area of 147,570 square kilometers. There is increased interest from developing country governments and the interna- • More than 80 percent of tional community in seeking ways to rapidly scale up access to improved sanitation. the population lives on less Because Bangladesh has had sanitation programs longer than most countries, in- than US $2 per day, and at cluding periods of rapid scale up, it can provide valuable lessons to donors and least 30 million inhabitants program implementers throughout the world. The World Bank’s Water and Sanita- are classified as extreme tion Program (WSP) in conjunction with the Government of Bangladesh and non- poor or ultra-poor. (AusAid governmental organizations collaborated to investigate the sustainability of 2010) sanitation behaviors and programs in Bangladesh. WSP contracted The Manoff Group, Inc. and its partners, Planning Alternatives for Change, LLC, and Pathways Consulting Services, Ltd., to carry out this research. 1.1 The Bangladesh Context Sanitation needs are significant in Bangladesh, which is the most densely popu- lated country in the world and one of the poorest. Adding to the challenge, about one-third of Bangladesh experiences annual floods and other parts of the country suffer seasonal water shortages. All of these factors have implications for the abil- ity of rural Bangladeshis to construct and maintain latrines.6 Improving sanitation is a high priority national policy goal in Bangladesh. In 2003, the Government of Bangladesh (GoB) set a target of Sanitation for All by 2010 at the first South Asian Conference on Sanitation (SACOSAN). At that time, only 28.8 percent of rural households in the country were using latrines, and countrywide usage was 33.2 percent. Efforts toward Sanitation for All began with an historic campaign from 2003 to 2006 to establish all areas of Bangladesh as open defecation free (ODF) by promoting and rewarding 100 percent latrine coverage. Intent on building on these and other achievements since 2003, the current government has extended the Sanitation for All action period up to 2013.7 6 CIA 2010; Local Government Division, Ministry of Local Government, Rural Development and Coperatives, Government of Bangladesh 2008 7 Government of Bangladesh, National Sanitation Secretariat 2010 www.wsp.org 1 Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Introduction 1.2 The History of Sanitation volunteers mobilized to destroy “unhygienic� latrines and Promotion in Bangladesh bring their region up to a new standard of safe defecation For many unions (the lowest tier of government organiza- practice. In Banaripara, the NGO Forum for Drinking Water tion), the 2003–2006 ODF campaign was built on a foun- and Sanitation was prominently involved in the social mobi- dation established by earlier sanitation programs. For more lization campaign. than four decades, the GoB (primarily through the Depart- ment of Public Health and Engineering [DPHE]) had been Meanwhile, other national and international NGOs started striving to promote safe water access and stop indiscrimi- developing their own sanitation and hygiene promotion ini- nate disposal of human feces. Deadly cholera outbreaks, tiatives, both with and without latrine distribution. Imple- which alarmed health officials, politicians, and the general mented in the far southeastern districts between 1991 and population, provided the initial impetus for this drive. Ef- 2001, CARE-SAFE/SAFER’s Software Only program has forts focused on water; sanitation changes came later. received the most international recognition. In northern Bangladesh, RDRS (Rangpur Dinajpur Rural Services) made In 1972, GoB-UNICEF support was mobilized for DPHE a strong push to upgrade sanitation practice and supported to provide a “demonstration of technology� for safe excreta some entrepreneurs producing latrine parts during the 1980s disposal. Village Sanitation Centers (VSC) were established, and 1990s, when demand was weak. National NGOs such as promoting pit latrines with water-sealed slabs; the pits were Grameen Bank, Proshika, and BRAC strongly encouraged lined with five concrete rings. Gradually this program was and funded group members’ installation of “hygienic� (ring- expanded to 460 upazilas (subdistricts), but it did not trigger slab) household latrines, many of which were produced in high levels of hygienic latrine use in the population. Unlike DPHE’s Village Sanitation Centres. the recent campaign, these early efforts focused mainly on urban areas, especially subdistrict headquarters towns, rather At that early stage, two different approaches to promoting than on rural villages. It was primarily the economically well- latrine use emerged in Bangladesh. These two approaches off households that took up latrine use; sanitation promotion were evident in different unions during the recent cam- messages were not directed to rest of the population or poor paign. One approach made more use of force, threat, and people apart from school children. In the late 1970s or early other types of coercion, while the other emphasized persua- 1980s, UNICEF started working on school sanitation with sion, intensive public education or training, educational the government schools’ hygiene curriculum. games for children, and self-monitoring. Eventually this lat- ter approach was carried forward by numerous organiza- In 1980, the United Nations declared the beginning of the tions implementing water and sanitation programs, International Water Supply and Sanitation Decade. Be- including most CLTS proponents. tween 1980 and 2000 the GoB, especially DPHE, some large NGOs, and UNICEF, launched concerted efforts to 1.3 Study Goals and Objectives introduce latrines to rural communities, some of which in- The goal of this study is to provide the GoB and its in- cluded the unions covered by this study. Key informants country partners with evidence on what makes sanitation mentioned these early programs as important background behaviors, facilities, related benefits, and programs sustain- context for their recent sanitation campaigns. able in the Bangladesh context. At the same time, this evi- dence will also help the international sanitation and hygiene The most dramatic and large-scale effort of this early period sector better understand the sustainability component of was the national Social Mobilization for Sanitation, a cam- scaling up sanitation programs. paign extending from the mid-1980s into the mid-1990s. DPHE was a central, driving force. Banaripara Upazila in The unit of study is the union, which is the lowest level of Barisal District was considered to be the most successful case government and administration in rural Bangladesh. There in the country. Government workers, elected local govern- are more than 4,400 unions in Bangladesh, ranging in popu- ment officials, schoolchildren and teachers, and numerous lation from 15,000 to 50,000. Each union has an elected 2 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Introduction chairman and a council consisting of 12 ward representatives; • CLTS NGO: campaign implementation conducted nine representing one ward each and three women represent- by local government with support from an NGO ing three wards each. The local name for the union council is dedicated to use of CLTS methods. Union Parishad, which is referred to here as the UP. • Non-CLTS NGO: campaign implementation con- ducted by local government with support from This study concerns the 481 unions that were declared ODF NGO programs not dedicated to CLTS about four and a half years before the study’s beginning. Pre- viously, there was no knowledge about which unions had sus- In all cases, the UP was the principal manager of the local tained their ODF status; and if not, why those behaviors, ODF campaign and close cooperation between governmen- facilities, or programs had not been maintained. tal and non-governmental organizations occurred at all levels. The concerned programs and the campaign had ended by The study focused on five specific objectives: the time this study began. In 27 study unions, however, a formal sanitation program followed the ODF campaign. 1. Determine the current status of latrine facilities built pre- and post-ODF declaration and sanitation 1.5 Background Information on Bangladesh practices. Governmental Administration 2. Understand the perceived benefits to households As shown in Figure 1, Bangladesh governmental adminis- and communities from community-wide ODF ap- tration operates through four principal administrative lev- proaches since declaring ODF status. els: nation, district, subdistrict, and union. (There is an 3. Understand whether programmatic inputs from local and national governments and civil society sanitation programs had been sustained to support FIGURE 1: ORGANIGRAM OF GOVERNMENTAL communities in maintaining their ODF status and ADMINISTRATION IN BANGLADESH helping the poor obtain access to latrines. Ministry of Local Government, Rural Development, and 4. Understand how the growth or attrition of sanitation Cooperatives products and services (e.g., masons, pit-cleaners, or financing) has affected the sustainability of sanitation behaviors and facilities and ODF status. District (64) 5. Most importantly, understand why households and District Commissioner (1 per district) communities had or had not sustained improved sanitation behaviors since ODF declaration. Subdistrict 1.4 Implementation Models Used Upaliza Nirbahi Officer (1 per subdistrict) in Union-level ODF Campaigns Four types of implementation models (details of each model are presented in Annex 1) were used to achieve union-wide Union (1 per union) ODF goals: • UP Chairman • UP Secretary • GoB Only: campaign implementation by elected • Councilwomen (3) union leaders and UP staff, such as village police, • Village Police • Office Helpers with no support from any other sanitation program; • Union Workers • GoB Donor: campaign implementation conducted with support from a program run by the Government of Bangladesh, Department of Public Health Engineer- Ward (9) ing (DPHE) in partnership with a donor organization www.wsp.org 3 Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Introduction additional level, the division, or group of multiple districts, • There are regional, ethnic, and socioeconomic varia- but it is not an administrative entity.) tions in the Bangladesh rural population’s response to sanitation promotion efforts. At the national level the Ministry of Local Government, • Effective approaches are generally understood to in- Rural Development, and Cooperatives (MLGRDC) is the clude appropriate institution building and the devel- entity ultimately responsible for union-level policies and opment of human resources at the local level. funding arrangements. The next administrative level below • The participation of local leaders is an essential part the national government is the district (also called zila). of many successful programs, especially if there is There are 64 districts in Bangladesh (which are clearly de- satisfactory coordination with volunteers and civil fined in the map on the first page of this chapter). Each is society organizations. under the authority of a District Commissioner who coor- dinates all governmental activities in the district. Every dis- Sanitation research indicates that sustained behavior trict is divided into subdistricts (upazilas),8 with an Upazila change results from giving high priority and adequate re- Nirbahi Officer (UNO) providing administrative coordina- sources to hygiene promotion and public education. Fac- tion functions at that level. The subdistrict includes multi- tors determining hygiene behavior change include ple unions whose activities are monitored by the UNO. program intensity, support from influential individuals, Each union is divided into nine wards, each of which elects promotion of self-help attitudes, and attendance at hy- a male member to the union council (or Union Parishad/ giene training. There are always obstacles to full accep- UP). The UP chairman is elected independently, and along- tance of sanitation improvement, but the existing studies side the nine ward representatives are three elected female are positive in supporting the claim that, “Intensive hy- council members, each of whom represents three wards. giene promotion interventions, including small groups Each union has a small staff, which includes an appointed and personal contact, probably will have a tangible and UP Secretary, who is an officer of the civil service, some vil- sustained impact.�9 People’s participation is assumed to be lage police (chowkidars), some office helpers, and other staff important: “It is now widely recognized that the best in certain unions. guardians of water resources and the environment are people working hand in hand with institutions.�10 These 1.6 Guiding Concepts principles grounded the development of the instruments Many studies have been conducted on defecation behavior used in this study. change in South Asia and elsewhere. A literature review conducted during the first phase of this study revealed 1.7 Organization of the Report themes that would serve as the research team’s guiding con- The report is divided into eight sections. Following this in- cepts. Key findings from the literature include: troductory section, Section II gives an overview of study methodology. Section III presents detailed findings on la- • Building awareness of public health principles is a trine facilities and defecation arrangements, and on owner- basic program need, but careful and sensitive pro- ship, maintenance, and defecation-related practices of the gram implementation is equally important. elderly, the disabled, and children. Section IV pre-sents • Access to equipment has not been emphasized. findings on people’s perceptions about recent sanitation • A major challenge exists in shifting people’s mind-set changes along with some relevant cultural background. Sec- from fecal-oral disease transmission as an individual tion V focuses on institutional factors that do or do not or household behavioral issue to viewing this issue as support sanitation improvements among the rural popula- a community concern. tion, including the poor. Section VI describes the situation of the “supply chain� of products and services necessary to 8 The subdistrict was formerly called thaana. There is an elected upazila chair and 9 a vice-chair, and a council. The upazila council system, however, was not yet Cairncross and Shordt 2004 10 functioning at the time of this study. Hartvelt 1997 4 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Introduction support latrine use in rural areas. Section VII offers an overview of multiple fac- tors that do or do not support sustainability of latrine use and associated prac- tices. And Section VIII suggests conclusions and insights for future sanitation programming at scale. At the end of each section there is a brief comment on how findings relate to each study objective, as listed in Section 1.3. To protect the confidentiality of sources, study union names are not used in this report and names of respondents have been changed. In place of each union name a unique identifier is used. This identifier includes a serial number and a shorthand reference to the approach used during the sanitation campaign: • “G� or “GO� for a GoB-only approach • “G-Do� or “G-Don� for a GoB donor program • “NG� for a non-CLTS NGO approach • “CL� for a CLTS approach • “CL/D� for a CLTS under the Dishari program Study union identification numbers with district locations are listed in Annex 2. Some English words, especially ‘purity’ and ‘pollution,’ are often written with single quotes. This is an anthropological convention. It serves to remind the reader that the words’ meaning in the Bengali language cannot be precisely trans- lated into English—that the English words can only partially express the impor- tant concepts associated with the equivalent Bengali words. www.wsp.org 5 II. Methodology This section reviews the quantitative and qualitative study (GoB) defines a “hygienic latrine� as being, “a san- methods used in a total of 53 unions; 50 of which were itation facility the use of which effectively breaks covered by a questionnaire survey conducted in 3,000 ran- the cycle of disease transmission.� The strategy fur- domly sampled households. Basic definitions used in the ther states, “There is no universal design for a hy- study are explained. gienic latrine that can be effectively used under all socio-economic and hydro-geological conditions. 2.1 Definitions and Terminology It is therefore important that a wide range of sani- The study team used a combination of quantitative and tary or hygienic latrine technologies is available qualitative research methods to address the principal re- to suit different conditions.� A latrine is shared search questions. After consultation with WSP and the by more than two households is not considered Study Consultative Group11 in Dhaka, the team selected 50 “hygienic� according to this definition. Minimal of the 481 unions that had been declared “100 percent sani- requirements for a hygienic latrine facility listed in tized,� or ODF, by June 2005. These sample unions are de- this strategy are: scribed in Annex 2. • confinement of feces away from the environment; • sealing the passage between the squat hole and For purposes of this study, the following terms are used: the pit to effectively block the pathways for flies and other insect vectors, thereby breaking the • Sanitation behaviors. This includes defecation prac- cycle of disease transmission; and tices (open or fixed place); latrine use maintenance • venting of foul gases generated in the pit through (cleaning slab/pit, emptying/repairing), and upgrad- a properly positioned vent pipe to keep the la- ing (adding slab, superstructure, lining pit, investing trine odor-free and encourage continual use of in technologies, e.g., twin pit latrines); and provid- the hygienic latrine. (The Ministry, however, ing assistance to dependents (disposal of children’s or excluded the venting requirement by a February elders’ or disabled persons’ feces). This study’s defini- 2010 amendment.) tion of “sanitation� is restricted to the management • Improved latrine. This term is defined by the Joint of human excreta. Monitoring Programme of WHO and UNICEF • Facilities. This includes latrines of all types con- and includes the following types of facilities: structed prior and subsequent to communities’ • flush toilet, piped sewer system, septic tank; declared to be ODF. Durability of sanitation fa- • flush/pour flush pit latrine; cilities is related to availability of quality materi- • ventilated improved pit latrines; als, appropriate designs, construction, and skilled • pits with slabs; and labor. Facilities also include community and pub- • composting. lic latrines, located at roadsides, schools, markets, • JMP does not consider the facilities above to be and mosques, which the team observed but did not improved if they are shared by more than one study in detail. house. • Hygienic latrine. In the National Sanitation Strat- • Unimproved latrines. According to the JMP, unim- egy (2005: 8), the Government of Bangladesh proved latrines have one or more of the following features: • flush to an unknown place; 11 This group was comprised of representatives of government, academia, national and • pits with no slab; international NGOs, and donor organizations • no facilities, bush, or field; 6 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Methodology • “hang� latrines that extend out over open land or • Related benefits. These include perceived benefits as water; and defined by individuals and local groups after becom- • buckets ing ODF, including cleaner environment, increased • Shared latrine. This is a latrine that safely confines pride, dignity, comfort, social networks, health, pri- feces from human contact and the environment, and vacy, and security (particularly of women). would otherwise be considered ‘improved’ except that more than one household regularly uses it. This 2.2 Study Union and Village includes households that have established joint own- Selection Procedures ership of a latrine with other, usually related families, The 53 study unions (50 covered by a household survey) and also less formal arrangements with neighbors. were selected primarily using a stratified random sampling • Open defecation (OD). Defecation in bushes or fields technique. A sample size of 53 unions was used because it or other outdoor locations. represents about 10 percent of the unions declared ODF by • Coverage. In this study, coverage refers to the usage June 2005. Information was collected about each of the of latrines. 481 unions declared ODF by June 2005, including pro- • Open Defecation Free (ODF). This term is used gram intervention approach, time of ODF declaration, in this report rather than “100 percent sanitized geographical characteristics, and nature of follow-up sanita- union,� the language associated with the sanitation tion program implemented after ODF declaration, if any. campaign. When UPs were declared to be “100 per- The team used this information to sort the 481 unions. In cent sanitized,� the criterion was that all households areas where there were very few examples of a particular had latrine facilities confining feces. Other aspects subgroup (approach, time of declaring ODF, or follow-up of total sanitation outlined in the 2005 National program coverage), the team selected all of the unions rep- Sanitation Strategy—such as proper maintenance resenting the less-represented criteria to ensure representa- for continual use, hygienic practice, or number of tion of the criteria in the overall sample. For example, only households using a latrine—were not considered in 10 CLTS unions had been declared ODF as of June 2005, making the declarations. Confinement of feces from and they are spread over different geographical areas. There- the environment i.e. use of a latrine that separates fore, the team included all of them in the group covered by feces from human contact is the first step on the way this study. In places where a specific approach was more to becoming ODF. ODF thus means that all house- concentrated, the team selected the unions randomly from holds in a location avoid both open defecation and unions in the area. Using these procedures, the team tried using an unimproved latrine. to avoid selection bias. However, at least three unions were • Sustained ODF. This term is defined both statisti- purposively included in the sample due to historic or other cally (high percentages of households using sturdy reasons. and well-maintained latrines) and socially (broad awareness and commitment to maintaining ODF Follow-up NGO sanitation programs covered 27 of the se- throughout multiple locations and social groups). lected unions. This group includes some in which the orga- Verified problem-solving activities and formal or nization conducting campaign-related activities continued informal enforcement of local rules against open its work for a period of one to three years after the sanita- defecation are also considered as positive evidence tion campaign ended. In others, the follow-up or currently of sustained practice. New house construction and operating program started later on. In only three unions family division processes should include installa- was the NGO involved in the sanitation campaign still tion of new latrines. Ongoing systems providing present at the time of this study. In CLTS/Dishari unions, replacement supplies, latrine repairs, and pit-emp- the full NGO program had ended at the time of the study, tying services also are essential to sustained ODF but a project-funded UP officer continued to work on sani- situations. tation issues. www.wsp.org 7 Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Methodology TABLE 1: STUDY UNIONS BY PROGRAM APPROACH AND FOLLOW-UP PROGRAMMING Demography Research Coverage Follow-up Programming Household Rapid Rural Sanitation Household Survey and Appraisal or Program Total Survey Qualitative Reconnais- Program No Program Currently Approach Population Household Unions Only Study sance Only Follow-up Follow-up Operating GoB only 619,333 113,381 24 19 4 1* 12 12 12 GoB donor 274,932 47,427 9 5 3 1** 5 4 1 CLTS NGO 300,421 54,163 10 5 5 0 4 6 4 Non-CLTS NGO 315,522 54,957 10 6 3 1* 6 4 5 Total 1,510,208 269,928 53 35 15 3 27 26 22 *Union with no program follow-up **Union with program follow-up Once in a union, the field research team randomly se- Eighteen unions were selected for in-depth research cover- lected three villages (or sections of villages) with a cluster age. They were picked purposely to represent diverse geo- of at least 100 households. One selected village was always graphical regions and intervention approaches. In two of close to the UP headquarters, one at a middle distance, these unions, the study involved only rapid rural appraisal and the third was far away or remote. Interviewers col- (RRA) methods and no household survey. Two other unions lected all quantitative and qualitative data (not including were covered by RRA methods plus the household survey. interviews with decision makers, local political leaders, In one union a reconnaissance team visited for three days, and sanitation leaders and organizations) from these vil- and there was no household survey. Some characteristics of lages. Within each selected village or cluster, 100 house- study unions are described in Table 1. holds were listed using a standard sampling format, and 20 households were selected from this list by means of a 2.3 Household Survey: Data Collection systematic random sampling method. Using this method, and Analysis 60 households in all were covered by the questionnaire The semi-structured questionnaire for the household sur- survey in each union and 3,000 households across 50 vey elicited five types of data: study unions. • current latrine set-up and household members’ def- The team conducted household-level survey interviews ecation habits, and developed “union profiles� (with special reference to • history of household latrine use and responses to sanitation) in all study unions.12 Geographical and pro- floods or other environmental crises, gram characteristics of selected unions are described in de- • knowledge of and attitudes toward latrine use, tail in Annex 2. • socioeconomic details on the household, and • exposure to campaigns and ODF knowledge. 12 Union profiles include salient political, geographic, climatological, and 2.3.1 Quality Control demographic information, as well as details on sanitation—including the history of The team followed quality control procedures in both campaigns and government and NGO activities in the union. The profiles include current government and NGO activities and the level of sanitation involvement quantitative and qualitative data collection and analysis. of the UP and its leaders, and also subjectively rated information (e.g., level of The team controlled questionnaire data quality through a seasonal migration or the intensity of natural disaster) that might contribute to the sanitation status of individuals (e.g., in migrant populations) and households. combination of measures: 8 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Methodology • The deputy team leader engaged supervisors and The outcome of the analysis is presented in Section III and enumerators from an existing panel known to him discussed in subsequent sections. Regression results indi- as competent and diligent. All were trained on the cate how much apparent differences in the use of improved specifics and requirements of this study. or shared latrines and their maintenance among different • A supervisor and at least two quality-control officers subgroups are due to different characteristics of the popula- followed up on interviewers at every step of fieldwork. tion subgroups, once the impact of other factors are held The method included observing the interview process, constant. performing field-level editing and consistency checks, and revisiting some randomly identified households. The survey team visiting each union filled out a “Union • Survey interviewers met daily with those conduct- Profile.� Team members also made subjective judgments ing qualitative research to discuss findings, prob- about the level of engagement in sanitation of the UP chair- lems, and other issues whenever the two groups were man13 as well as observing the UP office latrine. Informa- working in the same unions. tion from the union profiles is integrated into the report. • The qualitative research supervisors observed quality control by meeting daily with their teams to review 2.4 Qualitative Research in Selected Unions findings and discuss any problems or issues need- 2.4.1 Selection of Unions for In-depth Study ing attention, as is standard practice in team ethno- In-depth study unions were selected according to overall graphic research. characteristics, suggesting that they could offer learning op- portunities (e.g., presence of large migrant populations, 2.3.2 Statistical Analysis past presence of an active NGO sanitation program or spe- Detailed tables were generated for the entire set of 3,000 cial environmental conditions). A qualitative study team sampled households, broken down into major subgroups stayed for four to five days in 13 of the unions selected for based on: in-depth study. • approaches followed in the ODF declaration process, A reconnaissance team (RT) visited six unions in order to • geographical characteristics of the area, identify interesting cases and collect detailed background • post-ODF follow-up with major sanitation pro- information. They spent two to three days trying to get a gram(s), and sense of the present level of sanitation awareness, activity • socioeconomic groupings of the households through levels of leaders, and other pertinent issues. RT members a wealth ranking index. conducted key informant and group interviews in the union and at the upazila (subdistrict) level about the history In addition to tabulating the household survey data, the of sanitation promotion activities and prepared short re- team ran multivariate logistical regression analyses on the ports to helped orient the full in-depth study teams who data using STATA statistical software. The team had de- later visited most of the same places. fined several indicators from the variables that would likely contribute to the use of improved or shared latrines, and the 2.4.2 Qualitative Methods of Study cleanliness of latrines. Because there is a high prevalence of The team employed a number of different qualitative meth- sharing sanitation facilities in Bangladesh that safely con- ods to explore the issues of this study. Interviews and struc- fine feces from human contact and the environment, the tured observations were done using guides or checklist researchers felt it was important to analyze the quantitative questions, respectively, to ensure comparability among data by combining into one group the segment of house- unions. Interviewers were not limited to the listed ques- holds that share together with single family households that tions; rather they were encouraged to explore any interest- don’t share. The reason for this was to try and identify dif- ing new topics that arose. A basic minimum set of questions, ferences between households that use a facility that safely confines feces from those that do not. 13 At the time of the study, all UP chairmen in Bangladesh were male. www.wsp.org 9 Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Methodology however, was covered in each interview type. The principal multiple types of interviews, ways in which social networks interview types are listed in Annex 3. have influenced people’s behavior and/or collective change processes. Additional activities included: Case studies are integrated into the text of the report. They • survey observations of feces during transect walks, describe specific situations and give detailed quotes from house visits, and in all other local situations; interviews. Their value to the analysis is in showing the • transect walks, including short visits to households; conditions under which specific changes occurred or no • household visits and observations using a semi- changes occurred. They also describe the types of obstacles structured interview protocol; and that people or groups encounter. They provide an opportu- • stakeholder meetings in Dhaka and at local levels nity for the reader to hear people explain themselves in their with NGO and governmental representatives and own words. Case studies reveal complexities of specific situ- others (e.g., multilateral organizations). ations and offer insights into contextual factors influencing behavior change and decision-making processes that statis- The in-depth research teams consisted of three to four per- tical analysis of narrowly defined variables is unable to do. sons each (one field team leader/research associate, two re- The selected case studies often represent typical comments search assistants, and a sanitation specialist). They and observations from multiple study unions. crosschecked and verified information obtained from vari- ous sources about local social dynamics, environment, tech- 2.5 Limitations of the Study nologies, attitudes toward OD, and personal behaviors. One limitation of this study is the absence of baseline data They also looked into the institutional supports of or ob- and ongoing monitoring information. The government re- stacles to general sanitation improvement. quired baseline studies in all unions in 2003. The team searched for these studies, but they were not available. Some qualitative methods, especially focus group discus- Without documentation of actual latrine coverage distribu- sions, enhanced the team’s understanding of collective pro- tion, the team had to rely on oral reports to assess the degree cesses and social dynamics (at the neighborhood, village, to which sanitation had improved or declined in the sample union, or broader levels) and the extent to which these pro- unions. The statistical data collected as part of this study cesses support elimination of open defecation. Key infor- gave a fairly accurate picture of the present status of sanita- mant interviews shed light on UP points of view and, tion in sample unions. together with child interviews, were also especially useful ways to gain insight into individual and household pro- Time constraints required selection of certain paras (sec- cesses related to defecation behavior and sanitation im- tions of a village) or villages rather than others for in- provement decision-making. depth interviews, and it is possible that the authors missed some potentially valuable observation opportuni- 2.4.3 Qualitative Analysis ties. However, within the available time, the approach The outcome of these in-depth inquiries was a set of notes, taken enabled strong case comparisons across different including social analysis, of the ways in which each union’s types of environments and programmatic influences, special circumstances—history, leadership, sanitation inter- and comparison between survey and in-depth findings in vention strategies, physical constraints, and other factors— all places. had or had not supported a decline in open defecation and built opportunities, skills, and motivation to adopt hygienic The team did not control for population size or number of defecation practices. The study team explored and analyzed households in the three villages that the quantitative survey multiple points of view (different age and gender groups, team sampled in each union. The same number of house- for example, or the disabled) and looked at the concerns of holds (20) was sampled in each village, regardless of the the poor. The qualitative research teams explored, in number of people or households in the village. This means 10 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Methodology that on one level, the household sample of each union may not be representative of the union as a whole, as a village of 4,000 inhabitants and a village of 2,500 inhabitants would each have a randomly drawn sample of 20 households. How- ever, a 3,000 household randomly drawn sample from 50 unions representing different sanitation approaches, social groups, and geography is likely to be rep- resentative of the whole universe of 473 unions declared ODF as a result of the sanitation campaign. Four and a half years or more after the sanitation campaign, it was difficult to pick up a great many clear differences between different sanitation approaches because of a variety of factors, such as the mobility of the population, and the sharing of information among organizations implementing the various sanitation approaches. The last category included, for example, the members of the Study Consultative Group, many of whom were members of organizations implement- ing one of the sanitation approaches. These stakeholders had been talking to each other well before the inception of this study. Therefore, it is possible that organi- zations could have been implementing features of each others’ programs. How- ever, we have only anecdotal data to suggest that this had occurred. www.wsp.org 11 III. Status of Latrine Facilities and Defecation Arrangements: Latrine Characteristics, Durability, and Changes This section addresses Study Objective No. 1: To determine an analysis of findings on latrine ownership duration and the current status of latrine facilities built pre- and post-ODF upgrading, downgrading, and other changes. It also dis- declaration, and sanitation practices. Section 3.1 emphasizes cusses community and public latrine observations. Latrine findings on latrine types and their physical characteristics. types are described according GoB and JMP criteria. 89.5 Section 3.2 discusses ownership, sharing, and maintenance percent of all household latrines were found to adequately of facilities. confine feces. But only 66 percent were found to be “clean.� The study team observed 30 community and public latrines Key Findings (see below for definition). Four and half years after UPs in this study were declared ODF: 3.1.1 Latrine Categories and Defecation • 89.5 percent of sample households own or share a Arrangements: Survey Findings latrine that safely confines feces. Of the remaining The household survey distinguishes three broad categories 10.5 percent of households, 2.5 percent do not have of household defecation arrangement: any latrine; 5.5 percent have a hanging latrine or fa- cility that drains directly into the environment; and • Open place defecation in bushes or fields; no house- 2.5 percent use an open pit without a slab. hold latrine (2.6 percent). • 70 percent of sample households have owned their • Use of unimproved latrines (7.9 percent), of which current latrine for at least three years, indicating there are three types: that the majority of latrines built are fairly durable. • hanging latrine with no pit, • All four implementation approaches resulted in • open pit latrine having no cover, and sustained high latrine use and low rates of open • any other latrine for which the ring or the lined defecation. The use of improved or shared latrines pit has been broken or has an intentionally cre- and prevalence of open defecation across the four ap- ated passage allowing easy out-flow of feces.14 proaches varied slightly. One possible explanation for • Use of one of three kinds of improved or shared latrine the similarity in sustained outcomes across approaches (89.5 percent): could be the government’s countrywide commitment • latrine with a squat slab and a lined pit but no to diffuse the idea that latrine use is important for closure or cover over the drop hole; household health and development. The significance • latrine with a slab or other secure cover over the and power of the government’s commitment may drop hole, or a polyethylene flap preventing in- have been the cornerstone for influencing the social sects from flying into or coming out of the pit; and norms in favor of improved sanitation behaviors and • latrine with an enclosed, non-leaking pit that is facilities regardless of the specific approach. covered by a slab with a water seal. • Only 44 percent of household latrines were found to be clean (i.e., to not have any feces visible on The above are based on 16 different types of defecation latrine floor, pan, or water-seal. Although latrine places observed and recorded on questionnaires. Those with use appears to be high, hygienic maintenance seems vent pipes, septic tanks, offset pits, double pits, and other to be an issue. variations have been merged into the improved or shared categories, depending on the condition of the slab and the opening to the pit. 3.1 Status of Household Latrines and Prevalence of Open Defecation This section reviews findings on defecation patterns, catego- 14 A hanging latrine is a frame or platform extending over earth or water; an “open pit ries of latrines used, and their maintenance status. It includes latrine� does not have a squat platform or slab on the pit. 12 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Status of Latrine Facilities and Defecation Arrangements TABLE 2: HOUSEHOLD STATUS ACCORDING TO ODF survey, it is interesting to find that the total number of “im- DEFINITION, n = 3,000 proved� facilities according to the JMP definition is similar Status Percentage to the total found in the most recent 2009 Multiple Indi- Using a improved or shared facility that cator Cluster Survey (54.3 percent—“improved� and 49.9 confines feces from human contact and the percent—“GoB hygienic�).17 environment 89.5 Defecation in fields/bushes (OD), hanging la- As the last two rows in Table 4 show, 36.6 percent of sample trine, open pit, or a facility that is intentionally households share a latrine that safely confines feces. The drained into the environment 10.5 table also indicates that a large proportion of latrines have neither intact water-seals nor flap nor any other devices covering the hole. In general, any unbroken pit with a slab that adequately confines feces is counted as an improved and shared latrine Figure 2 shows the breakdown according to GoB standards. is not distinguished in the above counts. The proportion of “hygienic� latrines according to GoB standards is very low because the GoB definition excludes Table 2, based on direct observation of more than 3,000 the large percentage of latrines that do not effectively seal households’ defecation arrangements, shows that almost 90 the feces in the pit or ring with a cover, flap or water-seal; percent of the sample was using a latrine that adequately or are shared by more than two households. contained feces four to five years after the end of the na- tionwide sanitation campaign and post-ODF declaration. Because the JMP definition of an “improved� latrine does This suggests that ODF was sustainable during this period not exclude those with broken water seals, the percentage for a great majority. of sample household latrines that can be considered “im- proved� is larger than the “hygienic� group. Figure 3 shows Table 3 shows frequencies of the three broad types of defecation places according to the approach used in the ODF campaign and geographical area. Comparing ap- proaches, this table shows relatively high frequencies of improved or shared latrines in households covered by FIGURE 2: PERCENTAGE RURAL HOUSEHOLD LATRINE COVERAGE IN ODF DECLARED UNIONS—GOVERNMENT CLTS or GoB-only approaches, and also in char15 or hilly DEFINITION geographic areas. Factors statistically associated with use of improved or shared latrines are discussed later (see 37% Table 9).16 Classification of Latrines According to 52% JMP and GoB Definitions Table 4 presents the proportion of survey households with latrine types and characteristics according to criteria respec- 8% 3% tively used by JMP and the GoB to define “improved� or Key “hygienic� latrines. The percentages of households sharing Unhygienic latrines and information on use of a vent pipe are listed in Hygienic the table, along with construction types that are relevant to Shared by > 2 households JMP and GoB definitions. Although this is not a national No latrine/Open bush 15 17 A char is an island produced through accretion of river silt, a sand bar. Bangladesh Bureau of Statistics, June 2010 16 Greater variation was observed in comparing areas with and without follow-up sanitation programs, and comparing socio-economic status groups. www.wsp.org 13 14 TABLE 3: CLASSIFICATION OF LATRINES USED BY APPROACH AND GEOGRAPHICAL AREA (PERCENTAGE, n = 3,000) Present Study GoB 2010 JMP 2010 Total None/Hang- None/Hang- No Latrine Unim- Improved ing/Open Pit ing/Open Pit Unim- Classification (OD) proved or Shared Latrine Hygienic Unhygienic Latrine Improved proved Percentage Number By Approach CLTS 2.2 3.8 94.0 6.0 39.2 54.8 6.0 51.0 43.0 100 600 Non-CLTS NGO 4.3 6.5 89.3 10.8 34.6 54.6 10.8 50.9 38.3 100 540 Long-Term Sustainability of Improved Sanitation in Rural Bangladesh GoB donor 2.7 14.8 82.5 17.5 37.7 44.8 17.5 57.5 25.0 100 480 GoB only 2.0 7.8 90.1 9.8 35.9 54.3 9.8 53.0 37.2 100 1,380 By Geographical Area Arid/plains 4.6 2.2 93.2 6.8 36.2 57.0 6.8 48.3 44.9 100 780 Char 1.1 4.4 94.4 5.5 36.1 58.4 5.5 55.0 39.5 100 180 Flood prone 1.5 10.8 87.6 12.3 37.9 49.8 12.3 52.1 35.6 100 840 Coastal 0.0 18.3 81.7 18.3 35.0 46.7 18.3 53.9 27.8 100 180 Hilly 0.6 1.1 98.3 1.7 43.9 54.4 1.7 73.9 24.4 100 180 Mixed 3.0 10.2 86.8 13.2 34.8 52.0 13.2 52.9 33.9 100 840 Total Percentage 2.6 7.9 89.5 10.5 36.6 52.9 10.5 52.9 36.6 100 Total Number 77 237 2,686 314 1,099 1,587 314 1,588 1,098 3,000 Status of Latrine Facilities and Defecation Arrangements Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Status of Latrine Facilities and Defecation Arrangements TABLE 4: PERCENTAGE OF LATRINE TYPES AND SHARING PRACTICES THAT MEET NATIONAL AND JMP DEFINITIONS OF “HYGIENIC� AND “IMPROVED� 2010 GoB 2004 GoB JMP Definition Definition of Definition of of Improved Number Percentage Hygienic Latrine Hygienic Latrine Latrine Latrine Types No latrine/open defecation in bush/field 77 2.6 No No No Hanging latrine/open pit latrine 96 3.2 No No No Latrines allowing feces to flow into environment through a broken ring or other device 141 4.7 No No No Pit latrine or septic system with slab but no water seal, a broken water seal, and/or no other cover or flap over the hole 1356 45.2 No No Yes Pit latrine or septic system with cover, flap, or polyethylene closing off the hole 172 5.7 Yes No Yes Latrine with water seal intact (both ring-slab la- trines and latrines with septic tanks) 1158 38.6 Yes No Yes Latrine w/ water seal intact (ring-slab latrine or latrine with septic tanks) with vent pipe 538 17.9 Yes Yes Yes Latrine (ring-slab or septic) with water-seal intact but no vent pipe 620 20.7 Yes No Yes Sharing (a, b, c) Improved latrine shared by only two households 583 19.4 Yes Yes No Improved latrine shared by more than two households 515 17.2 No No No Notes: (a) It is assumed that households occupying rented houses are using their latrines as single households (n = 18). (b) Jointly owned latrines reported as not being “shared� were counted as being shared by two households (n = 43). (c) It is assumed that if a household reports using a latrine “owned by another household,� this latrine is used by only two households (n = 181). the breakdown using the JMP definition, where 52 percent FIGURE 3: PERCENTAGE RURAL HOUSEHOLD LATRINE COVERAGE IN ODF DECLARED UNIONS—JMP DEFINITION of households qualify as using “improved� latrines, 37 per- cent share latrines (only 8 percent of these were shared by 3% more than two households), 8 percent use hanging or open 8% structure latrines, and about 3 percent have no facility. Households with Unimproved Latrines (8 percent of total sample) 37% The study identifies two types of unimproved latrines— 52% those that are structurally “unimproved� by JMP stan- dards, such as open pits or hanging latrines, or latrines that people have intentionally drained to the outside. Key These latrines may be very sturdily built pucca structures, Improved but have broken rings or other nonfunctioning devices Sharing otherwise improved that allow feces to flow out onto open ground or into Unimproved/Hanging/Open pit water bodies. Intentionally drained latrines save the cost No latrine/Open bush of pit emptying. www.wsp.org 15 Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Status of Latrine Facilities and Defecation Arrangements Households with open pits (see Figure 4) or hanging la- FIGURE 4: OPEN PIT LATRINE IN CHAPAI-NAWABGANJ DISTRICT (CL-3) trines were unevenly distributed across study unions. The team observed households with these types of latrines in 34 (68 percent) of the 50 household survey unions. They were found more in the coastal unions (18.3 percent), GoB-donor areas (14.8 percent), non-follow-up unions (11.7 percent), and in the lower wealth quintiles. One Patuakhali District union (G-Do-9) had the highest percentage, at 60 percent of the households. This is a southern coastal region that is vulner- able to cyclones which can wreck latrines. The following findings relate to households using either traditional hanging latrines or open pit latrines. The users of intentionally-drained latrines were not asked these ques- • The majority (61 percent) of respondents using un- tions because such latrines were classified as unimproved improved latrines said they were never counseled; only after the survey was completed. and even more (68 percent) said that they were never pressured to install an improved latrine. Only 9 per- • Most of the households, a small percentage of the cent of the respondents admitted that they had been overall sample, using hanging latrines or open pits had helped or that someone had offered to help them descended the “sanitation ladder.� Sixty-two percent move up to an improved latrine. of households using hanging latrines or open pits were • The majority (58 percent) of these households that use reported to have used an improved or shared latrine unimproved latrines expressed willingness to install a bet- in the past. Two-thirds of this group had used a better ter latrine within the next 12 months; but 42 percent type of latrine within the past year, and 84 percent were unwilling to do so. Most (86 percent) of those who within the past two years. The most recently used la- were not willing said that “they had no money� to install trine was self-owned (58 percent), jointly owned (22 a better latrine. There were also other reasons, such as percent), owned by a relative/neighbor (13 percent), “No one to take on the task� (14 percent) and/or “Lack or owned by a landlord (6 percent). The consequences of space� (12 percent). The same respondent often pro- of flooding and the two recent major cyclones are evi- vided multiple reasons. Grouping the amount of money dent in this, often unwilling, descent from owning or they were willing to spend indicates that 39 percent sharing an improved latrine. would spend Tk.1000 (US$14.60) or less for a latrine; • More than three-fourths (76 percent) of these re- 23 percent between Tk.1001-3000 (to US$43.80); and spondents mentioned problems in using their unim- 23 percent mentioned more than Tk.3,000. The remain- proved latrines. “Bad smell� (68 percent), “People ing 16 percent did not mention any amount. Ring-slab say bad words to us� (22 percent), and “People look latrines of various types with or without water seals were down on us� (23 percent) were the most frequently the choice of most wishing to install a better latrine. mentioned problems. These reasons, especially the last two, are indicative of normative change, because OD Annex 4 presents information on study unions with higher and hanging/open pit latrine use is clearly not socially percentages of open defecation and unimproved latrine acceptable anymore. Because it is common to place the usage. latrine near the edge of the compound, often near the border with a neighboring bari, foul odors are a source Latrine Superstructure of conflict between neighbors. Latrine placement de- In the monsoon season, pit latrines are vulnerable to damage. pends to a large extent on the wish to avoid ‘polluting’ Flooding is a problem in low-lying areas. Rain is a problem feces, rather than just logistics (see Section 4.7). in all places, as it can weaken the supports for rings and slabs, 16 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Status of Latrine Facilities and Defecation Arrangements FIGURE 5: TWO LATRINE EXAMPLES latrine users (69 percent). A total of 77 respondents (2.6 percent) out of the 3,000 sample households admitted that household members used open places for defecation. Although a small part of the sample, it is important to discuss OD in detail because understanding the conditions and motivations that lead to OD can help programmers to address them. Out of the 50 sample unions covered by the household survey, openly defecating households were recorded in 18 (36 percent) unions. They clustered in specific unions. In two unions, more than a quarter (28 percent) of sample households admitted to practicing OD. In two other unions, around 15 and 13 per- cent of the households, respectively, practiced OD. Above, a new latrine with a roof (left) and a latrine with no roof and broken slab (right.) The proportion of openly defecating households varied moderately by approach and region and highly by socio- causing them to shift and crack. The best protection against economic status and union. A higher percentage (4.3 per- rain damage is a roof on the superstructure. The two photos cent) of survey households in non-CLTS NGO unions above show images of a latrine with a functional roof and one reported OD than in unions covered by other approaches with no roof, as well as structural damage. Table 5 presents (Table 6). The openly defecating households are concen- household survey findings on latrine superstructures. As this trated in the lower wealth ranking subgroups, but seven table shows, 52 percent of the improved or shared latrines households were from the two highest groups. Although have roofs over their structures, and the better superstructures percentages are small, differences among approaches are sta- are far more common among higher income households. tistically significant (Chi-square tests), so that it is unlikely that the small differences are due to chance. Open Defecation: Household Survey Findings Although a small proportion overall, in some unions a signifi- Of these households that currently have no facility, 81 percent cant minority (over 25 percent) practiced OD. And, of this reportedly had used an improved or shared latrine in the past two small number of open defecators, most had previously been years. Most of these households had owned or jointly-owned TABLE 5: PERCENTAGE OF LATRINE SUPERSTRUCTURE TYPES BY HOUSEHOLD WEALTH QUINTILE Household Wealth Quintile 1st 2nd 3rd 4th 5th Total Improved or Shared Latrines n = 505 n = 521 n = 537 n = 556 n = 567 2,686 Latrines with Roof Pucca with roof 3.2 5.0 8.8 21.9 57.1 19.9 Tin/ bamboo fencing with roof 24.4 30.3 34.8 40.6 29.6 32.1 Subtotal (Latrines with Roof) 27.6 35.3 43.6 62.5 86.7 52.0 Latrines without Roof Tin/ bamboo fencing without roof 15.8 16.7 15.6 13.1 5.8 13.3 Walls of jute cloth/polythene 23.2 20.9 15.6 10.8 3.2 14.4 Walls of jute stick/straw/leaf 32.5 26.3 24.4 13.5 3.9 19.7 Abandoned 1.0 0.8 0.7 — 0.4 0.6 Subtotal (Latrines without Roof) 72.4 64.7 56.4 37.5 13.3 48.0 Total 100 100 100 100 100 100 www.wsp.org 17 Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Status of Latrine Facilities and Defecation Arrangements TABLE 6: SURVEY HOUSEHOLDS CONTINUING WITH OPEN • 92 percent said that they had “no money to install one�; DEFECATION, BY APPROACH • 48 percent had “too little space�; and/or No Latrine/Open Defecation Only • 7 percent had “no one to take on the task.� Approach Percentage Number NGO CLTS 2.2 13 Household survey and in-depth study findings on open Non-CLTS 4.5 23 defecation were similar but not identical. During tran- GoB donor 2.9 13 sect walks in three villages of each study union, research- GoB only 2.1 28 ers using qualitative study methods conducted “surveys Total 2.6 77 of feces,� checking for evidence of open defecation near paths or roads, and following fecal smells to their source. Some open defecation was found by this method to occur (58 percent) their latrine, while 35 percent shared with relatives/ in around two-thirds of the unions visited by the in-depth neighbors, and 4 percent rented from a landlord. study team, although it is now considered a socially unac- ceptable practice. The exception is that some elderly males A large majority of open defecators defecate at dawn and females continue OD through force of habit; but they (80 percent). Others say they defecate outdoors at night are not usually criticized severely for this. Further analysis (9 percent) or as they need (11 percent). The main problems of open defecation is presented in Section VII. mentioned, especially by women and young girls were: The amount of OD differed some by approach: the five • needing to hurry; unions found to have the most OD (according to in-depth • feeling ashamed; methods) included three covered by the CLTS approach, one • being unable to defecate when they need to; Non-CLTS union, and one GoB-only union where an ASEH • space shortage; and program had followed up after the initial ODF declaration. • listening to bad words or otherwise suffering Household survey results from these same unions found humiliation. 12 percent, 11 percent, 0 percent, 20 percent, and 0 percent, respectively, having no latrines. Even in lower ranked unions, Women’s and girls’ need to defecate at dawn or postpone def- the amount of OD differed some by approach. ecation until after dark is motivated by the need to adhere to rules of purdah and helps to explain why women have been a Ranking Unions by OD Scores19 driving force in the transition to latrine use (see Section 4.7). The study team ranked unions by amount of OD observed (see Annex 4). Visiting at crop harvesting time, the reconnais- Almost one-third (30 percent) of the respondents from sance team saw evidence of much OD in agricultural fields openly defecating households said they were never coun- and in banana groves in some unions. The presence of sea- seled; and about half (49 percent) said that they were never sonally in-migrating agricultural laborers appeared to greatly pressured by anyone to install an improved latrine. Only 12 intensify the OD problem. Eight of the 18 unions covered by percent of the respondents said they were helped or offered in-depth study methods have large numbers of in-migrants. any help with obtaining an improved latrine. In two study unions they use public latrines (or school, mosque, or owners’ latrines). They also were found to defecate A majority (57 percent) of the OD respondents expressed outdoors (in fields or other open places) in five study unions. readiness to install an improved latrine within the next 12 months.18 The reasons provided (multiple responses) by Although they have a small proportion (2.2 percent) with who were not willing were: no latrines, a larger proportion of survey households with latrines in CLTS areas (11 percent) admitted doing some 18 A majority (58 percent) said that they would spend Tk.1000 or less for the latrine 19 and 16 percent would not mention any amount. Ring-slab latrines of various types Annex 4 presents the results of this scoring procedure and details on each union’s with or without water seal were the choice of the most. situation. 18 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Status of Latrine Facilities and Defecation Arrangements FIGURE 6: PERCENTAGE OF HOUSEHOLDS RESPONDING THAT AT LEAST ONE HOUSEHOLD MEMBER PRACTICES OPEN DEFECATION, BY APPROACH (n = 2,686) 12 10 Percentage 8 6 4 2 0 CLTS Non-CLTS GOB donor GOB only Total Approach Source: Household survey OD than in other areas. (Figure 6) Findings in some CLTS promoted for a long time now, is not yet accepted by the unions suggest that possibly the absence of UP coercion and majority of latrine users, as demonstrated by the high pro- fear is at least partially responsible for this result. portion of water seals that are broken. Water seals are also difficult to maintain from a practical standpoint in water- Hygienic Status of the Latrine: “Clean� and “Unclean� shortage areas.20 The field survey teams documented several Types maintenance characteristics of the improved or shared la- Along with access to an improved or shared latrine, main- trines they observed (see Annex 5 for full list), but classified tenance of a hygienic standard is essential to attainment of whether the latrine was “clean� or “unclean� by the following “sanitation� coverage in the real meaning of the word. In criteria: Bangladesh, it is evident that water sealing of latrines, though • Latrine pit leaking profusely, and/or • Feces visible on the latrine floor, pan, or water-seal. FIGURE 7: AN UNCLEAN LATRINE IN BARISAL DISTRICT (G-DO-1) The team classified latrines showing neither of these condi- tions as “clean.� The frequency of clean and unclean latrines in sample household improved or shared latrines is shown in Figure 8 (using the latest GoB definitions) and Table 7 (using the JMP definitions). No matter which definition was used, when “improved� and “unimproved� latrines are considered together, only about 44 percent of latrines were observed to be “clean.� Improved or hygienic latrines tended to be cleaner, but even among these latrines, only about half of improved latrines were observed to be clean and only 60 percent of hygienic la- trines were clean. The issue of cleanliness is important from 20 Seasonal water shortages are reported by a somewhat higher percentage (12 percent) of households with no water-seals or broken water-seals than those with water seals (9 percent). However, this is not a statistically significant difference. www.wsp.org 19 Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Status of Latrine Facilities and Defecation Arrangements Only 44 percent of improved FIGURE 8: PERCENTAGE OF HOUSEHOLDS BY GoB DEFINITION OF “HYGIENIC� AND “UNHYGIENIC� LATRINE CLASSIFIED AS CLEAN AND UNCLEAN (n = 2,896) or shared latrines were found 100 90 to be “clean.� 80 39.90 70 55.70 66.60 Percentage 60 Key 50 Unclean 40 Clean 30 60.10 20 44.30 33.40 10 0 Hygienic (GoB) Unhygienic (GoB) Total a public health perspective, since any feces left unconfined is susceptible to potential transmission through various vectors such as insects or animals. The criteria of a strong foul odor was not used to classify a latrine as unclean, but it is interesting that foul odor is an important consideration for latrine users, most of whose health beliefs associate disease spread with characteristics of the air around them (‘bad air/wind’ is a commonly perceived cause of illness). A foul or good smell therefore affects people’s feelings about latrines and their motivation to use them. “Clean� and “unclean� are not correlated to the GoB’s hygienic/unhygienic defini- tion meaning that if it is a ‘hygienic’ latrine structure it does not mean it is prop- erly maintained or cleaned. Figure 8 shows that a high percentage of ‘hygienic’ (39.9 percent) latrines are unclean. Using the JMP definition of ‘improved’, the study showed that 49.1 percent of latrines were unclean. When shared latrines are considered the total percentage of unclean latrines goes up to 55.7 percent. This study shows that cleanliness does appear to be slightly correlated with sharing (more description is below under multivariate analysis). Table 8 provides a breakdown of the different criteria to classify a latrine as unclean. Multivariable Logistic Regression Analysis The team used multivariate logistic regression analysis to identify the deter- minants for using an improved or shared latrine as well as having a clean or TABLE 7: PERCENTAGE OF IMPROVED AND SHARED LATRINES CLASSIFIED AS CLEAN AND UNCLEAN, BY JMP GROUP Improved—Not Shared (n = 1,588) Shared (n = 1,098) Total Clean 50.9 34.9 44.3 Unclean 49.1 65.1 55.7 Total 100 100 100 20 Scaling Up Rural Sanitation Long-Term Sustainability of Improved Sanitation in Rural Bangladesh Status of Latrine Facilities and Defecation Arrangements TABLE 8: PERCENTAGE OF ALL IMPROVED AND SHARED unclean latrine. The logistic regression analysis is presented LATRINES CLASSIFIED AS UNCLEAN (n = 1,495) separately from the simpler statistics to clarify and elaborate Feces Visible upon relationships suggested earlier. on the Floor, Profuse Leak- Strong Bad “Unclean� within the ing of the La- Smell in and Latrine Pan, or in the trine Pipe, Pit, around the Because of the large percentage of households that share a Criteria Gooseneck or the Tank Latrine* latrine that would otherwise be classified as an improved Yes 96.6 12.6 46.7 latrine, this study grouped ‘improved’ and ‘shared’ to- No 3.1 87.4 53.3 gether for the multivariate logistic regression analysis to Total 100 100 100 better understand the differences between households *Strong bad smell is included here because it is so important to users. However, it is who use a latrine that safely confines feces from those that not included in our criteria for unclean latrines. do not. TABLE 9: FACTORS ASSOCIATED WITH HAVING AN IMPROVED OR SHARED LATRINE21 Number (Percentage) 95 Percent Number of Using Improved or Odds Significance* Confidence Interval Variables and Values Respondents Shared Latrine Ratio (p value) Lower Upper Improved/Shared Latrine (All) 3,000 2,686 (89.5) Significant Effect Approach to ODF Non-CLTS 2,400 2,122 (88.4) 1 CLTS 600 564 (94.0) 1.81 0.00 1.24 2.64 Post-ODF program: No follow-up 1,560 1,353 (86.7) 1 Follow-up 1,440 1,333 (92.6) 1.86 0.00 1.41 2.44 Recalled ODF campaign No 956 811(84.8) 1 Yes 2,044 1,875 (91.7) 1.72 0.00 1.34 2.22 Anyone visited home and talked about latrine use Not visited 2,255 1,988 (88.2 1 Visited 745 698 (93.7) 1.48 0.03 1.04 2.11 Gender of HH head Male-headed HH 2,771 2,470 (89.1) 1 Female-headed HH 229 216 (94.3) 2.56 0.00 1.40 4.69 Wealth quintile 1st 600 505 (84.2) 1 2nd 604 521 (86.3) 1.12 0.52 0.80 1.56 3rd 596 537 (90.1) 1.62 0.01 1.11 2.37 4th 600 556 (92.7) 2.17 0.00 1.40 3.34 5th 600 567 (94.5) 2.72 0.00 1.64 4.52 * Significance is indicated by p