from EVIDENCE to POLICY Learning what works for better programs and policies February 2016 TANZANIA: Do Campaigns to Get People to Wash Hands & Use (Improved) Toilets Work? Across the developing world, contaminated water and poor limited success. From curbing open defecation to convinc- hygiene and sanitation cause some one million deaths every ing people to regularly wash their hands with soap and year. In Sub-Saharan water, changing behavior has proven to be very difficult in Africa, most of these many countries. WATER AND SANITATION deaths are among chil- The World Bank is committed to providing oppor- dren under five years of tunities for healthy child development, and ensuring age and are due to se- safe sanitation and good hygiene is critical to achieving vere and recurrent diar- that. In Tanzania, the World Bank’s Water and Sanita- rhea from the spread of tion Partnership worked with the government to create dangerous pathogens and implement campaigns to improve sanitation and re- from human feces. duce illness among young children by encouraging hand- Even when not fatal, washing and use of improved sanitation such as toilets. severe diarrhea prevents children from absorbing nutrients, A randomized evaluation, built into the program, found and research shows this can have lifelong consequences for that while open defecation was reduced, the handwash- their physical and cognitive development. Evidence from ing campaign wasn’t successful at getting people to wash small-scale studies (known as “proof of concept”) support their hands with soap and water, and neither campaign the theory that improvements in handwashing and sanita- led to meaningful health benefits, even when combined. tion can have a positive, and meaningful, impact on health. The evidence reveals the difficulties of reducing diar- However, efforts to improve hygiene and use of latrines or rheal disease and the need for more research to iden- toilets at a larger scale in real-world settings have had only tify successful strategies. Context Around 70 percent of Tanzania’s population lives in rural human contact. Additionally, 18 percent of households in areas, where poverty is high and an estimated 9 percent of rural areas still regularly practice open defecation. children die before their fifth birthday. Open defecation is The World Bank’s Water and Sanitation Program is work- a critical problem. A cholera epidemic in the 1970s spurred ing with governments around the world to implement rural the construction of latrines, but many of these have since sanitation and handwashing campaigns. These efforts are fallen into disrepair and the use of improved sanitation has part of two international campaigns, the Global Scaling Up declined. While about 80 percent of Tanzanians have access Handwashing and the Global Scaling Up Rural Sanitation to a latrine, less than 10 percent have latrines with a slab or programs (see Evidence to Policy note “What Gets People to some other floor material to help separate fecal matter from Wash their Hands? Impact Evaluation Evidence from Peru and Vietnam”). In Tanzania, the government worked with improved sanitation, such as properly constructed latrines the World Bank to implement and evaluate sanitation and and toilets. The Government of Tanzania and the World handwashing campaigns that were rolled out between the Bank also had a specific interest in understanding the indi- end of 2009 and early 2011. The aim was to increase rates vidual and combined effects of implementing handwashing of handwashing with soap and boost demand for and use of and sanitation programs separately and together. Evaluation The government picked ten districts across the country to The handwashing campaign was aimed at moth- implement the programs. The districts contained a total of ers with children under the age of five. It included print 245 wards—each ward has a population of around 12,000 and radio media campaigns, training community activ- WATER AND SANITATION people—and 181 rural wards were included in the evaluation. ists, road shows, and promotional events urging people These wards were divided into four groups: one received to wash their hands properly. The program also provided the handwashing intervention only, a second received the technical assistance to help build cheap and water-efficient sanitation intervention only, a third received both and the handwashing stations, called tippy-taps. Both programs fourth received none. Overall, the sample was poorer than focused on positive messages, rather than shaming tactics, the national average because it was limited to rural areas. and neither provided subsidies. The rural sanitation program used what is known as The endline survey was conducted in 2012, about one Community Led Total Sanitation to increase demand for year after the programs ended. The survey covered 3,619 services. Community members are brought together with households and 5,768 children under five. Researchers a trained leader who focuses on the communal dangers examined the programs’ impact on latrine construction, of open defecation and how it can be solved. People are open defecation, handwashing and the health of children shown where open defecation occurs and how fecal matter under five years old. ends up in their food and water. A mass media campaign promotes good sanitation, while public events use skits Nearly 58 percent of children in Tanzania are anemic, some 44 percent of children are stunted, and diarrhea is common, with 14 percent of and songs to reinforce the message. To improve supply, children experiencing symptoms within a two-week period. local masons are trained in building slabs for latrines and Data from World Bank other things to upgrade latrines. Results Households exposed to the sanitation campaign above the 38 percent of households that had built private were more likely to switch to private latrines or latrines in areas where there wasn’t a sanitation campaign. other improved sanitation systems. People exposed to the campaign were also less likely to use shared latrines, something which is common in rural In areas where the sanitation campaign ran, private latrine Tanzania and can worsen the spread of fecal matter. There construction rose between 10 and 12 percentage points was a 9.2 percentage point drop in use of shared latrines This policy note summarizes World Bank Policy Research Working Paper #7164, “Promoting Handwashing and Sanitation: Evidence from a Large-Scale Random- ized Trial in Rural Tanzania,” Bertha Briceno, Aidan Coville, Sebastian Martinez, World Bank Water Global Practice & Development Research Group, January 2015. http://documents.worldbank.org/curated/en/2015/01/23804984/promoting-handwashing-sanitation-evidence-large-scale-randomized-trial-rural-tanzania in areas where the sanitation campaign alone took place who were observed washing hands before handling food. and a 7.6 percentage point drop in areas where both the Overall, the numbers remained very small. handwashing and sanitation campaigns took place. The There were some small improvements however in interventions also significantly increased access to improved households exposed to the handwashing campaign, either sanitation. While half of households in the control areas on its own or in combination with the sanitation cam- had access to an improved latrine, this increased by 10 paign: Children were more likely to be clean, based on percentage points in areas that received both campaigns, whether or not they had dirty hands, fingernails or faces; and by 15 percentage points in areas that received only the and caregivers had cleaner hands. sanitation campaign. Regular open defecation was reduced, but occasional open defecation continued. WATER AND SANITATION About 11 percent of people in areas where the sanitation campaign took place said they regularly defecated in the open, compared with 23 percent in the control group. However, more than half of households in all groups re- ported that they still sometimes defecated in the open, a rate unchanged from before the start of the campaign. Animal feces were still widespread around dwellings, un- derscoring the fact that containing human fecal matter was just part of the challenge. In Tanzania. . . 46 percent of people lack access to improved drinking water sources The campaigns were less successful at changing 40 percent of the time, child feces are disposed of unsafely 84 percent of schools lack working hand washing facilities people’s handwashing behaviors, even while More than half the rural population spends at least 30 minutes a day people’s knowledge of the importance of using collecting water soap and water did improve. Data from UNICEF and World Bank Overall, the handwashing campaign had little success in translating knowledge into behavior change. Caregivers in Neither program—on its own, or in combination areas where the handwashing campaign took place—with —had any positive impact on children’s health. or without the sanitation component—were more likely to know about the critical times to wash hands with soap. Researchers looked at diarrhea rates as an indication of short However, people weren’t any more likely to wash their term-health; and weight and hemoglobin levels (low levels hands with soap, based on their self-reporting. Forty seven indicate anemia, which can be a sign of poor nutrition) as percent of caregivers in both the control communities a medium-term measure of health; and height and head and in areas where campaigns took place reported that circumference as a longer-term indicator of improved health. they washed their hands after contact with fecal matter. Individually, the campaigns showed no effects on any measure However, when researchers directly observed people, only of child health. When looking at the combined intervention, 12 percent actually washed their hands. the researchers find some statistically significant findings in There was only a 1.6 percentage point increase in health outcomes, but these are inconsistent and biologically handwashing before food preparation (in areas where the insignificant, suggesting that neither the sanitation program, handwashing campaign took place and in areas with both nor the handwashing program, nor the two together were handwashing and sanitation campaigns). This compares able to generate meaningful health improvements for children with the 1.3 percent of caregivers in the control group under the age of five years. Conclusion As development experts seek ways to improve the health It’s important to understand how to balance incentives and well-being of children around the world, identifying to encourage people to use improved sanitation and wash strategies that effectively reduce diarrheal disease and their hands with the demands of implementing these pro- improve children’s health is proving difficult. Simple grams at scale. It’s clear that water and sanitation programs and cost-effective solutions like handwashing with soap can lead to health improvements, especially for children, and water have the potential to improve people’s lives, but it’s harder to know how to structure and implement but if campaigns are unable to change the way people these programs so they are effective. The focus for research- behave, billions of people around the world won’t real- ers, policymakers and implementers alike needs to be on ize the benefits. figuring out how to make these programs work at scale. WATER AND SANITATION The Strategic Impact Evaluation Fund, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help alleviate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health and job opportunities for people in developing countries. For more information about who we are and what we do, go to: http://www.worldbank.org/sief. The Evidence to Policy note series is produced by SIEF with generous support from the British government’s Department for International Development. THE WORLD BANK, STRATEGIC IMPACT EVALUATION FUND 1818 H STREET, NW WASHINGTON, DC 20433 Produced by the Strategic Impact Evaluation Fund Editor: Aliza Marcus Writer: Daphna Berman