34873 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia This regional study draws up policy recommendations for large-scale rural sanitation programs in South Asia where more than 900 million people (66 percent of the total population) remain without access to adequate sanitation. The Water and Sanitation Program May 2005 is an international partnership for improving water and sanitation sector policies, practices, and capacities to serve poor people Report The findings, interpretations, and conclusions in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. The World Bank does not guarantee the accuracy of the data included in this document and accepts no responsibility for any consequences of their use. Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Contents Acknowledgments 4 Foreword 5 List of Abbreviations 7 Executive Summary 9 1 Introduction 11 2 Methodology 13 3 Background 17 4 Findings 19 4.1 Case studies 4.1.1 Institutional arrangements 4.1.2 Program approaches 4.1.3 Social intermediation 4.1.4 Sanitation promotion 4.1.5 Sanitation technology 4.1.6 Supply chains 4.1.7 Program monitoring and coordination 4.2 Case study outcomes 4.2.1 Technology choice 4.2.2 Toilet access and usage 4.2.3 Open defecation 4.2.4 Hygiene behavior 4.2.5 Technology costs 2 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 4.2.6 Program costs 4.2.7 External support 5 Analysis 35 5.1 Overall performance 5.2 Factors of success 5.3 Constraints 6 Scaling-Up Rural Sanitation 45 6.1 Potential perfomance at scale 6.2 Constraints to scaling-up rural sanitation 6.3 Strategies for scaling-up rural sanitation 7 Policy Implications 55 8 Recommendations for Further Research 59 9 References 61 Annex 1: Community-led Total Sanitation 63 Annex 2: Case Studies from Bangladesh 67 Annex 3: Case Studies from India 83 Annex 4: Case Study from Pakistan 121 References 132 3 Acknowledgments This study was conducted by the Water and Sanitation (WaterAid India), Roger Fitzgerald (WaterAid India), Program-South Asia. It was prepared by Andrew James S K Srivastava (RSPMU, Maharashtra), Kamal Kar Robinson and task managed by Soma Ghosh Moulik. (Independent consultant), Tapan Kumar Ghosh (JBPDO The study was peer reviewed by Eduardo A. Perez (World Kheshpur, West Bengal), M V Rao (District Management Bank, Water Anchor Sanitation Team). This document West Medinipur, West Bengal), Matindra Chandra Debnath would not have been possible without the assistance of (BDO Sankrail, West Bengal), Shakti Chattopadhyay the UK Department for International Development (DFID) (SIPRD, West Bengal), R Gaipur (BDO Mangaon, and AusAID who provided funding support. Maharashtra), staff of Jivala NGO (Maharashtra), Chanda Khan Dalvi (CEO Ahmednagar, Maharashtra), Lahu Kanade Special thanks are due to Junaid Ahmad (World Bank), (Deputy CEO Ahmednagar, Maharashtra), Renu (UNICEF Khawaja Minnatulla (WSP-SA), Shafiul Azam Ahmed Mumbai), Dr Syed Tauqir Hussain Shah (NRSP, Pakistan), (WSP-SA), Raja Rehan Arshad (World Bank), Tanveer Mohammed Shafiq (Nazim Dunyapur, Pakistan), Khalid Ahsan (Danida ­ Bangladesh) for their support and advice Warriach (LPP, Pakistan), Iftikhar A Toor (LGRDD Punjab, and to Vandana Mehra (WSP-SA) for design and Pakistan), Jagadeeshwar (State Water and Sanitation publication arrangements. Many thanks to the WSP-SA Mission, Andhra Pradesh), Venkateswarulu (PRED-RWS, team; Pronita Chakrabarti, Mariappa Kullappa, C Ajith Andhra Pradesh), Ajay Jain (Collector Kurnool, Andhra Kumar, JVR Murty, and Kazi Adil Ahmed Shafi for assisting Pradesh), Sumita Dawra (Collector Karimnagar, Andhra directly in the field work and to Onika Vig, Syed Farrukh Pradesh), Damodaran Sait (Gramalaya, Tamil Nadu), Ansar, Md. Abul Fayez Khan who provided organizational M Manohara Singh (DRDA Trichi, Tamil Nadu), support for the preparation of the document. M Subburaman (SCOPE, Tamil Nadu), Shah M A Habib (NGO Forum Dinajpur, Bangladesh), Mohammed Azahar Ali Thanks must also go to those that took time out to provide Pramanik (NGO Forum, Bangladesh), Milan Kanti Varva information to the study and discuss the issues involved (BRAC, Bangladesh), Mac Abby (Plan International, in scaling-up rural sanitation, including: Paul Deverill Bangladesh), S M A Rashid (NGO Forum, Bangladesh), (UNICEF India), Raj Shekhar (Rajiv Gandhi National Amanullah Al Mahmood (DPHE, Bangladesh), Abdul Drinking Water Mission, India), M N Roy (Secretary, Quader Choudhury (GoB-UNICEF Project, Bangladesh), Panchayati Raj and Rural Development Department, Rawshan Ara Begum (LGD, Bangladesh), and Timothy Government of West Bengal), Shunmaya Parmavisaran Clayden (WaterAid, Bangladesh). 4 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Foreword Despite significant investments over the last 20 years, successful approaches from small-scale, participatory South Asia faces the most daunting sanitation challenge sanitation programs and adapt them for effective use in in any region in the world. More than 900 million South large-scale rural sanitation programs? Asians (66 percent of the total population) remain without access to adequate sanitation. The vast majority of this Based on lessons learned from eight case studies of unserved population are rural inhabitants but, at present, innovative rural sanitation programs in Bangladesh, India, rural sanitation programs in the region are barely keeping and Pakistan, this report summarizes the findings of a pace with population growth. One of the Millennium regional study on scaling-up rural sanitation conducted by Development Goals is to halve the population without the Water and Sanitation Program-South Asia (WSP-SA). access to hygienic sanitation facilities by 2015. While Detailed analysis of program performance and context is governments in South Asia have pledged to meet this used to draw out `factors of success' and common goal, its achievement will entail the provision of constraints, and to suggest potential strategies for sustainable sanitation services to more than 450 million scaling-up program approaches. people over the next 10 years. While there are few truly successful large-scale sanitation This urgent challenge gives rise to a classic development programs on which to base firm recommendations, the dilemma: how to develop rural sanitation programs report lays out policy implications for large-scale rural capable of rapid and large-scale provision of cost-efficient sanitation programs. It calls for new approaches to sanitation services, without cutting back on program sanitation development, and for a new emphasis on elements critical to sustainability and long-term welfare measuring success by long-term improvements in public improvements. Put another way: is it possible to take health and well-being, rather than on the number of toilets built. Catherine Revels Regional Team Leader Water and Sanitation Program-South Asia 5 Despite significant investments over the last 20 years, South Asia faces the most daunting sanitation challenge of any region in the world. 6 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Abbreviations ADP Annual Development Program OPP Orangi Pilot Project BDO Block Development Officer PIHS Pakistan Integrated Household Survey BPL Below poverty line PMU Project monitoring unit BRAC Bangladesh Rural Advancement Committee PRD Panchayats and Rural Development CCCD Child-centered Community Development PRED Panchayati Raj Engineering Department CRSP Central Rural Sanitation Programme PRI Panchayati Raj Institution DPHE Department of Public Health Engineering RGNDWM Rajiv Gandhi National Drinking Water Mission DRDA District Rural Development Agency RKM Rama Krishna Mission FFW Food For Work RSM Rural Sanitary Mart GNI Gross National Income RWS Rural Water Supply GO Government Order SACOSAN South Asian Conference on Sanitation GoI Government of India SGBC Sant Gadge Baba Campaign GoM Government of Maharashtra SHG Self-help group GP Gram Panchayat SIPRD State Institute of Panchayats and IEC Information, Education & Communication Rural Development ISL Individual Sanitary Latrines SRP Sector Reform Program JSDF Japan Social Development Fund SWSM State Water and Sanitation Mission KfW KfW Bank Group TMA Tehsil Municipal Administration LCS Low Cost Sanitation TNWDC Tamil Nadu Women Development Corporation LGRDD Local Government and Rural Development Department TSC Total Sanitation Campaign LPP Lodhran Pilot Project UNICEF United Nations Children's Fund MDG(s) Millennium Development Goal(s) UNO Upazila Nirbahi Officer MPDO Mandal Parishad Development Officer VERC Village Education Reseach Centre NGO Non-governmental Organization VSC Village Sanitation Committee NRSP National Rural Support Program WSP Water and Sanitation Program O&M Operations and Maintenance WSP-SA Water and Sanitation Program-South Asia 7 Large-scale sanitation programs should combine government and NGO (or local organization) resources. 8 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Executive Summary In South Asia, more than 900 million people nInvestmentinhygienepromotionandsocial (66 percent of the total population) remain without intermediation (at household level); and access to adequate sanitation. Despite significant nProvisionofaffordablesanitationoptionstothepoor. investments, rural sanitation coverage in the region is The more successful programs provided high access to barely keeping pace with population growth. Clearly, sanitation, and ensured high toilet usage through a current approaches to the development and provision combination of participatory processes, hygiene of rural sanitation services in the region are either promotion, and institutional incentives (financial rewards not effective, or are not at sufficient scale to make for achieving universal toilet coverage, community bans on an impact on the enormous population that lacks open defecation, fines for open defecation, and so on). adequate sanitation. The case study analysis also identified a number of This regional study was commissioned by the Water `common constraints': and Sanitation Program-South Asia (WSP-SA) to address nWidespread failure to monitor local outcomes (for some of these issues. The main objectives of example, open defecation, toilet usage, handwashing); the study were: nHigh hardware subsidies (including the provision of nTo develop case studies of innovative approaches to free toilets); rural sanitation in South Asia; nIneffective social intermediation (notably by nTo analyze the factors of success (and constraints) government bodies); and found in these case studies; nUnsustainable supply chains. nTo assess potential strategies (and constraints) to Only two of the case studies examined large-scale scaling-up the approaches used in case studies; and sanitation programs. Therefore, the assessment of nTo draw up policy recommendations for large-scale rural strategies for scaling-up rural sanitation was largely sanitation programs in the region. theoretical, based on the case study analysis and some more general thinking on likely constraints to scaling-up Seven of the eight case study programs use a `total rural sanitation. Five potential strategies for scaling-up sanitation' approach to promote behavior change, rural sanitation emerged: including low-cost toilets in India and Bangladesh. The nIncrementalprogramdevelopment; eighth case study program implements simplified rural nPartnering between local governments and NGOs; sewerage schemes in Pakistan using a `component- nNeed for cost-effective implementation; sharing' approach. The sanitation programs studied range nFormation of community self-help groups; and in size from a small-scale NGO program covering nMacro-monitoring of sanitation programs. 12 villages in one district to a large-scale government program that provided more than 1.5 million toilets in Large-scale sanitation programs need to be hybrids that Andhra Pradesh last year.1 combine use of government resources and monitoring networks with the employment of NGOs (or other local Based on the case study findings, 10 performance organizations) that have social development skills and indicators were used to rate the overall performance of community rapport. The case studies also highlight the each case study program. A detailed analysis was then importance of not going to scale too quickly; of regular carried out, which identified the following key `factors macro monitoring and reporting; and of encouraging of success': cost-effective implementation by advocating low hardware nFocusonstoppingopendefecation(ratherthan subsidies and careful targeting of IEC and hygiene building sanitation facilities); promotion activities. 1Full case studies are included in the Annexes to this report. 9 One of the Millennium Development Goals is to halve the population without access to hygienic sanitation facilities by 2015. The closing sections of this report examine the policy locally appropriate policies on matters such as social implications resulting from this regional study and make intermediation, hygiene promotion, sanitation marketing, recommendations for further research. Unsurprisingly, the financial incentives, accountability to users, and study concludes that there is some merit to the `total program finance. sanitation' concept. In cases where the total sanitation approach had been used, program managers and local South Asia contains more poor people without access to government officials were aware that their main objective sanitation than any other region on earth, which puts its was to stop open defecation, and that this required national governments under extreme pressure to make community-wide action, universal toilet use, and hygiene the most of the limited available resources for the behavior change. Opinion was divided as to how these development of sanitation services. In the past, this meant changes should be effected, but there was little argument pouring money into building heavily subsidized toilets, but about the approach. In this respect, the `total sanitation' there is increasing evidence that this approach tends to concept is a major step forward, as this level of shared result in low toilet usage and wasted investments. understanding and purpose was sadly lacking in many New approaches are needed to make a substantial and earlier sanitation programs. sustainable impact on public health. This study suggests However, the variable case study performances confirm that the focus of large-scale sanitation programs should that the total sanitation approach is no `magic bullet' for be on stopping open defecation and on improving rural sanitation. The total sanitation concept focuses hygiene behavior on a community-by-community basis, attention on stopping open defecation and on the with success measured not by the number of toilets built, importance of community-wide action, but large-scale but by long-term improvements in public health sanitation programs also need carefully thought out and and well-being. 10 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 1 Introduction In South Asia, more than 900 million people (66 percent of important step forward. Key stakeholders from South Asia2 the total population) remain without access to adequate recognized the need for new approaches and for the sanitation. The vast majority of this unserved population scaling-up of the provision of rural sanitation services if are poor and live in rural areas, making the provision of any genuine attempt is to be made at reaching the MDGs. affordable rural sanitation services of vital importance to both public health and poverty alleviation in South Asia. Those present at SACOSAN pledged to accelerate progress by working in partnership with key sector In recognition of the magnitude and severity of this stakeholders to design and implement improved national challenge, governments, external support agencies, and sanitation policies and programs. NGOs in the region have made huge rural sanitation investments over the last few decades. However, despite As a result, the Water and Sanitation Program-South Asia these investments and efforts, rural sanitation coverage in (WSP-SA) commissioned a regional study with the the region is barely keeping pace with population growth. following objectives: nTo develop case studies of innovative approaches to Clearly, current approaches to the development and rural sanitation in South Asia; provision of rural sanitation services in the region are nTo analyze the factors of success (and constraints) either not effective, or are not at sufficient scale to make an found in these case studies; impact on the enormous population that lacks adequate nTo assess potential strategies (and constraints) to sanitation. One of the key challenges facing the rural scaling-up the approaches used in case studies; and sanitation sector in South Asia is to develop large-scale nTo draw up policy recommendations for large-scale rural national programs that produce sustainable and affordable sanitation programs in the region. rural sanitation services. Following the completion of eight case studies in 2004 This process is essential if governments within the region (see Annexes), this report is the main output from the are to achieve their Millennium Development Goals regional study. It presents an analysis of the case study (MDGs), which include halving the number of people findings and draws out the factors of success in these without access to hygienic facilities by 2015, and case studies. The report also examines whether the providing universal access to sanitation by 2025. successful approaches from the case studies can be The recent South Asian Conference on Sanitation scaled-up into larger programs, and outlines the policy (SACOSAN), held in Dhaka during October 2003, was an implications arising from the study findings and analysis. 2Including government ministers, senior civil servants, NGO representatives, and donor agency representatives from Afghanistan, Bangladesh, Bhutan, India, Maldives, Myanmar, Nepal, Pakistan, and Sri Lanka. 11 One of the key challenges facing the rural sanitation sector in South Asia is to develop large-scale national programs that produce sustainable and affordable rural sanitation services. 12 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 2 Methodology The terms of reference proposed that the cases studied (including transect walks, group discussions, and should be examples of new and innovative approaches to interviews with individual household members); and rural sanitation that represent the different countries, nVisits to nearby villages not involved in the contexts, and challenges within the region. sanitation program. Each of the case studies was based around the Given the limited duration of the study (three months) and following framework: the logistical requirements, the fieldwork was limited nContext (national and local issues that may to eight case studies chosen by the respective WSP influence outcomes); country offices. In each case, the rapid appraisals nApproach (main principles and activities of the conducted for the study involved: sanitation program); nCollation of background material by WSP and sanitation nInstitutional model (main institutions involved in the program staff; sanitation program); nInterviews with key informants on rural sanitation nSanitation promotion (social intermediation, hygiene policies and issues; promotion, local demand); nInterviews with local government officials; nSustainability (technical, social, institutional, financial, nInterviews with the managers and staff of the environmental); and sanitation program; nScaling-up (is the approach likely to be successful nVisits to villages involved in the sanitation program at scale?). List of Case Studies Country Project Bangladesh Total Sanitation Approach (Local Government Rajarhat) Total Sanitation Approach (NGO Forum) Total Sanitation Approach (Plan Bangladesh) India West Bengal TSC (Local Government + local NGOs) Maharashtra TSC (Local Government Ahmednagar + local NGOs) Andhra Pradesh TSC (Local Government + Engineering Department) Tamil Nadu TSC (Gramalaya NGO + WaterAid + Local Government) Pakistan Lodhran Pilot Project, Punjab (Local NGO supported by national NGOs) TSC = Total Sanitation Campaign (Government of India national sanitation program) Note: Exchange rate ­ US$ 1: Bangladeshi Taka 59; US$ 1: Indian Rs 46.33; US$ 1: Pakistani Rs 57 (based on 2004 rates) 13 Good hygiene behavior denotes practices that keep people and their surroundings clean and free from illness and infection, for example, washing hands with soap after defecation. 14 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Definitions For the purposes of this report, the following definitions apply: Sanitation Safe management and disposal of human excreta, for example, through the use of toilets and good hygiene behavior. Note: `Environmental Sanitation' is a broader term, encompassing interventions that maintain public health by providing a clean environment and reducing exposure to disease, for example, behaviors and facilities that work together to safely manage and dispose of human and animal excreta, refuse, and wastewater; to control disease vectors; and to improve personal and domestic hygiene. Rural The rural space is that which is not urban. Note: This classification varies according to the criteria used in each area or country. In general, the rural population comprises those communities living outside cities and towns, but it may also include rural towns below a certain size (for example, 5,000 inhabitants). Sanitation hardware Sanitation facilities, for example, toilets, septic tanks, soakaways, sewerage systems, handwashing facilities, and so on. Sanitation software Program activities that support and promote the provision of sanitation services and facilities, for example, community development, training, media campaigns, hygiene promotion, and so on. Hygiene behavior Good hygiene behavior denotes practices that keep people and their surroundings clean and free from illness and infection, for example, washing hands with soap after defecation. Total sanitation approach A community-wide approach whose main aim is universal toilet use (total sanitation) in each community covered by the program. The total sanitation approach focuses on stopping open defecation on a community-by-community basis by highlighting the problems caused to all by open defecation within and around the community, and by ensuring that every household either builds and uses their own low-cost toilet, or has access to a shared toilet. Scaling-up rural sanitation Increasing the scale, the rate of provision, and the sustainability of rural sanitation services, such that universal sanitation coverage can be reached and maintained within a reasonable time frame. This implies: Inclusion (the vast majority of the target population is provided with improved and sustainable services within a reasonable time frame); and Institutionalization (a system of actors and institutions is in place with the necessary capacity and resources to deliver sustainable sanitation services indefinitely). After Davis & Iyer (2003), and Lockwood (2004) 15 In a period when decision-makers are recognizing the importance of adequate sanitation for public health and poverty alleviation, South Asia contains more poor people without sanitation than any other region. 16 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 3 Background Rural sanitation is a critical issue for South Asia. In a unserved population in South Asia and perhaps 30 period when decision-makers are recognizing the percent of those unserved globally. It should be noted that, importance of adequate sanitation for public health and despite significant efforts to improve data collection, poverty alleviation, South Asia contains more poor people national sanitation coverage figures from most countries without sanitation than any other region on earth. The vast in South Asia remain inaccurate. In part, this reflects majority of this unserved population live in rural areas. genuine difficulties associated with making household-by- household assessments on a national scale. The figures presented at SACOSAN confirm that, among the three South Asian countries covered by this study, All too often, sanitation coverage figures are overestimates India has by far the lowest sanitation coverage. More than based on the number of toilets built by previous sanitation 750 million people in India are without access to adequate programs, without allowances for incomplete projects, or sanitation, which represents about 80 percent of the for collapsed and abandoned toilets. Comparative Regional Data Name Population Pop. Density Literacy GNI Total Rural (nr/km2) (per capita) Bangladesh 136 million 87% 944 41% US$ 360 India 1,048 million 72% 353 56% US$ 480 Pakistan 145 million 66% 188 45% US$ 410 South Asia 1,401 million 72% 293 56% US$ 460 Source: WDR 2004 (data from 2002); GoI Census 2001; Baseline survey 2003; www.banglapedia.search.com Access to Improved Sanitation in South Asia Country Rural Urban Total Unserved Sanitation Sanitation Sanitation Population Bangladesh 41% 61% 48% 71 million India 18% 56% 28% 755 million Pakistan 41% 94% 62% 55 million South Asia 24% 66% 34% 925 million Source: SACOSAN Country Papers; World Development Report 2004; PIHS 2002; JMP 2004 17 The main advantage of the total sanitation approach over conventional policies is that it is a community-wide approach, which requires that every household in the community stops open defecation and uses a sanitary toilet. 18 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 4 Findings The case studies are based on a series of rapid appraisals nComparison of case study outcomes; conducted during January-March 2004, and on the data nIdentificationoffactorsofsuccessandcommon available at the time of the appraisals. constraints; and nAssessment of potential performance at scale. This report is based on the case studies, and is intended to be a preliminary piece of work that: 4.1 Case studies nPulls together current sanitation success stories and Full case studies are included in the Annexes to this report: innovations in South Asia; nAnnex 2: Case Studies from Bangladesh (three); nHighlights the key issues that emerge from these nAnnex 3: Case Studies from India (four); and case studies; and nAnnex 4: Case Study from Pakistan. nIdentifies policies and approaches that appear worthy of more rigorous study. 4.1.1 Institutional arrangements The case studies fall into two categories: As mentioned in the introduction, one of the key challenges nFour public cases (financed by the government and in expanding access to sanitation and improving public implemented by the local government); and health is to scale-up successful small-scale approaches into nFour NGO cases (financed by non-governmental donors large-scale national programs. Therefore, this analysis has a and implemented by NGOs). particular focus on the scale at which the case study programs operate, and on the relevance and replicability of The first three public cases (Andhra Pradesh TSC, West Bengal TSC, Ahmednagar TSC) are similar, in that all three the case study approaches at large scale. are part of the Government of India's Total Sanitation The findings and analysis are presented in the following Campaign (see Annex 3 for details) and follow its guidelines. four steps: However, the Andhra Pradesh TSC and West Bengal TSC nComparison of case study approaches; cases examine State-wide sanitation programs, whereas the Case Studies Case Country Program Sanitation Approach Technology Ahmednagar, Maharashtra TSC Total sanitation Low-cost toilets Andhra Pradesh TSC India Total sanitation Toilets and bathrooms Gramalaya, Tamil Nadu TSC Total sanitation Low-cost toilets West Bengal TSC Total sanitation Low-cost toilets Rajarhat Local Government Total sanitation Low-cost toilets NGO Forum Bangladesh Total sanitation Low-cost toilets Plan Bangladesh Total sanitation Low-cost toilets LPP Pakistan Component-sharing Settled sewerage 19 This analysis has a particular focus on the scale at which the case study programs operate, and on the relevance and replicability of the case study approaches at large scale. Ahmednagar case study examines a pilot program being financed by non-government donors. NGO Forum and implemented in only two districts (Ahmednagar and Nanded) Plan Bangladesh are well-established and well-supported in Maharashtra. NGOs, which operate across Bangladesh. In contrast, the Lodhran Pilot Project (LPP) in Pakistan is a small, local The fourth public case (Rajarhat, Bangladesh) is a NGO formed relatively recently in direct response to local one-off local government intervention, a small sanitation sanitation problems. program initiated by the chief administrator of the sub-district (Upazila) and financed by the sub-district The Gramalaya case study is something of a hybrid: Gramalaya is one of WaterAid India's partner NGOs in government independently of any central or local government programs. southern India, but is now implementing part of the government TSC program in Tamil Nadu. Local government The four NGO cases involve sanitation programs manages the district TSC project, but it has contracted 14 implemented by non-governmental organizations and NGOs (including Gramalaya) to implement the project. Public Cases Case Policy Institutions Start Annual Program Coverage Date Implementation Finance Villages Households Andhra Pradesh TSC District govt. Govt. (TSC) 2003 (16,700) 1,670,000 West Bengal TSC District govt. Govt. (TSC) 1999 (8,500) 850,000 Ahmednagar TSC District govt. Govt. (TSC) 2003 300 (30,000) Rajarhat Local govt. Sub-district govt. Local govt. 2001 (180) 18,0003 Estimate based on 100 households per village NGO Cases Case Policy Institutions Start Annual Program Coverage Date Implementation Finance Villages Households NGO Forum NGO National NGO Donors 2001 600 (60,000) Plan Bangladesh NGO International NGO Donors 2002 100 (10,000) Gramalaya TSC/NGO Local NGO Donors & govt. 2003 30 (3,000) LPP NGO Local NGO Donors 2001 12 (1,200) Estimate based on 100 households per village 3Annual coverage of Rajarhat sanitation program (36,000 household toilets were built in two years). 20 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Gramalaya is well-respected locally, and most of its Total Sanitation Approach operational costs are financed by external donors, thus the district government allows Gramalaya to implement its two The total sanitation approach recognizes that sanitation sub-district TSC programs relatively independently. is both a public and a private good, and that individual hygiene behavior can affect the whole community ­ if 4.1.2 Program approaches your neighbors defecate in the open, then your children Seven of the eight case study programs use a `total risk excreta-related disease even when the members of sanitation approach'. This approach derives from the your own household use a sanitary toilet, wash their `community-led total sanitation' approach developed by hands, and practice good hygiene. In this sense, `total sanitation' refers to a community-wide ban on open NGOs (WaterAid and VERC) in Bangladesh (see Annex 1). defecation, and requires that everyone in the community The Lodhran Pilot Project (LPP) in Pakistan is the sole either owns or has access to a sanitary toilet. exception. It utilizes a `component-sharing' approach The main advantage of the total sanitation approach over modelled on that of the Orangi Pilot Program (OPP), a conventional policies is that it is a community-wide well-known urban sanitation success story from the approach, which requires that every household in region. The challenge of providing sanitation infrastructure the community stops open defecation and uses a is divided into `internal' components (sanitary toilet, sewer sanitary toilet. connection, and lane sewer) and `external' components Therefore, this approach involves even the poorest and (main sewers and disposal works). most vulnerable households in the community, and ensures that both the community and the local Rather than sharing the costs of each component, the government focus on assisting these households to gain responsibility for providing the components is shared: access to adequate sanitation facilities. construction of the internal components is financed and managed entirely by the community; provision of the external components, technical assistance, hygiene nCatalyzing collective action to stop open defecation; promotion, social guidance are the responsibility of LPP. nSupporting the development of community-wide sanitation facilities; There are four critical elements to the total nPromoting toilet usage and improved hygiene sanitation approach: behavior; and Agencies Used in Public Cases Case Community Sanitation Hygiene Supply Development Promotion Promotion Chains West Bengal TSC Local govt. Partner NGO* Partner NGO* Partner NGO Ahmednagar TSC Local govt. Contract NGO Contract NGO NGO/govt. Contract NGO Rajarhat Local govt. Local govt. Local govt. Local govt. Andhra Pradesh TSC Govt. Government Govt. Govt. * NGO `motivator' working on commission 21 The use of local NGOs for social intermediation has several advantages: it bridges the gap between rural communities and distant or powerful program staff; and it provides large sanitation programs with important local knowledge and credibility. nInstitutionalizing monitoring, support, and supply district government has signed short-term contracts with chain mechanisms. 20 local NGOs, and these contracts are regularly reviewed and renewed (or cancelled), based on pre-agreed In each of the seven case studies using a total sanitation performance indicators. Only two of the eight cases approach, these elements have been implemented in a (Andhra Pradesh and Rajarhat) do not use NGOs for social different manner, using different institutional and intermediation. All activities in the Rajarhat program, financing models. As a result, despite being based on including social intermediation, are carried out by local similar concepts, the case study programs vary widely and government officers. In Andhra Pradesh, the state have very different outcomes. engineering department has resisted the involvement of 4.1.3 Social intermediation NGOs in the Total Sanitation Campaign, preferring to The relationship between sanitation promoters and rural employ private individuals, known as resource officers, to households or communities is a key aspect of sanitation undertake sanitation promotion. These resource officers programs. In six of the cases studied, the social are answerable to local government engineers, and intermediation role is performed largely by local NGOs generally have little training or experience in community with experience in community development. The use of development or the use of participatory approaches. local NGOs for social intermediation has several advantages: it bridges the gap between rural communities 4.1.4 Sanitation promotion and distant or powerful program staff; and it provides Each of the case study programs involves at least one of large sanitation programs with important local knowledge the following sanitation promoting activities: and credibility. LPP and Gramalaya are local NGOs that nMass media sanitation promotion (for example, regional employ local staff, thus conduct their own social campaigns conducted through newspaper and radio intermediation activities within their relatively small advertisements, wall paintings, printed leaflets, programs. In three of the other cases (West Bengal TSC, sanitation conventions); NGO Forum, and Plan Bangladesh), long-term nParticipatory sanitation promotion activities (for partnerships have been formed with local NGOs, who are example, community activities such as social mapping, then trained and supported to undertake social defecation and contamination mapping, transect walks, intermediation activities. In the Ahmednagar case, the group discussions4); Agencies Used in NGO Cases Case Community Sanitation Hygiene Supply Development Promotion Promotion Chains Plan Bangladesh Partner NGO Partner NGO Partner NGO NGO/private Gramalaya in Trichy NGO NGO NGO NGO/private NGO Forum in Partner NGO Partner NGO Partner NGO Partner NGO Bangladesh LPP in Pakistan NGO NGO NGO NGO/private 4For more details of typical participatory activities, see Annex 1 `Community-led Total Sanitation'. 22 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Sanitation Promotion in Public Cases Case Mass Participatory Institutional Targeted Media Activities Incentives Messages West Bengal TSC Yes ­ Yes Yes Ahmednagar TSC Yes Yes Yes ­ Rajarhat ­ ­ Yes ­ Andhra Pradesh TSC Yes ­ Yes ­ nInstitutional incentives (for example, financial awards for the programs studied claim to offer several different stopping open defecation; bans on open defecation; social sanitation technologies, with the exception of the LPP marketing of low-cost sanitation components); and case (only settled sewerage) and the West Bengal TSC nTargeted hygiene messages (for example, household (standard low-cost toilet). delivery of locally appropriate messages on basic hygiene practices such as handwashing, food and water hygiene). Both the Andhra Pradesh TSC and the Gramalaya program in Trichy promote expensive sanitation facilities with Broadly speaking, the government-funded sanitation separate cubicles provided for the toilet and bathroom. programs (that is, the four cases involving the Government The other cases promote single-cubicle toilets, allowing of India's Total Sanitation Campaign) are the only the users to decide whether to use this facility for bathing, programs with the resources to carry out mass media or whether to construct their own bathing facility. sanitation campaigns. Demand for bathing facilities was evident in the Andhra The government programs also use institutional Pradesh TSC program. Many of the toilet pans in single- incentives, such as bans on open defecation, with local cubicle toilets had been blocked or covered so that the government enforcement. In contrast, the smaller NGO toilet enclosure could be more easily used as a bathroom programs tend to favor participatory processes and and laundry facility. targeted hygiene promotion. In most cases, the sanitation technologies were well Given the difficulties in assessing the impact of constructed and working as intended, but technical software activities, the rapid appraisals conducted for this study did not include a detailed examination of problems were observed in the Rajarhat (see Annex 2) individual sanitation and hygiene promotion activities. and Andhra Pradesh TSC (see Annex 3) cases, and Therefore, more lengthy and rigorous hygiene-specific there were questions over the sustainability of the LPP research is required to determine the effectiveness and sewerage systems (see Annex 4). efficiency of these different approaches to sanitation In Andhra Pradesh, many of the toilets have been built and hygiene promotion. with overflow pipes that discharge pathogenic effluent 4.1.5 Sanitation technology into the area surrounding the home, or with open vent For rural households, the policies that affect them most pipes that could create fecal contamination routes. In are often those relating to the cost and model of the Rajarhat, the problems relate to the durability of the technology promoted by the sanitation program. Most of toilet components, many of which appear to be broken, 23 The NGO programs focus on their ongoing projects, with little post-construction monitoring of communities in which sanitation projects have been completed, and little capacity to monitor sanitation coverage or public health impact outside their project areas. Sanitation Promotion in NGO Cases Case Mass Participatory Institutional Targeted Media Activities Incentives Messages Plan Bangladesh ­ Yes ­ Yes Gramalaya TSC Yes Yes ­ Yes NGO Forum ­ Yes ­ Yes LPP ­ Yes Yes ­ damaged or abandoned after only short periods of reduce transport costs. The remaining four cases (Andhra usage. The LPP sewerage systems are well-designed Pradesh, Ahmednagar, Gramalaya in Trichy, and Plan in and constructed, but there has been inadequate Bangladesh) depend on local markets to supply the provision for the regular maintenance tasks and necessary sanitary wares (or the raw materials for long-term repairs required by this type of scheme. construction of home-made toilets). In some of these cases, the sanitation programs have encouraged local suppliers to 4.1.6 Supply chains manufacture (or source) suitable sanitary wares, and have Three types of supply chains were observed: assisted rural households and communities in obtaining nRural Sanitary Marts (RSMs); these wares. But the private suppliers are very different from nCommunity projects; and the RSMs and community projects: most of them are not nLocalmarkets. dependent on sanitation programs for business (as they sell a range of other products); they compete against other local The RSM model is used in the West Bengal TSC and in Rajarhat. It involves the establishment of a network of local production centers that manufacture and supply A Bathroom or a Toilet? standard sanitary wares (toilet platforms, toilet pans, pipework, concrete rings, cover slabs for leach pits), The provision of bathing facilities is an important policy according to program specifications. Prices are usually issue. Most rural women would appreciate a private bathing facility close to their home, as there are fixed across the sanitation program, independent of local otherwise few suitable spots where they can wash costs or conditions. properly. Some sanitation specialists argue that a combined toilet and bathroom facility has more utility In both the NGO Forum and LPP cases, sanitary wares to rural households than a simple toilet, thus is more are manufactured and supplied by temporary production likely to be well used and maintained. centers established within the communities. These `community projects' focus on meeting the short-term However, the additional utility must be balanced demand generated by intensive sanitation promotion, and against the additional cost, particularly if a second cubicle is added to the design, as this policy decision are normally shut down once universal sanitation will affect affordability by the poor, and may limit coverage is reached. Community projects aim to produce the number of people that the sanitation program sanitation wares more cheaply than local markets, using can serve. NGO finance and assistance to buy materials in bulk and 24 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia suppliers for the sanitation trade; and they price their Key program outcomes examined by the sanitary wares according to production costs and study include: local conditions. nTechnology choice; nToiletaccessandusage; 4.1.7 Program monitoring and coordination nOpendefecation; The West Bengal TSC is the only sanitation program with a nHygiene behavior; and dedicated unit that monitors and coordinates macro-level nProgram costs. progress in the sanitation sub-sector. The sanitation cell of the West Bengal State Institute of Panchayats and Rural 4.2.1 Technology choice Development (SIPRD) is responsible for monitoring Most of the case study programs claim to promote a sanitation coverage, conducting reviews and evaluations, range of sanitation technologies, but there was very little identifying gaps and weaknesses in the program, and evidence of this choice in the villages visited. Only providing support and training to the district TSC projects. two of the sanitation programs revealed any real technology choice: The TSC programs in Maharashtra, Andhra Pradesh, nGramalaya (US$ 13 low-cost toilet and US$ 32 and Tamil Nadu are monitored by the respective State two-cubicle toilet and bathroom model); and Governments, usually through combined water and nPlan Bangladesh (range of very low-cost sanitation units within the State departments responsible home-made toilets). for rural development. This institutional arrangement ensures that sanitation programs are well-coordinated and Despite the variable willingness and ability to pay found in integrated with other rural development programs, but most rural communities, only one sanitation technology tends to reduce the time and attention paid to the was found in the following cases: sanitation sub-sector. nLPP (connection to settled sewerage system); nAhmednagar (toilet with ceramic pour flush pan); The NGO programs focus on their ongoing projects, with nWest Bengal (RSM-manufactured toilet platform with little post-construction monitoring of communities in cement mosaic pan); which sanitation projects have been completed, and little nRajarhat (RSM-manufactured toilet platform with cement capacity to monitor sanitation coverage or public health pan and concrete ring); impact outside their project areas. The NGOs in nNGO Forum (toilet platform with plastic pan and Bangladesh (NGO Forum and Plan) are making greater concrete ring); and efforts to coordinate their efforts with local government, nAndhra Pradesh (two-cubicle toilet and but their sanitation programs and monitoring bathroom model). mechanisms remain independent of wider data collection processes. None of the case study programs offer low water use sanitation technologies for use in drought-prone areas, or 4.2 Case study outcomes low-cost toilets for use in areas with high water tables. Program outcomes are difficult to determine accurately on the basis of a handful of rapid appraisals. Assessing 4.2.2 Toilet access and usage the cause of program outcomes is harder still, and usually Conventional sanitation programs tend to focus requires rigorous research over a long period. on the construction of sanitation facilities, and are often deemed successful simply because they reach their Therefore, the discussions below highlight the common coverage targets. findings and issues emerging from the fieldwork conducted to date, but are not intended as a definitive However, it is far more important to examine whether assessment of case study outcomes. these facilities are actually in use, as a significant number 25 Another interesting indicator of performance is access to sanitation among poor households. Only two of the programs (West Bengal TSC and Ahmednagar TSC) had high sanitation coverage among poor households. Outcomes in Public Cases Case Technology Toilet Hygiene Program Choice Usage Behavior Costs West Bengal TSC Poor Good Average Average Ahmednagar TSC Average Good Average Average Rajarhat Poor Poor Poor Low Andhra Pradesh TSC Poor Poor Poor High Outcomes in NGO Cases Case Technology Toilet Hygiene Program Choice Usage Behavior Costs Plan Bangladesh Good Good Average Low Gramalaya Average Good Good High NGO Forum Poor Average Average Average LPP Poor Poor Poor High of toilets are either never used or are abandoned some implemented by local government and those implemented time after completion. by NGOs. While the better performing programs all have high sanitation coverage and toilet usage, even the more Access to sanitation was high in all of the case study effective NGO programs struggled to persuade the poorest programs using a `total sanitation approach'. The exception households in each community to build and use toilets. was the LPP program, which focused on building sewerage systems with little emphasis on toilet access or usage. It This reflects the NGOs' reliance on successful collective thus had much lower total sanitation coverage. action, and their inability and reluctance to sanction households unwilling to invest in a toilet or change their Another interesting indicator of performance is access to hygiene behavior. sanitation among poor households. Only two of the programs (West Bengal TSC and Ahmednagar TSC) had The longest-running sanitation program studied, the West high sanitation coverage among poor households. Both Bengal TSC, was the only case in which reliable evidence are government programs, and both involved some form of of full leach pits was found. In the West Bengal local government enforcement of the ban on open communities, most of the toilets were in regular use, defecation, and some local government assistance in and about half the toilet users stated that their original financing toilets for very poor households. This illustrates leach pits had filled and that toilets had been relocated a fundamental difference between the programs above new pits. 26 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Toilet usage was observed to be high (>70 percent) in three prevalence of open defecation is, therefore, an important of the Indian cases (Ahmednagar TSC, West Bengal TSC, measure of program outcomes. It indicates the size of the and Gramalaya TSC) and in the Plan Bangladesh case, but population without access to a toilet, and confirms was average (30-70 percent) or low in the four other cases whether those that have toilets are using them (particularly (Andhra Pradesh TSC, Rajarhat, NGO Forum, and the LPP) in cases where 100 percent toilet coverage is claimed). with clear evidence of disuse (blocked toilets, broken In general, two different approaches were taken to toilets, and goods stored in toilets) common in both the catalyzing the collective action needed to stop open Andhra Pradesh TSC and Rajarhat cases. defecation. The NGO programs used intensive 4.2.3 Open defecation participatory processes to raise awareness of the The seven case study programs using the total sanitation communal hazards associated with open defecation (see approach (that is, all except the LPP) state that stopping Annex 2), then carried out hygiene promotion activities open defecation is one of their primary objectives. The and assisted communities in the rapid construction of Access to Sanitation in Public Cases Case Access to Sanitation* Total Poor Households Toilet Usage Open Defecation West Bengal TSC High High High Average Ahmednagar TSC High High High Average Rajarhat High Low Average Widespread Andhra Pradesh TSC High Low Low Widespread * In villages visited Access to Sanitation in NGO Cases Case Access to Sanitation* Total Poor Households Toilet Usage Open Defecation Plan Bangladesh High Average High Average Gramalaya High Average High Average NGO Forum High Average Average Widespread LPP Average Low Average Widespread * In villages visited 27 The case study findings suggest that NGOs have reasonable results among those that decide to build toilets, but that they struggle to reach other sections of the community. low-cost and home-made toilets. In contrast, the nSigns prohibiting open defecation (West Bengal TSC, government programs relied more on financial NGO Forum, Plan Bangladesh); incentives (hardware subsidies, payments on stopping nFines for people caught defecating in the open open defecation) and sanctions (government-enforced (Ahmednagar TSC, West Bengal TSC); bans on open defecation; denial of welfare benefits nRewards for reporting people defecating in the open to those without toilets). (Ahmednagar TSC); and nRemoval of bushes (defecation sites) in the vicinity of No detailed surveys were conducted for this study, the village (Ahmednagar TSC). but a series of transect walks and household visits revealed visible evidence of continuing open 4.2.4 Hygiene behavior defecation in four of the cases: Andhra Pradesh TSC, Improvements in hygiene behavior were examined by Rajarhat, NGO Forum, and the LPP. There was little checking the availability of handwashing facilities evidence of regular or systematic monitoring of open (soap or ash, water container) in the vicinity of toilets, by defecation in any of the case study programs, despite examining the cleanliness of the household and its some claims that defecation sites were visited to surroundings, and by discussing the benefits of toilet use monitor and police the practice. and improved sanitation with individual households and with community leaders. However, some of the more successful case study programs employed other innovative approaches to Gramalaya, an NGO that gives special emphasis to hygiene stopping open defecation: promotion, made the largest impact on hygiene behavior. Handwashing facilities were available in almost every toilet, and knowledge of sanitation issues was widespread in its project communities. Toilet Usage One of the best indicators of regular toilet usage is a Improved hygiene behavior was also apparent in both the full leach pit, or (in single-pit systems) a toilet that has NGO Forum and Plan Bangladesh programs, but these been relocated above a new leach pit. Unfortunately, improvements were less widespread and less sustained this indicator is less useful in sanitation programs that than in the Gramalaya case. All three of these NGOs have been operating for less than a year, as the leach (Gramalaya, NGO Forum, and Plan Bangladesh) focus on pits are unlikely to be full even if the toilets have been hygiene promotion. in regular use. The case study findings suggest that they have reasonable But questioning whether leach pits are full is a useful results among those that decide to build toilets, but that exercise in itself, as it draws the attention of both they struggle to reach other sections of the community. program staff and toilet users to the need to implement It seems that these NGOs lack the mandate or authority reliable and hygienic procedures for detecting full pits, to persuade reluctant or resistant households to install for bringing into service unused pits, and for emptying toilets or to improve their hygiene behavior. or replacing single leach pits. In some cases, these problems reflect political and social In the absence of full leach pits, toilet usage can be assessed by observation: Is the toilet wet from recent divisions within communities, with several instances usage? Is the toilet clean? Is water available for anal where households refused to follow advice or adopt cleansing and toilet flushing? Is there evidence of practices recommended by community hygiene promoters disuse (such as dust accumulation, blockages, toilets from another political or social group. in need of repair, or goods stored in the toilet enclosure)? Are handwashing facilities available? Hygiene behavior was above average in both the Ahmednagar TSC and West Bengal TSC cases, 28 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia although there was little evidence of effective appropriate hygiene promotion materials. Despite these hygiene-specific interventions. efforts, hygiene behavior was found to be very variable between communities. In Ahmednagar, the Sant Gadge Baba Campaign (see Annex 3: Case Study 5) has greatly increased people's This may relate to the mode of social intermediation, awareness of wider sanitation issues, and the TSC has which is conducted largely by village-level motivators focused on stopping open defecation, but neither of these who receive a commission from the partner NGO for each campaigns has had much impact on handwashing or on toilet sold. general hygiene. In West Bengal, local government bodies have invested in hygiene promotion activities and the In some areas, these motivators carry out their hygiene government's partner NGOs have developed locally promotion duties well, but in others the commission Cost of Typical Sanitation Model (US$ per household) 0 10 20 30 40 50 60 70 80 LPP* US$ 71 Ahmednagar US$ 17 NGO Forum US$ 7 West Bengal US$ 8 Rajarhat LG US$ 3 Gramalaya US$ 13 Plan Bangladesh User Subsidy US$ 2 Andhra Pradesh** US$ 59 * LPP user contribution includes cost of internal sewer and house connection ** Effective cost (based on estimated value of rice and cash subsidy) 29 Expenditures on software activities and program management have a significant influence on performance, replicability, and potential for scaling-up. system appears to encourage them to sell toilet Forum, and Plan Bangladesh) offer no hardware subsidy components rather than focus on improving hygiene and and promote low-cost toilets, whereas the Indian public health. programs promote more expensive toilets with subsidies of 50 percent or higher: 4.2.5 Technology costs The cost of the sanitation technologies, and the extent to nAverage toilet cost in Indian cases (excluding AP) = which construction is subsidized, varies hugely. The chart US$ 12.80 (68 percent subsidy); and below compares the relative cost of the typical sanitation nAverage toilet cost in Bangladesh cases = US$ 4.00 model in each case, sorted according to the amount paid (0 percent subsidy). by the user. Interestingly, the hardware cost of the rural The four Indian cases are part of the Total Sanitation sewerage schemes implemented by the LPP (US$ 71 per Campaign, thus should offer a standard US$ 11 household connection) is only 20 percent higher than the toilet subsidy to below poverty line (BPL) households. cost of the toilet and bathroom facilities built under the However, in three of these cases the hardware subsidy has Andhra Pradesh TSC (US$ 59 per toilet). been altered by local policy: Moreover, the LPP sewerage schemes manage to leverage nUS$ 59 hardware subsidy provided in Andhra Pradesh user contributions equal to about 50 percent of the TSC (additional resources from food-for-work program or development costs, thus reducing the hardware subsidy to from State Government funds); US$ 34 per household. In contrast, the Andhra Pradesh nUS$ 8 hardware subsidy provided in Ahmednagar TSC TSC provides its users with 100 percent hardware (US$ 3 State contribution spent on other program subsidy.The three Bangladesh cases (Rajarhat, NGO costs); and Estimated Program Costs in Public Cases Program Costs (US$ per household)5 Case Software Program Software6 Hardware7 User Total Share Subsidy West Bengal US$ 178 US$ 4 US$ 4 US$ 25 68% 84% Ahmednagar US$ 25 US$ 11 US$ 9 US$ 45 56% 80% Rajarhat US$ 2 US$ 0 US$ 3 US$ 5 40% 40% Andhra Pradesh US$ 13 US$ 599 US$ 0 US$ 73 19% 100% User = User contributions to hardware costs Software share = Percentage of total costs spent on software and overheads 5Software costs in TSC programs based on TSC financial progress reports, thus do not reflect the way in which the States have decided to spend their budgets (for example, intensive one-year IEC campaign in Andhra Pradesh). 6Software costs include estimated program overheads and small allowances for external agency support. 7Hardware costs based on lowest cost sanitation facilities offered to below poverty line households. 8Additional State Government funds and support were provided in East and West Medinipur districts. 9US$ 48 of the hardware subsidy in AP is the value of the food-for-work rice provided. 30 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia nUS$ 4 hardware subsidy provided in West Bengal NGO cases). Despite this, total hardware costs (hardware (US$ 7 balance spent on other program costs). subsidy plus user contribution) are estimated to be lower than total software costs (software costs plus overheads) Subsidy policy is more complex in the Ahmednagar TSC, in all cases except three (Rajarhat, the LPP, and Andhra where conditional financial incentives are used instead of Pradesh). Two of these cases (the LPP and Andhra upfront hardware subsidies. Households do not receive a Pradesh) involve expensive sanitation technologies, thus payment until after construction of their toilet and, even have unusually high hardware costs, while the third then, payment is delayed until the entire community has (Rajarhat) reports no software expenditures, as all program access to a sanitary toilet and the village is declared `open activities were undertaken by local government officers defecation free'. Further, the TSC subsidy is shared who were temporarily diverted from their normal duties. between the BPL household and the lowest level of local government (Gram Panchayat), with 75 percent (US$ 8) The LPP sanitation program promotes a more expensive going to the household, and the remaining 25 percent technology (simplified sewerage) than the other cases, and providing an incentive for the local government to assist in operates on a very small scale (only 12 communities), thus reaching universal toilet coverage. has the highest average program costs. However, severe drainage problems in the program area help the LPP to Similar financial incentives are now being offered to the leverage unusually high user contributions (US$ 37 per different tiers of local government under the TSC's Nirmal household), which significantly reduces the share of Gram Puraskar scheme (see Annex 3). However, no awards program costs subsidized by the LPP. had been made at the time that the case studies were carried out, thus it is unlikely that this policy has had any After the LPP, the next most expensive sanitation substantial impact on program outcomes. programs (according to average cost per household) are the four TSC programs from India. This reflects the 4.2.6 Program costs amount of money being invested in rural sanitation by the Expenditures on software activities and program Government of India. However, the broad range of average management have a significant influence on performance, program costs (US$ 25-73 per household) and software replicability, and potential for scaling-up. Unfortunately, allocations (19-77 percent) illustrate the widely differing information on total program costs proved difficult to interpretations of the central TSC guidelines adopted by obtain during the rapid appraisals. Hardware subsidies and State and district authorities across India. expenditures are well-known and easy to check, but few of the sanitation programs compile reliable information The cost comparison also highlights above-average about their spending on software activities (community software expenditures by the Gramalaya TSC program. development, training, IEC, sanitation and hygiene External donors (notably WaterAid UK) finance more than promotion) or on program overheads (management, half of this software expenditure, with the remainder monitoring, reporting, logistics). coming from the standard TSC software budget. However, the district TSC budget is managed and allocated by local The tables give an indication of relative program costs government, thus much of the government software based on the limited financial data available at the time of funding is spent on mass media activities at district level, the study or, where reliable data were unavailable, on rather than on community or household-level activities. estimates based on the information collected during the The Rajarhat case is estimated to have the lowest program rapid case study appraisals. costs, at around US$ 5 per household. This low cost was Given the paucity of the data on software and overhead made possible by temporarily diverting local government costs, it is likely that non-hardware costs have been staff from their normal duties during the intensive underestimated in most cases (particularly in the smaller sanitation program, which makes this approach difficult to 31 Most of the case study programs receive either technical or financial assistance from external support agencies. Estimated Program Costs in NGO Cases Program Costs (US$ per household) Case Software Program Software Hardware User Total Share Subsidy Plan Bangladesh US$ 10 US$ 0 US$ 2 US$ 12 83% 83% Gramalaya US$ 45 US$ 11 US$ 2 US$ 57 77% 96% NGO Forum US$ 14 US$ 0 US$ 7 US$ 21 67% 67% LPP US$ 35 US$ 34 US$ 37 US$ 106 33% 65% User = User contributions to hardware costs Software share = Percentage of total costs spent on software and overheads Estimated Average Program Costs (US$ per household) US$ 0 US$ 20 US$ 40 US$ 60 US$ 80 US$ 100 US$ 120 Plan Bangladesh nHardware subsidy nUser contribution West Bengal TSC nSoftware and overheads Ahmednagar TSC Gramalaya TSC NGO Forum Rajarhat Andhra Pradesh TSC LPP Note: Case studies are sorted by performance (see Section 5.1: Overall performance) 32 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia External Support in Public Cases Case Technical Donor Type of Support Provided Support Finance West Bengal TSC UNICEF <5% RSM concept; funding of SIPRD Ahmednagar TSC WSP <10% Policy; training; exposure visits Rajarhat UNICEF <5% RSM funding Andhra Pradesh TSC ­ ­ External Support in NGO Cases Case Technical Donor Type of Support Provided Support Finance Plan Bangladesh WSP >80% Program design; training; finance Gramalaya WaterAid UK >30% Training; policy; finance NGO Forum ­ >60% Finance LPP NRSP >60% Training; management; finance replicate at scale, and difficult to sustain over a longer the public cases, this support is relatively minor, involving period. The only direct expenditures reported in the technical assistance such as training, policy support, and Rajarhat case were for the establishment of rural sanitary indirect financial assistance, for example, UNICEF's marts using funds and support provided by UNICEF. funding of State-level sanitation coordination bodies in India. In the NGO cases, external support agencies play a 4.2.7 External support more significant role, providing substantial technical Most of the case study programs receive either technical assistance in important areas such as program and policy or financial assistance from external support agencies. In design, and financing the majority of NGO program costs. 33 The challenge of stopping open defecation on a community-by-community basis focused attention on the provision of sanitation services to the poorest and most disinterested households. 34 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 5 Analysis 5.1 Overall performance studies score highly in all 10 areas, but four of the One of the main objectives of this regional rural sanitation case studies (Plan Bangladesh, West Bengal TSC, study was to assess `what works and what doesn't'. This Ahmednagar TSC, and Gramalaya TSC) are rated as section attempts to draw out common factors of success, having above average overall performances, and thus and common constraints, from the preceding case are classed as successful. study findings. It is apparent that neither the government nor the NGO Before doing this, it is necessary to state how this study case studies have any clear advantage in overall defines success, as it is a very subjective term. For the performance, as the top ranked cases include two purposes of this study, a successful sanitation program is government models (West Bengal and Ahmednagar) and defined as one that: two NGO models (Plan and Gramalaya). nImproves the sanitary conditions of the poor (majority of poor households); Similarly, despite the success of the three other Indian nMakes a sustained change in community behavior TSC case study programs, the Andhra Pradesh TSC fared (majority of households); badly, suggesting that success is dictated by more than nHas positive impacts on public health, well-being and country context. And the two highest-spending sanitation local environments; programs (the LPP and Andhra Pradesh) were the lowest nIs as cost-effective and self-financing as possible; ranked, demonstrating that the amount spent is less nDevelops local markets for appropriate and affordable important than the way in which it is spent. All of which sanitation facilities; confirms the importance of the approach used by the nCreates sustainable support mechanisms for rural sanitation programs, and justifies more detailed analysis of sanitation services; and the underlying factors of success. nOperatesatscale(orisreplicableatscale). 5.2 Factors of success Given this definition, and the available information, the The four most successful sanitation programs use following performance indicators have been used to rate markedly different financial and technical approaches to the relative success of the case studies: achieve similar overall performance ratings. However, 1. Prevalence of open defecation (widespread ­ average ­ none) despite these differences, there are three areas in which 2. Hygiene behavior (poor ­ average ­ good) the more successful case studies have adopted 3. Access to sanitation by the poor (low ­ average ­ high) similar approaches: 4. Environmental sanitation improvements nFocusonstoppingopendefecation(ratherthan (none ­ average ­ high) building sanitation facilities); 5. Extent of self-financing (0% ­ 50% ­ 100%) nInvestmentinhygienepromotionandsocial 6. Program cost per household (high ­ average ­ low) intermediation (at household level); and 7. Range of toilet components and designs utilized nProvisionofaffordablesanitationoptionstothepoor. (poor ­ average ­ good) The challenge of stopping open defecation on a 8. Local availability of sanitation wares and services community-by-community basis focused attention on the (poor ­ average ­ good) provision of sanitation services to the poorest and most 9. Regular support and monitoring disinterested households, as these are often the ones (rare ­ average ­ frequent) most reluctant to change their hygiene behavior and stop 10. Implementation at scale (small ­ average ­ large) open defecation. In turn, this new focus highlighted the Despite the coarse and subjective scoring system, the need to provide carefully targeted household-level overall performance ratings (see chart) give some idea of sanitation and hygiene promotion, and offer low-cost the relative success of the case studies. None of the case sanitation technologies appropriate to the needs and 35 The more successful programs provided high access to sanitation, and ensured high toilet usage, through a combination of participatory processes, hygiene promotion, and institutional incentives. demands of these poor or reluctant households. The TSC, and Rajarhat) have each neglected at least one of more successful programs provided high access to these three `factors of success'. sanitation, and ensured high toilet usage, through a There are other factors that influence their poor combination of participatory processes, hygiene performance, notably subsidy policies that favor the promotion, and institutional incentives (financial rewards non-poor, and standardized technical solutions that for achieving universal toilet coverage, community bans fail to allow for variation in user preference and on open defecation, fines for open defecation, and so on). In addition, the successful programs promoted low-cost willingness to pay. sanitation technologies with zero (or low) hardware But it is apparent that all the unsuccessful programs are subsidies, which freed up a greater proportion of supply-driven, concentrating on building standard toilet program funds for social intermediation and hygiene designs (or sewerage systems) rather than focusing on promotion activities. program outcomes such as stopping open defecation or At the other end of the scale, the three cases with the improving hygiene behavior. The successful case studies worst performance ratings (the LPP, Andhra Pradesh suggest a number of lesser ingredients of success. Overall Case Study Performance 0 2 4 6 8 10 12 14 16 18 20 Plan Bangladesh West Bengal TSC Ahmednagar TSC Gramalaya TSC NGO Forum Rajarhat nGood performance Andhra Pradesh TSC nAverage performance nPoor performance LPP Note: Performance ratings scored using 10 indicators (maximum score = 20) 36 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Factors of Success Case Context Institutional Financial Social Technical Studies India Huge TSC program District Govt govt. projects Nirmal Gram Incremental policy projects Use of pilots Puraskar changes Use of pilots West Bengal Medinipur Ram Krishna Mission UNICEF Good IEC and Mass production TSC sanitation NGO assistance hygiene of low-cost program 322 RSMs and Low subsidy promotion platform (US$ 8) Socialist motivators (US$ 4 cf. normal Ban on open government SIPRD (state (State US$ 11 TSC defecation High population san. unit) sanitation unit) subsidy) (fines) density Women's self-help self- Block and GP groups help groups incentives Ahmednagar Rich State Pilot programme in 2 program GP and community Local NGOs TSC Sant Gadge dists. in two districts incentives (on conducting social Baba Campaign Driven by local govt. reaching 100 intermediation Previous failed Model village in each village in percent coverage) Participatory sanitation program block each block GP providing free ignition Donor support toilets to some Ban on open Exposure visits households defecation (fines) Andhra Progressive GP sanctions toilets Food for Work Pradesh govt. outlook Good monitoring of monitoring Program TSC Investment in financial and physical of financial and infrastructure progress physical progress Gramalaya Long-term Very small-scale 90 percent Focus on 2 toilet models TSC support from program High quality program NGO-funding stopping open (US$ 13 and WaterAid of NGO staff High quality of from external defecation US$ 32) NGO staff TSC has different Regular WaterAid donors Participatory Supporting private Regular WaterAid approach in each monitoring SHG loan funds ignition sanitation marts monitoring district (14 NGOs WSP influence to Good hygiene Emphasis on WSP influence to in Trichy) stop open defecation stop open defecation promotion wider sanitation approach Child-centered and environment Women's self-help approaches groups (federations at (federations block level) State at block level) Rural San. Society State Rural Sanitation Society 37 All of the unsuccessful programs are supply-driven, concentrating on building standard toilet designs (or sewerage systems) rather than focusing on program outcomes such as stopping open defecation or improving hygiene behavior. Case Context Institutional Financial Social Technical Studies Bangladesh High population Vibrant NGO sector 20 percent ADP density for sanitation SACOSAN 2003 Rajarhat Driven by chief No hardware Savings schemes Low-cost toilets administrator subsidy 99 percent (US$ 3) Involvement of Low-cost sanitation coverage religious leaders program achieved in and local leaders UNICEF-funding sub-district for RSMs NGO Forum Apex body for 900 production Zero hardware Introducing Low-cost toilets 635 NGOs centers subsidy participatory with plastic pans WaterAid/VERC ignition (US$ 7) training Plan In process of Small-scale Zero hardware Participatory and Low-cost toilets Bangladesh scaling-up program subsidy child-centered (US$ 1) program to five (focus on small approaches Innovative sub-districts communities) Ban on open home-made Partners with defecation toilet designs local NGOs Pakistan Importance of privacy for women LPP Support from Support from OPP Component- Low cost settled powerful local and NRSP sharing (50 percent sewerage systems champion Community development (US$ 71 per Densely clustered contracting costs paid by household) housing Well-trained staff community) Well-designed Exposure visits systems These stem from innovative approaches or policies nMonitoring and regulation of open defecation that appear successful in one (or more) of the case studies, (community inspections, rules, and fines); but which have not yet been widely tested nInvolvement of local government, local NGOs, or validated. civil society organizations and federations of self-help groups in monitoring, facilitation, and evaluation; Institutional factors nSanitation and hygiene promotion by local NGOs and nIncremental improvements in program self-help groups; approach and institutional arrangements (use of 38 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Constraints Case Context Institutional Financial Social Technical Studies India History of toilet Large govt. US$ 11 subsidy to Minimum technical subsidies programs BPL households standards (pour- flush toilet) West Bengal Tribal population Large-scale (850,000 Coercive Cement TSC Landless households) approach (fines, mortar pans No alternative ration controls, suppliers government Community selection patrols) (linked to SGBC) Ahmednagar Drought-affected No State Relatively No pit emptying TSC areas sanitation expensive toilet strategy body design (US$ 20) Need designs for Poorest given water scarce free toilets areas Andhra Populist policies Large scale (1.67 Expensive Lack of hygiene Minimum design = Pradesh (action plan) million households) toilet design promotion solid walls, offset TSC Drought-affected Eng. Dept. (US$ 59) pits, ceramic pan districts implementing High State (US$ 59) Focus on rural WS Temporary resource subsidy Design faults 50 percent officers for (rice and cash Inadequate training scheduled or social work = US$ 59) of masons and OB castes No monitoring engineers of usage Gramalaya Low rural Shortage of suitable High software Problems TSC sanitation coverage local NGOs costs reaching reluctant (14-17 percent Local govt. (US$ 17 and per and resistant across State) not involved household) households Bangladesh High incidence of Govt. policy ADP-funding High proportion poverty undermining NGO to be used of landless Frequent flooding policy (zero subsidy) for toilet households subsidies Rajarhat 55 percent Lack of Coercive Standard toilet Local Govt. landless community approach design households involvement Limited hygiene RSMs no longer RSMs run by DPHE promotion operating Inadequate follow-up NGO 18 percent rural One village per Dependent on Standard toilet Forum sanitation NGO per year donor-funding design coverage Shortage Pit emptying of suitable NGOs problems Local govt. not involved 39 The case studies highlight that rural households revert to their old habits very quickly if new toilets become blocked, broken or smelly, and if nobody is on hand to provide timely advice or encouragement. Case Context Institutional Financial Social Technical studies Plan 18 percent Limited High software Problems Bangladesh rural sanitation monitoring costs reaching reluctant coverage Dependent on and resistant donor-funding households Pakistan Widespread Ongoing Negligible govt. Limited No low-cost drainage problems devolution to TMA investment participation toilet designs in Southern Punjab (political resistance by women and low capacity) LPP Political resistance Small-scale Dependent on Social exclusion No O&M cost to NGO schemes program donor-funding (seasonal workers recovery Local govt. Affordability and tenants) No O&M cannot fund to poor No hygiene planning (household promotion Disposal of contribution untreated effluent = US$ 38 and settled sludge without toilet cost) pilots, testing of innovations, and regular 5.3 Constraints capacity building); 5.3.1 Lack of local monitoring and support nSub-national sanitation units to monitor, support, and The case studies illustrate the importance of regular coordinate local programs; monitoring and post-construction support by external nExposure visits to successful projects (for resistant agencies. This proved to be inadequate (or absent) in every communities and local officials); single case. nIndependent sanitation reviews prior to payment of Community after community noted that interest and incentives or awards; and nPublic ceremonies to present sanitation subsidies, motivation had been high while the NGO or program officers were working in the village, but that toilet incentives, and awards. usage dropped off once the sanitation project Social factors was finished. nChild-centerd approaches (children's involvement in Behavior change takes time to set in. The case studies monitoring open defecation, promoting hygiene, and highlight that rural households revert to their old habits encouraging behavior change). very quickly if new toilets become blocked, broken or Financial factors smelly, and if nobody is on hand to provide timely advice nFinancial incentives to stop open defecation (at or encouragement. community and local government level. Few of the case study programs have any long-term Technical factors mechanisms to support communities after the nPromotion of a range of technology options (including initial phase. As a result, rural households are expected home-made toilets). to empty their leach pits, replace their toilets and 40 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia police open defecation in their community with little prolonged absence of open defecation, which can be more external assistance. readily checked (by inspecting common sites of open defecation) than a gradual increase in sanitation coverage The total sanitation approach used by most case study across several hundred villages. programs is meant to focus on outcomes rather than inputs, with programs aiming to stop open defecation in In practice, the focus on open defecation proves to be a each community, rather than build a fixed number of largely theoretical advantage as none of the case study toilets. This approach allows flexibility in the programs have developed a reliable or sustainable method implementation of local projects and recognizes that an of monitoring open defecation. abandoned or unused toilet has no impact on hygiene behavior or public health. It should also make sanitation Despite assertions about stopping open defecation, the programs easier to monitor, as success is evidenced by a case study program managers still measure progress by Overall Performance vs Hardware Subsidy Performance (scored: 0-20) " $ & Plan Bangladesh West Bengal TSC Ahmednagar TSC Gramalaya TSC NGO Forum Rajarhat nPerformance nHardware subsidy LPP Andhra Pradesh TSC 0 10 20 30 40 50 60 70 Hardware subsidy (US$ per household) 41 The case study findings confirm that government officials rarely have the experience, capacity, inclination or patience to undertake the lengthy and participatory processes involved in most rural sanitation programs. the amount of funds dispersed, the number of toilets subsidies. In many villages, fancy new two-cubicle toilets constructed, and the number of villages covered. were found empty and abandoned, while home-made toilets with earthen floors were clean swept and well- 5.3.2 Unchanged hygiene behavior among men maintained. This does not suggest that sanitation In many cases, members of rural households that had programs should only promote low-cost toilet designs, or installed new toilets stated that recent sanitation and that one approach is inherently better than the other, but it hygiene promotion activities had resulted in the women does confirm that the matter is more complex than and children improving their hygiene behavior and using supposed by some sanitation practitioners, and that local toilets, then admitted that male household members demand needs to be carefully examined. continue to defecate in the open despite the presence of a private sanitary toilet close to the home. Six of the case studies provide hardware subsidies of US$ 11 or less (per household), whereas the two worst Interviews with male members of poor households performing cases (Andhra Pradesh and the LPP) provide revealed that they are often away from home for long hardware subsidies of US$ 59 and US$ 34, respectively. periods, thus have little choice but to defecate in the fields. On a large scale, this represents a huge difference in It was clear that this habit was hard to break, with many of program costs, whatever the software expenditures. these men admitting that they did not like to use their household toilets even when at home. Several NGOs In these two cases, the high hardware subsidies also noted that working males from poor rural households create other problems: political wrangling by government often feel that sanitation is more important for women and organizations that want to retain control of lucrative children, and have little time or inclination to attend infrastructure projects; interest from local elites that want participatory hygiene promotion sessions. to capture high profile benefits for their constituencies; and a reduced sense of ownership by those that receive 5.3.3 High hardware subsidies the heavily subsidized facilities. The high hardware The case study findings suggest an association between subsidies tend to shift the balance of these programs high hardware subsidies and poor performance (see chart), towards serving the non-poor, with few of the poor but otherwise fail to show any definitive link between benefiting from the high hardware subsidies, or stopping subsidy policy and performance. open defecation. There is an ongoing debate among sanitation practitioners Under the Andhra Pradesh TSC, most households have as to whether it is more effective to promote low-cost built some form of toilet either to obtain the substantial toilets for the poor, or to promote expensive models with subsidy offered (US$ 16 cash and 100 kg rice coupons) or both bathroom and toilet (financed by micro-credit loans because they have been coerced by local government or subsidies). Those favoring the more expensive models officials. As a result, a large proportion of these new toilets suggest that there is greater demand for a private bathing are now either abandoned or being used for other space than for a toilet, and that rural households are more purposes (for example, to house livestock and store likely to use and maintain attractive designs than basic household goods). low-cost toilets. It is also argued that users upgrade basic models within a very short period, thus showing demand In the LPP sewerage schemes, rural households are meant for more expensive designs. to match the high hardware subsidy with their own contributions, and to be heavily involved in scheme The case study findings contradict these views. The planning, design, and implementation. This should result sanitation programs that promoted expensive toilet and in system users feeling a high level of ownership of their bathroom models were less successful than the other facilities, and ensure community commitment to the cases, despite the provision of generous hardware sustainability of the schemes. However, the LPP case 42 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia study (see Annex 4) reveals that poorer households feel received a free toilet had little idea why the toilet had little ownership for their facilities. Many of them were been built, and had little intention of using the facility pressured into providing free labor in lieu of cash imposed on them. contributions, and have not built either the connection Similar problems were observed in both the Andhra chambers or the toilets that are needed to take advantage Pradesh TSC and NGO Forum programs, where local of the expensive new sewerage systems. As a result, the government or NGO officials had given free toilet richer residents reap the benefits of the heavily subsidized components to poor households in the hope of achieving schemes, while the poorest remain without sanitation. universal coverage, only to find (during the rapid However, the elimination of hardware subsidies is no appraisals) that these households had never bothered to guarantee of success. Both the NGO Forum and Rajarhat install the toilets. sanitation programs have `zero hardware subsidy' policies 5.3.5 Social intermediation by government bodies but their performances were rated as average or below- Another problem area is the use of public sector agencies average. In addition, `zero subsidy' sanitation programs to conduct social intermediation and hygiene promotion suffer when subsidy policy is inconsistent across the activities. Social development in rural areas requires a program area. sensitive and participatory approach, with the In Bangladesh, local government officials are planning to effectiveness of social intermediation or hygiene utilize the 20 percent ADP funding allocated to rural promotion dependent on the quality and application of the sanitation to provide free toilets to the poorest section of facilitators undertaking the community and household- the rural population. level activities. Likewise BRAC, one of the largest and most influential The case study findings confirm that government officials NGOs in Bangladesh, proposes to offer large hardware rarely have the experience, capacity, inclination or patience subsidies to those deemed `hard to reach' (generally the to undertake the lengthy and participatory processes 10-15 percent of the rural population that are slow to involved in most rural sanitation programs. adopt sanitation facilities). Clearly, hardware subsidies Local health officials are likely to have more of the offered by these programs are likely to have an adverse requisite skills and application, but there was little effect upon any sanitation programs promoting `zero evidence of any involvement by health officials in the subsidy' policies. sanitation programs studied. 5.3.4 Provision of free toilets The more successful cases utilize NGOs to conduct social The financial incentives paid to local government in the intermediation and hygiene promotion activities. But the Ahmednagar TSC were a factor in its above-average case studies also suggest that NGO sanitation programs performance, but also created some perverse incentives. without local government involvement find it difficult to Upon achieving universal coverage within their persuade reluctant or resistant households to change jurisdiction, the TSC project pays Gram Panchayats (GPs) their behavior. Local NGOs have often earned the US$ 2.70 per BPL household. This financial incentive is trust and respect of the communities in which they work, intended to encourage GPs to assist and persuade but rarely have the mandate or authority to enforce their reluctant households to install and to use toilets. policies or negotiate with those that oppose NGO approaches or projects. Unfortunately, some GPs decided to accelerate the process by building free toilets for those that they deemed Three of the TSC government programs either contract or unable to afford the new facilities. While this approach partner with local NGOs in order to carry out community- ensures high sanitation coverage, many of those that level activities. This is the strongest institutional 43 Despite resistance from politicians and line departments that wish to retain control of such infrastructure programs, rural sanitation is increasingly considered the responsibility of local government. arrangement examined: it allows local government to be used to produce standard components at large scale, facilitate the process, to monitor performance and enforce thus benefiting from economies of scale and from shared local policy; and it allows government resources to be knowledge of cost-efficient production techniques. used to mobilize the social development skills and However, this form of supply chain appears to be a specialist knowledge held within local NGOs. constraint when the community project is completed, or Several of the case study programs complained of a when universal coverage is achieved in the locality, as the shortage of NGOs with the right blend of skills and local RSM then has little or no demand for its products. These experience, and found that their existing NGO partners are RSMs are generally dependent on monopoly supply of often unwilling or unable to expand beyond their local subsidized program technologies, and often struggle base. Both Gramalaya and NGO Forum actively recruit and when sanitation programs end and they have to operate in train small NGOs thought to have potential, but there is a a free and competitive market. limit to the number of suitable NGOs and facilitators Another supply chain constraint is the transportation of available within each area. There is also a risk that the heavy components (for example, toilet slabs, ceramic toilet financial incentives offered to NGOs by government pans) from the supplier to remote rural communities. programs will attract profit-seeking individuals rather than When distances are large, it is often uneconomic for each cost-effective organizations committed to local household to pay for separate transportation. In the development. Several of the case study programs now Ahmednagar, Gramalaya, and LPP cases, either the partner pay NGOs (or individual promoters) by commission, NGO or the local government arranged for bulk purchase with payments linked to the number of households that of components from a local supplier (often on credit) build toilets. and for mass transportation of these components This approach may help to get toilets built, as in Andhra to the village. Pradesh, but these incentives need to be linked to hygiene Group purchases result in lower prices, but it is also behavior, toilet usage, and open defecation, if any important that the individual households are given an sustainable public health benefits are to be realized. adequate choice of technologies, and are involved in 5.3.6 Sustainability of rural sanitary marts the process of selecting suppliers and ordering Several of the cases (West Bengal TSC, Rajarhat, and NGO components. All too often, poor households have little Forum) utilize RSMs to supply toilet components to their idea where their sanitation components originate from, sanitation programs. These production centers are and are unaware whether there is any alternative to the generally established using program funds, and are technology promoted by the NGO or community that dedicated to supplying the particular sanitary wares managed the process. As a result, these households are promoted by the sanitation program. The advantage of the completely dependent on the NGO or community leaders RSM model is that, as in the West Bengal TSC case, it can for any repairs or replacements. 44 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 6 Scaling-Up Rural Sanitation One of the objectives of the regional study on rural constraints to scaling-up listed above, but will alter the sanitation in South Asia was to assess whether the relative importance of these constraints. Rural sanitation approaches used in the case studies were suitable for programs require different resources to RWS programs, scaling-up. In particular, the aim was to examine whether with more emphasis on the facilitation of the household- successful approaches and policies utilized by small-scale level activities that are so critical to demand generation participatory programs are suitable for use in large-scale and sustainability. Similarly, sanitation supply chains sanitation programs. need to be responsive to individual household demand rather than aggregate community demand, resulting in Little substantive research has been carried out on higher sales and more regular trade of a range of scaling-up rural sanitation services, so this study has sanitary wares. examined the applicability of a rural water supply framework developed in a recent discussion paper titled Rural sanitation is also more institutionally complex, `Taking sustainable rural water supply services to scale'.10 often falling between the government departments This paper identifies four common constraints to scaling responsible for water supply, rural development, health, up rural water supply: and environment. All too often, sanitation is linked with nInsufficient resources (funding, human and institutional water supply, but rural sanitation programs do not face capital, supply chains); the same technical challenges, thus require skills other nLack of knowledge or shared understanding (principles than engineering expertise found in rural water and roles not fully understood); supply departments. nResistance (key stakeholders unwilling to support Despite resistance from politicians and line departments program); and that wish to retain control of such infrastructure programs, nUntested implementation conditions (different social, rural sanitation is increasingly considered the technical, policy, user contexts). responsibility of local government. But small local These constraints appear sufficiently generic to apply to authorities rarely have the capacity or resources to create both rural water supply and rural sanitation services, but separate sanitation units or to implement effective there are several important differences between the two sanitation programs. In addition, competition for resources sub-sectors, as discussed below. Rural sanitation is becoming fierce in increasingly autonomous local programs should be easier to scale-up, as the challenge of governments, and sanitation expenditures usually have safe disposal of human excreta from the household less political support than water supply or other remains similar across a region or country, and over time. local priorities. 6.1 Potential performance at scale There are a few technical variations, such as drought- Two of the case study programs are already operating `at affected areas (where flush toilets are less popular) or scale': the Andhra Pradesh TSC and the West Bengal TSC water-logged areas (where leach pits drain less effectively), are huge sanitation programs covering entire Indian but nothing like the greater complexity and cost States, each of which holds more than 60 million people. associated with scaling-up rural water supply (due to the Between them, these two programs provided rural ever-increasing difficulty in finding and developing adequate water resources as coverage, population, and sanitation to more than two million households water consumption rise). in 2003-04. The other six case study programs are much smaller in scale, covering from 12-600 rural communities Differences between rural water supply and rural annually. Four of these cases (Ahmednagar TSC, sanitation are unlikely to change the fundamental Gramalaya TSC, Plan Bangladesh and the LPP) are in the 10Davis & Iyer (2002): Taking sustainable rural water supply services to scale: A discussion paper. 45 Each of the four NGO programs involved small rural communities with favorable starting conditions, and was reliant on a small cadre of well-trained and well-supported facilitators. process of scaling-up their programs, but none of them and expensive to make the changes and improvements can yet be considered large-scale programs. needed to ensure that this huge program generates sustainable benefits to public health. 6.1.1 Andhra Pradesh TSC at scale The Andhra Pradesh program has very similar problems 6.1.2 West Bengal TSC at scale to those found in an earlier large-scale sanitation The West Bengal TSC program is a very different case. program in Maharashtra (see Case Study 5). A huge It is the product of more than 10 years of continuous amount of resources were invested in the intensive program development; it has had significant technical program in Andhra Pradesh, but implementation was assistance from UNICEF; it is cost-effective; and it too rapid; social intermediation and hygiene promotion is well adapted to local conditions and institutional were weak; and the program has been too rigid and arrangements. However, despite recent successes in technical in its approach. expanding and accelerating the program, the intensive approach is dependent on good local governance, and Some US$ 100 million has already been spent; much of it has not proved successful in districts with weak or borrowed from the Food-For-Work program (see Case disinterested administrations. Furthermore, the RSM Study 6 in Annex 3), but sanitation coverage in Andhra approach, which is based around standardized production Pradesh remains below 40 percent. Thousands of new of a very low-cost toilet platform, has not adapted well to toilets have been constructed, but many are either either technical challenges (for example, water-logged technically flawed, or no longer in use. The Government of areas) or the diverse demands of rural households. Andhra Pradesh's decision to promote an expensive toilet design (typical cost US$ 61) and to provide a 100 percent 6.1.3 Ahmednagar TSC at scale hardware subsidy to below poverty line households has The Ahmednagar TSC has perhaps the most replicable and rapidly exhausted program funds, with the result that the scaleable approach of the six small to medium-scale government has had to borrow additional funds in order to programs. Its conditional financial incentives have been meet its promise to provide sanitation to all BPL widely praised and are now incorporated into the national households. Those involved in the sanitation program are guidelines of the Total Sanitation Campaign, and its now aware of its shortcomings, but it will be both difficult institutional model (local government contracting out Government Case Studies Institutions Annual Program Coverage Case Implementation Finance Villages Household Andhra Pradesh District govt. Govt. (TSC) (16,700) 1,670,000 West Bengal District govt. Govt. (TSC) (8,500) 850,000 Ahmednagar District govt. Govt. (TSC) 300 (30,000) Rajarhat Sub-district govt. Local govt. (180) 18,00011 Estimate based on 100 households per village 11Annual coverage of Rajarhat sanitation program (36,000 household toilets were built in two years). 46 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia social intermediation to local NGOs) appears the most program and, therefore, the sustainability of the sanitation suitable for large-scale implementation. However, despite improvements in Rajarhat is questionable, as is the use of external support from the Water and Sanitation Program- this type of model at scale. South Asia, and vigorous leadership by the Ahmednagar Despite good overall performances, the approaches used district government, the TSC program is struggling to in the four NGO cases (NGO Forum, Plan Bangladesh, find reliable local NGOs that are experienced enough to the LPP, and Gramalaya TSC) appear to have less conduct social intermediation and hygiene promotion potential at scale. activities. It has also struggled to overcome the social and technical difficulties associated with promoting Each of the four NGO programs involved small rural pour-flush toilets in drought-prone areas. communities with favorable starting conditions, and was reliant on a small cadre of well-trained and well-supported 6.1.4 Rajarhat program at scale facilitators. The NGO sanitation programs are also The Rajarhat case illustrates the potential strength of local dependent on donor-funding, which makes it more government at scale. This program raised sanitation difficult for them to take part in government programs that coverage in an entire sub-district (36,000 households) involve radically different policies or approaches, and from 16 percent to 99 percent in only two years, with raises questions about their sustainability. minimal external funding or support. However, this sanitation program was driven by the remarkable The number of communities that an NGO can work in at any enthusiasm, energy, and commitment of the sub-district's time is determined by its program finance. Most adopt a chief administrator, and involved the suspension of many rolling approach, whereby a new block of communities are local government duties while the program was ongoing, tackled every year depending on the funds available. But this making it difficult to replicate. This case also illustrates the approach is based around service development, and rarely problems associated with non-specialist government allows for long-term follow-up and monitoring in the ever- officials undertaking social intermediation and sanitation growing number of communities covered by these programs. promotion activities in addition to their other roles and responsibilities. The approach was coercive rather than 6.1.5 Gramalaya program at scale participatory, and hygiene promotion was inadequate. Gramalaya is the only one of the four NGO cases that is Both toilet usage and hygiene behavior have been in rapid implementing a government sanitation program. Gramalaya decline since the local authorities finished the sanitation made some compromises in order to take part in the TSC in NGO Case Studies Institutions Annual Program Coverage Case Implementation Finance Villages Household NGO Forum National NGO Donors 600 (60,000) Plan Bangladesh International NGO Donors 100 (10,000) LPP Local NGO Donors 12 (1,200) Gramalaya Local NGO Donors and govt. 30 (3,000) Estimate based on 100 households per village 47 Durable sanitation facilities can be expensive, thus most conventional sanitation programs provide hardware subsidies to make their sanitation facilities affordable to the poor. Tamil Nadu, but the district administration defer to through its 635 partner NGOs. But its institutional model Gramalaya on most implementation issues, secure in the is based on each partner NGO working in only one new knowledge that the local government program is benefiting village per year, making it difficult to expand the program from the extensive donor resources that Gramalaya has at now that it is struggling to find additional partner NGOs. its disposal. Theoretically, the NGO Forum program is easier to scale-up However, the Gramalaya case is neither a typical NGO than the Gramalaya program, through the addition of more program, nor easily replicable at scale. Gramalaya is a small partner NGOs, but there is a loss of quality due to the limited local NGO, built around a tight-knit group of unusually well- capacity and experience of many of its newer partners. NGO trained and experienced staff. Its successes owe much to Forum attempts to ensure the quality of its programs through good leadership, but even more to the long-term technical constant capacity building and monitoring, but this appears and financial assistance provided by WaterAid and several difficult and costly in such a large network. other international donors. Its relatively small program and NGO Forum manages to reduce its program contributions reliable financial support allow Gramalaya to spend more on by encouraging partner NGOs to raise funds locally to pay software activities than any of the other programs studied, for their activities. Unfortunately, little data is available on while the quality of its management and staff ensure that this the expenditures made by partner NGOs, making it money is spent effectively. difficult to ascertain the size and significance of these One of the key scale issues is the role of local government local contributions. in this program. NGOs such as Gramalaya prefer to take The NGO Forum program has few links with local the lead implementation role in their block and report government. As in the Gramalaya program, this reduces its directly to the district authorities. This tends to exclude ability to use institutional incentives or enforce sanctions, lower-tier local (Block and Gram Panchayat) authorities which makes it difficult to persuade reluctant or resistant from the process, and may be at the root of Gramalaya's households and individuals to improve their hygiene complaints about the slow provision of TSC subsidies. behavior and stop open defecation. This disconnect also Gramalaya also lacks the authority necessary to enforce limits the follow-up and local monitoring carried out by the compliance with community rules (for example, bans on NGO Forum program. open defecation), or the means to encourage and assist 6.1.7 Plan Bangladesh program at scale reluctant or severely constrained households (landless, Plan Bangladesh has reduced its average program costs tenants, widows, and so on) to take part in any collective by promoting very low-cost home-made toilets that are action to stop open defecation. entirely self-financed by user households. Despite a reluctance to over-stretch itself, Gramalaya Few details were available of Plan's software costs and is planning to expand its sanitation program by program overheads, but the approach adopted is intensive taking on staff from a failed NGO in a nearby district. and highly participatory, and Plan has a network of well- This expansion will involve starting work in another staffed and well-equipped offices around the country. 100 villages in this new district, and is likely to prove difficult unless Gramalaya can make its approach As a result, the program costs estimated by this study are less dependent on its exceptional staff and high likely to be under-estimates, and it is unlikely that this software expenditures. facilitator-dependent approach is either affordable or sustainable at large scale. Despite strengthening links with 6.1.6 NGO Forum program at scale local government, Plan's sanitation program is entirely NGO Forum has the largest sanitation program of the four dependent on donor-funding, and Plan has been unable to NGO cases, covering more than 600 villages annually influence local government plans to provide free toilets to 48 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia poor and vulnerable households. Plan Bangladesh is in the constraints to scaling-up rural sanitation. These are process of scaling-up its sanitation program with the discussed below, under the headings suggested by assistance of the Water and Sanitation Program-South Asia. Davis & Iyer (2002) in their discussion paper on scaling-up It is investing US$ 760,000 in a new program that aims to rural water supply, as discussed earlier. achieve full sanitation coverage in five sub-districts by mid- 6.2.1 Insufficient resources 2007. This increase in scale is already proving challenging, Durable sanitation facilities can be expensive, thus most with evidence that key stakeholders in the program area have conventional sanitation programs provide hardware not reached consensus on policy and practice. NGOs such subsidies to make their sanitation facilities affordable to as Plan can retain their unique approaches while working in the poor. But the cost of these hardware subsidies often small, well-defined geographical areas, but differences in limits program coverage. As a result, many sanitation understanding and approach become problematic when practitioners now advocate zero (or low) hardware these programs are scaled-up. subsidies, and encourage sanitation programs to promote 6.1.8 Lodhran Pilot Project at scale low-cost technologies and focus on software activities The LPP is the smallest sanitation program examined and such as social intermediation, capacity building, and has the highest program costs (per household). The LPP is hygiene promotion. However, increased attention to the a technical success, in that it has developed a viable and resource requirements of software activities and program low-cost approach to the provision of rural sewerage management reveals that these previously hidden costs schemes, which encourages user investment and delivers are a serious constraint to scaling-up the provision of rural the long-term sanitation solution that most rural sanitation services. communities desire. The case studies reveal important differences between the However, the benefits of the subsidized LPP sewerage smaller scale NGO programs and the larger scale schemes accrue largely to the non-poor, with no government programs. In general, the NGO sanitation alternative or lower cost options offered to the poor. The programs involve intensive participatory processes whose program pays little attention to stopping open defecation success is reliant on highly trained facilitators and or improving hygiene behavior, and there are questions carefully targeted activities. This approach is relatively over the sustainability and environmental impact of these expensive and human resource dependent, thus tends to relatively complex schemes. Finally, due to its high costs, be more successful in small-scale sanitation programs. In the approach appears unlikely to work at scale. contrast, the government programs tend to spend less on software activities, instead relying on institutional The LPP is an unusual case, in that it has received incentives to trigger behavior change. This approach is unprecedented financial support and technical assistance less costly and more easily replicable, but often lacks the from its powerful local champion, from the sanitation social intermediation element that is so important to specialists of OPP, from the NRSP, and from other effective community development. international donors. These powerful connections have also enabled it to bypass political resistance to its 6.2.2 Lack of knowledge or shared understanding schemes. The LPP is planning to scale-up its The case studies reveal several constraints related to a lack activities through a large donor grant, but it has been of knowledge or shared understanding. The first is the unable to attract any government finance for its problem of low awareness of the importance of adequate approach, which looks difficult and expensive sanitation to public health. to replicate. In the case studies, mass media campaigns and political 6.2 Constraints to scaling-up rural sanitation support played an important role in raising awareness and The case study findings highlight a number of common persuading local governments to invest their time and 49 Large-scale sanitation programs need to use pilot projects to test new policies and approaches against the full range of local conditions and contexts. At this stage, it is important to think about `scalability'. scarce resources in sanitation programs. In India, the countries studied (Bangladesh, India, and Pakistan) there was TSC program also introduced financial incentives and political resistance to lowering (or removing) hardware high profile awards to convince local governments subsidies, and institutional resistance to the involvement of to take an interest in stopping open defecation NGOs in large-scale government sanitation programs. within their jurisdiction. As discussed earlier, it has been traditional to provide Awareness is also important at the household level. hardware subsidies in rural sanitation programs in South However, the case study findings suggest that Asia. The Government of India's Central Rural Sanitation mass media campaigns are less effective in raising Programme (CRSP), the predecessor to the TSC, offered awareness among poor rural households than some hardware subsidies as high as US$ 54 per household. These rationed subsidies rarely reached the poor, but alternative methods, such as community-level or provided considerable political (and financial) capital to house-to-house sanitation and hygiene promotion local administrations. Many politicians and administrators activities. A key constraint is limited knowledge of the in the region remain unconvinced that it is possible to availability and functioning of low-cost sanitation provide adequate sanitation to the poor without large technologies. In many areas, poor households are hardware subsidies. unaware how to construct affordable low-cost toilets, or where to find sanitation components. In addition, many A more difficult problem is resistance to the involvement lose interest in toilet construction or usage after seeing of NGOs (or private sector organizations) in large-scale badly designed, improperly installed, or inadequately government-funded sanitation programs. This resistance maintained toilets. usually comes from vested interest groups, such as the line departments that traditionally control implementation 6.2.3 Resistance of rural sanitation projects, or the politicians that allocate Two key areas of resistance were encountered. In all three schemes. Efforts to decentralize the provision of sanitation services face similar resistance, but progressive local governments, such as the Ahmednagar Challenging Political Resistance District Government, are piloting programs that contract out social intermediation and hygiene promotion Politicians within the region tend to resist any lowering activities to NGOs, while retaining management and of hardware subsidies, fearing that any move in this control of local services. direction will be interpreted as an anti-poor strategy. 6.2.4 Untested implementation conditions The Government of Maharashtra (with assistance from Large-scale sanitation programs need to be flexible enough the Water and Sanitation Program-South Asia) tackled this resistance by taking local politicians on exposure to deliver services appropriate to the different social, visits to successful sanitation programs that use low technical, policy, and user contexts found in their large and or no subsidy approaches. diverse program areas and target populations. Most of the case study sanitation programs have adopted standardized After visiting rural communities that had managed to approaches, based around the provision of a single stop open defecation and had achieved universal sanitation technology, and sanitation promotion among sanitation coverage without hardware subsidies, and after reflecting on the failure of their own heavily- active, cooperative communities. This approach proves subsidized sanitation programs, these politicians reasonably successful in small programs, where responsive returned to Maharashtra determined to adapt the low communities can be selected ahead of more difficult cases, subsidy approaches to the local context. but is not effective in large-scale programs aiming to provide universal sanitation coverage. 50 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia For example, none of the case study programs have cultural preferences, demand for services, and institutional developed viable solutions to the provision of low-cost capacity. Program designers often prefer to begin pilot sanitation in water-logged or drought-prone areas. This activities in areas in which the likelihood of success is reflects the failure of the case study programs to pilot their high, but this approach can conceal challenges and approaches in more challenging circumstances, or build result in institutional models and guidelines that are in the flexibility and choice needed to respond to inappropriate when scaled-up to cover a wider area and non-standard situations. larger target population. 6.3 Strategies for scaling-up rural sanitation Local implementation capacity is another important There is no standard solution for the large-scale provision consideration. Large-scale sanitation programs may be of rural sanitation services. Nevertheless, there are some beyond the current managerial, technical, and financial useful lessons and insights to be drawn from the study capacity of local institutions, and need to be phased in findings and analysis, and these have been used to incrementally to match gradual improvements in local assemble the following strategies for scaling-up experience and capacity. Large-scale sanitation programs rural sanitation: should also be flexible enough to learn from experience, to incorporate local materials and technologies, and to Strategy 1: Incremental program development encourage innovation, rather than insisting on The case studies highlight the benefits of incremental standardized technologies and one-size-fits-all solutions. program development, and of testing policies and institutional arrangements before going to scale. In both Strategy 2: Partnering between the Andhra Pradesh and Rajarhat cases, rapid and local government and NGOs intensive sanitation programs raised awareness and The study findings suggest that the institutional model achieved impressive increases in coverage levels, but failed most likely to be effective at scale involves partnering to make sustainable changes to hygiene behavior or public between local governments and local NGOs. Several of the health, and realized too late that policies and approaches case studies highlight the benefits of local government could have been improved. involvement in large-scale sanitation programs, while the importance of effective social intermediation and hygiene Large sanitation programs may succeed in building promotion argues for NGO involvement. substantial numbers of toilets, but very few manage to provide well-used and sustainable sanitation services. This The case studies suggest that NGO-only programs find it confirms how difficult it is to generate genuine demand for hard to provide universal sanitation access, particularly sanitation facilities and change long-established patterns among less compliant or active households and of hygiene behavior when faced with the enormous communities. Local government programs tend to variations in social norms and preferences across be more institutionally-based, using financial incentives communities, districts, and regions. and government rules to galvanize collective and individual action. Large-scale sanitation programs need to use pilot projects to test new policies and approaches against the full range This approach lacks the emphasis on community of local conditions and contexts. At this stage, it is empowerment and hygiene promotion provided by the important to think about `scalability'. It has been NGO-only programs, but appears more effective in suggested12 that the first set of districts or communities reaching the poor and the excluded. Crucially, the selected should be representative of the entire target institutions involved in the local government approach are population with respect to technical challenges, social and also easier to scale-up and to adapt to local conditions. 12Davis & Iyer (2002). 51 Self-help groups provide a potential mechanism for the regular monitoring of environmental and public health in rural communities. Local governments are also ideally placed to undertake (or more on essential activities such as hygiene promotion. facilitate) the long-term monitoring and support of rural However, software activities need to be carefully planned, sanitation services. Most NGOs do not have the manpower monitored, and evaluated. Several of the case study or authority to monitor and enforce bans on open programs reported significant expenditures on IEC and defecation, or ensure safe disposal of sewage sludge and social intermediation, but had little impact on toilet usage leach pit contents. At present, local government priorities or hygiene behavior because the funds were not well used. are to increase access to safe sanitation, but their role will become more regulatory and public health focused as A key issue is the level at which software activities are sanitation coverage rises and sanitation services become conducted. The less successful programs appear to have more reliable. spent large amounts at the macro level: on conducting expensive poster and leaflet campaigns; on holding The main weakness of government sanitation programs workshops and local rallies; and on advertisements in local appears to be in the provision of social intermediation and media (newspapers, radio). In contrast, the more hygiene promotion. Other institutions are capable of successful programs invested in activities at the performing these roles, but local NGOs are often among community and household level, focusing on door-to-door the few locally-embedded institutions with the requisite campaigns, social marketing of sanitation products, and skills and experience. Where available, committed local hygiene promotion among poor and vulnerable groups. NGOs provide a ready source of facilitators and of Strategy 4: Formation of community self-help groups expertise in community development. Self-help groups (SHGs) may be an effective way of This study suggests that local governments that lack scaling-up sanitation promotion and provision, social development capacity are likely to improve the particularly when there is a shortage of suitable NGOs in effectiveness and sustainability of their rural sanitation the area. Several of the case study sanitation programs programs by delegating (or contracting out) social establish a couple of women's self-help groups in each intermediation and hygiene promotion activities to partner program community. The SHGs normally comprise NGOs, and that this institutional model is also likely to be 10-20 women who are given some basic training and the most effective at large scale. encouraged to undertake activities such as management of rolling loan funds (providing loans to Strategy 3: Need for cost-effective implementation purchase and install toilets) and the formation of Unlike small well-supported programs, most large-scale small enterprises selling handicrafts. Even the programs cannot afford to have high average (per least active SHG provides a forum for the discussion household) costs. In order to make any real impact on of community development activities, as well national sanitation coverage, the limited funds available to as a rich source of committed local sanitation and large-scale programs need to be used as efficiently and hygiene promoters. effectively as possible. Self-help groups also provide a potential mechanism for Based on the case study findings, the most cost-effective the regular monitoring of environmental and public health and successful sanitation programs seem to be those in rural communities. SHGs can monitor open defecation that have reduced hardware subsidies to a minimum and indicators of safe hygiene and sanitation (or to zero) and have invested the majority of their (handwashing, toilet use, toilet repairs, the number of funding in social intermediation and hygiene promotion leach pits that fill annually, and methods of disposal), and at the household level. Lowering hardware subsidies and they can also collect data on community health (prevalence promoting low-cost facilities enable sanitation programs of diarrheal incidents, number of disease-related to reach more poor households, and allow them to spend hospitalizations and deaths, seasonal variations). 52 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia The Tamil Nadu Women Development Corporation Strategy 5: Macro monitoring of large-scale (TNWDC) has been instrumental in encouraging the sanitation programs formation of more than 120,000 women's self-help groups Large-scale sanitation programs require regular in the State, and these are now the prime movers in the monitoring at the macro level. The case study programs Tamil Nadu TSC. The self-help groups have become so are all supposed to be monitored, but this study successful and involved in local development that confirms that reliable data and information are rarely they have formed federations, with each group of available, even in the smaller NGO programs. 20-25 SHGs represented by a Panchayat Level Federation This lack of information makes it difficult to identify leader who attends block development meetings and weaknesses or evaluate the effectiveness and coordination committees. efficiency of program policies, approaches, and expenditures. There are now 30,000 women's self-help groups in the West Medinipur district of West Bengal, all of which have The best macro-monitoring model from the case studies is been started in the last three years. Each of the 300,000 the dedicated sanitation unit established to monitor the members contributes a few rupees a day into a revolving West Bengal TSC. The State sanitation unit is located savings and loan fund, and can obtain small loans from within the SIPRD but is currently funded by UNICEF. this fund as and when needed. In 2003, the district The sanitation unit monitors and benchmarks district administration recognized the value and potential of this performances in order to expose weaknesses, and then huge network, and introduced a scheme that trained more provides support and builds capacity wherever needed. than 500 SHG members as voluntary health workers. It also assembles independent teams to review claims of universal sanitation coverage, and compares One of the first duties undertaken by these voluntary West Bengal's performance and policies with those from health workers was the completion of a health status around the region. survey in their village, providing information on recent ailments, approximate expenditure on medical treatment, This type of provincial or national sanitation body is immunization status, sanitation facilities, and general essential to collect and disseminate knowledge and hygiene practices. The government does not pay the learning, both of common constraints and of useful voluntary health workers, making the sustainability of the innovations from within the program area, and of regional scheme dependent on community contributions and and global best practice. goodwill, as well as long-term support from primary health centers. But the scheme has already proved Sanitation units are also effective coordination promising enough for the Government of West Bengal to mechanisms, providing a forum for sanitation stakeholders decide to introduce voluntary health workers in every and encouraging convergence on sanitation policies village in the State. and approaches. 53 Large-scale sanitation programs should develop sustainable supply chains based around local retail suppliers, thus encouraging price competition and accountability to consumers. 54 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 7 Policy Implications Need for better baseline information themselves, with most reliant on some form of external One of the broader issues to emerge from this regional intervention to catalyze the process. study is the need for better baseline information within the Local governments are best placed to manage rural sanitation sector. For example, the Government of sanitation programs and to enforce program rules (for Bangladesh commissioned a rapid baseline survey in example, bans on open defecation), but some form of 2003, which resulted in a 13 percent downward revision in social intermediation is needed between local the official national sanitation coverage (from 45 percent governments and rural communities. In most parts of to 32 percent). South Asia, local NGOs are currently the most likely The new baseline survey in Bangladesh was conducted agents of the social intermediation process, with using government, NGO, and donor resources, which additional long-term support and monitoring to be enabled the whole country to be covered in only three provided through the formation of self-help groups in months. This unified approach made the process more each community. transparent, and created unusual consensus on the Promotion of low-cost sanitation facilities revised sanitation coverage figures. The promotion of very low-cost sanitation technologies Total sanitation approach requires careful application was an important factor of success among the case There is some merit to the total sanitation concept, as studies. Large-scale sanitation programs should ensure revealed by the rapid appraisals conducted for this study. that rural households understand the minimum In almost every case, sanitation program managers and requirements of a sanitary toilet (that is, that it provides local government officials were aware that their main safe disposal of human excreta without risk of local objective was to stop open defecation, and that this contamination) and encourage the construction of cheap, required community-wide action, universal toilet use, and local toilet designs that meet these requirements. hygiene behavior change. Opinion was divided as to how Few rural sanitary marts are sustainable without program these changes should be effected, but there was little support, which suggests that private retail markets are the argument about the fundamentals. In this respect, the total long-term solution for cost-effective and large-scale sanitation concept is a major step forward, as this sort of supply of sanitary wares. Rural sanitary marts provide a shared understanding has been sadly lacking in many useful interim supply mechanism where local suppliers earlier sanitation programs. are reluctant to enter the market, or where new However, the variable case study performances confirm technologies (for example, plastic toilet pans in that the total sanitation approach is no `magic bullet' for Bangladesh) need to be introduced. However, wherever rural sanitation. The total sanitation concept focuses possible, large-scale sanitation programs should develop attention on stopping open defecation and on the sustainable supply chains based around local retail importance of community-wide action, but large-scale suppliers, thus encouraging price competition and sanitation programs also need carefully thought out and accountability to consumers. locally appropriate policies on matters such as social Effective hygiene promotion intermediation, sanitation marketing, hygiene promotion, Hygiene promotion remains crucial to the long-term hardware subsidies, financing, and accountability. success of rural sanitation programs, yet few programs Importance of effective social intermediation evaluate the effectiveness of their hygiene promotion Stopping open defecation within a community involves activities or assess their impact on hygiene behavior and significant changes in hygiene behavior and universal public health. Given the calls for more spending on social toilet usage, which requires both collective and individual intermediation and hygiene promotion, it is essential that action. Few rural communities manage this transformation the cost, effectiveness, and sustainability of large-scale 55 High hardware subsidies usually result in sanitation programs being able to reach fewer people, and prove tempting for non-poor households. hygiene promotion activities are carefully tested, planned, control over what is installed or the quality of the implemented, and monitored. installation. All too often, the program is being managed at the district level, and poor households are left with few Further, sanitation and hygiene monitoring needs to be channels to voice their concerns once universal coverage built into long-term public health monitoring systems, is proclaimed and the NGO (or other implementing agency) with monitoring results fed back into the planning has moved on to another community. and assessment of sanitation programs. These linkages will require greater integration between large-scale The case studies reveal two methods to improve rural sanitation programs and government accountability to poor households. The first is to devolve health administrations. program implementation to the lowest level of local government; and the second is to contract out Consistent subsidy policy implementation to providers such as local NGOs. Hardware subsidies can have a significant effect on demand for sanitation. High hardware subsidies usually Devolving responsibility to the lowest level of local result in sanitation programs being able to reach fewer government eliminates long delays (while information and people, and prove tempting for non-poor households. In decisions are passed back and forth along the chain of addition, households that build toilets under heavily- command), improves targeting (due to better local subsidized programs often feel less ownership for their knowledge), and increases local accountability (due to the facilities and may be less inclined to make any lasting higher accessibility and visibility of local leaders). Clearly, improvements to their hygiene behavior. there is a risk that local elites will attempt to divert resources, capture benefits, and falsify records, but this Where several sanitation programs are operating within the can be countered by regular monitoring, by benchmarking, same area, it is essential that sanitation stakeholders agree and by independent performance reviews. and formalize a consistent subsidy policy. The case study findings suggest that large-scale sanitation programs The second approach is to involve local service providers should offer minimal hardware subsidies wherever in government sanitation programs. In most rural areas, possible, with funds used instead to extend program this will mean local NGOs, as there are very few coverage and improve the effectiveness of private providers with the necessary social development software activities. skills and experience. NGOs can improve accountability by creating separation between local decision-makers Improve accountability to poor households and rural households. This institutional arrangement Large sanitation programs tend to be overly centralized allows local government to monitor and facilitate the and government-controlled, with policy and performance of NGOs acting as frontline service implementation decisions taking little account of the providers, while providing rural households with variable preferences and constraints of poor households. several ways to express demand, voice complaints, and Government and NGO programs persuade rural inform program managers of problems: either directly to households to invest large sums in sanitation facilities, but the NGO, or through their elected representatives and rarely feel accountable to these same households for the local government officials. The benefits of institutional long-term performance of their sanitation services. separation add further weight to earlier arguments for partnering between local government and local NGOs. In most of the case studies, poor households are asked to pay in advance for materials and for the installation of their Sustainable financing of cost-effective programs sanitation facilities. After paying relatively large sums, Large-scale rural sanitation programs require sustainable these households have to wait until the implementation finance, cost-effective implementation, and a consistent team is available to install their facility, and then have little policy environment. In the past, donor resources have 56 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia been allocated to specific projects or programs, which development of sanitation services. In the past, this meant resulted in a fragmented sector containing a few `islands pouring money into building subsidized toilets, but there of success'. Budget support by donors will improve is increasing evidence that this approach results in planning and coordination; produce a more homogeneous theoretical increases in sanitation coverage with little policy environment; and encourage the adoption of more impact on public health. cost-effective and pro-poor approaches in national sanitation programs. This study suggests that the focus of large-scale sanitation programs should be on stopping open South Asia contains more poor people without access to defecation and improving hygiene behavior on a sanitation than any other region on earth, which puts its community-by-community basis, and that success should national governments under extreme pressure to make the be measured not by the number of toilets built, but by most of the limited resources available for the long-term improvements in public health and well-being. 57 Regular follow-up by outsiders encourages rural households and community groups to continue with new hygiene practices and monitoring roles, and makes it more likely that toilets will remain clean and in use when leach pits fill. 58 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 8 Recommendations For Further Research Collection action to solve sanitation problems nTo assess the cost-effectiveness of the different Despite the best efforts of the case study programs, approaches and policies. it remains a challenge to develop genuine demand for More effective software investments sanitation among the poorest households in The significance of non-hardware expenditures in the case rural communities. study programs reinforces the need for better data A local ban on open defecation is one way to pressure collection, reporting, and evaluation of software reluctant households into improving their hygiene expenditures in sanitation programs. Effective and cost- behavior, but the case study findings suggest that both efficient software activities will be vital to the success of communities and local governments find it hard to enforce large-scale sanitation programs, but little is known about and sustain these bans. the real costs and relative effectiveness of the many different approaches to sanitation and hygiene promotion, Another approach (as used in the Ahmednagar TSC) is the capacity building, social intermediation, and so on. provision of financial incentives to achieve collective action. These financial incentives are payable to the local Local monitoring and institutional support government and to all below poverty line households once The one area in which all of the case study programs an independent review declares the area `free from open were weak was the monitoring and assessment of their defecation'. The idea is sound, but in Ahmednagar the own performance. Despite a recognition that the ultimate financial incentives paid to BPL households are relatively aim of every sanitation program is to improve public health small (US$ 8) compared to the typical cost of a toilet and well-being, program performance is almost always (US$ 20). In several of the villages visited, this has resulted measured by physical or financial progress. In other words, in the provision of free toilets to the poorest households government ministers and program managers are so that local governments can declare their jurisdiction interested in how many toilets have been built for their `free from open defecation' and claim their payment. money, rather than the program's long-term impact on the incidence of diarrheal disease or on infant mortality. Further research is required to examine effective approaches and incentives for the provision of sustainable Despite a common interest in following-up on sanitation sanitation services to the poorest, and for the collective activities; in ensuring the sustainability of sanitation action needed to stop open defecation and achieve services; and in monitoring toilet usage and open universal toilet usage in rural communities. defecation; none of the case study programs managed to establish an effective institutional support mechanism or Information on program costs develop reliable local monitoring systems. It proved difficult to assess total or average costs in the case study programs. In a few cases, this was due to the At the local level, regular monitoring is essential for the reluctance of successful program managers to admit success of decentralized implementation, and provides the real costs of their software activities and program important feedback on the sustainability of rural overheads, but in others it reflected a widespread failure to sanitation services. Regular follow-up by outsiders record and evaluate non-hardware costs. Further research encourages rural households and community groups to is required: continue with new hygiene practices and monitoring nTo examine sanitation program expenditures in roles, and makes it more likely that toilets will remain more detail; clean and in use when leach pits fill. nTo look at the sustainability of the sources and channels of program finance; This type of monitoring and follow-up helps rural nTo develop sustainable financial information and households to cope with minor technical problems and monitoring systems; and supply issues, which might otherwise lead to toilets 59 Further research is required to determine effective approaches and sustainable institutional models for long-term local monitoring and institutional support. being abandoned, and reinforces the authority and institutional support needed to cover issues such as interest of those trying to stop open defecation within technical advice (for example, on emptying or replacing the community. leach pits), access to local supply chains, and so on. Women's self-help groups are a promising development Further research is required to determine effective for the long-term monitoring of rural sanitation services approaches and sustainable institutional models for and hygiene behavior, but are unable to provide the long-term local monitoring and institutional support. 60 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia References Balachandra Kurup, K et al (1996) The community- Working Paper 184, Institute of Development Studies, managed sanitation programme in Kerala: Learning University of Sussex from experience, The Hague: IRC International Water Kolsky, P, E Bauman, R Bhatia, J Chilton, C van Wijk (2000) andSanitation Centre Learning from Experience: Evaluation of UNICEF's Davis, J & Iyer, P (2002) Taking sustainable rural water Water and Environmental Sanitation Programme in supply services to scale: A discussion paper, India 1966-1998, SIDA, Stockholm Washington, D.C.: Water and Sanitation Program Lockwood, H (2004) Scaling-up community Elledge, M (2003) Sanitation policies: Thematic management of rural water supply, The Hague: overview paper, Delft: IRC International Water and IRC International Water and Sanitation Centre, Sanitation Centre Thematic Overview Paper Government of India (2002) Central Rural Sanitation PIHS (2002) `Pakistan Integrated Household Survey: Programme (Total Sanitation Campaign): Guidelines, Round 4, 2001-02', Islamabad: Government of New Delhi: Department of Drinking Water Supply, Pakistan, Federal Bureau of Statistics Ministry of Rural Development, Government of India Schouten, T et al (2003) Scaling-up community Government of India (2004) Guidelines on Central Rural management: challenges and opportunities, Sanitation Programme: Total Sanitation Campaign, The Hague: IRC International Water and New Delhi: Department of Drinking Water Supply, Sanitation Centre Ministry of Rural Development, Government of India VERC (2002) Shifting millions from open defecation to Government of Pakistan (2002) Pakistan Water Sector hygienic latrines, Dhaka: Dhanshiri Printing and Strategy: Medium Term Investment Plan, Islamabad: Publishing Co. Ministry of Water and Power, www.waterinfo.net.pk/ WSP (2000) The growth of Private Sector Participation splight4.htm in Rural Water Supply and Sanitation in Bangladesh, Harriss, J (2000) How much difference does politics New Delhi: Water and Sanitation Program- make? Regime differences across Indian states and South Asia rural poverty reduction, London: London School of WSP (2001) Jal Manthan 4: Launching Sector Reforms ­ Economics, LSE Development Studies Institute supporting the Government of India pilot demand- Working Paper Series No. 00-01 responsive approaches to rural water supply and IRC (2002) E-conference: Beyond the community ­ on sanitation, New Delhi: Water and Sanitation scaling-up community management of rural water Program-South Asia supplies, www.irc.nl/content/view/full/691 WSP (2002a) Jal Manthan 5: Igniting change: Tackling the JMP (2004) Joint Monitoring Programme for water sanitation challenge, New Delhi: Water and Sanitation supply and sanitation: sanitation data, Program-South Asia www.wssinfo.org/en/335_san_asiaS.html WSP (2002b) Jal Manthan 7: Making sanitation work, Kar, K (2003) Subsidy or self-respect? Participatory total New Delhi: Water and Sanitation community sanitation in Bangladesh, Brighton: IDS Program-South Asia 61 Despite the best efforts of the case study programs, it remains a challenge to develop genuine demand for sanitation among the poorest households in rural communities. 62 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Annex 1 Community-led Total Sanitation 63 YTC 64 Lessons Learned from Bangladesh, India, and Pakistan Annex 1 Scaling-Up Rural Sanitation in South Asia Community-led Total Sanitation Sanitation investments are normally targeted at individual nPromotion of low-cost homemade toilets constructed households, on the basis that both construction and use using local materials (rather than standard toilet designs of toilets depend on private decisions and household-level imposed by outsiders). hygiene behavior. Most traditional sanitation programs This approach recognizes that sanitation is both provide some form of subsidy to reduce the cost of a public and a private good, and that individual hygiene building a toilet, and back this financial incentive with behavior can affect the whole community ­ if your sanitation promotion and hygiene education that highlight neighbors defecate in the open, then your children risk the benefits of toilet use and good hygiene behavior. excreta-related disease even when the members of your This approach normally results in an incremental change own household use a sanitary toilet, wash their hands, in sanitation coverage, with improvements within a and practice good hygiene. In this sense, `total sanitation' community becoming steadily more difficult once early refers to a total stop on open defecation, which requires adopters and non-poor households have installed that everyone in the community either owns or has access sanitation facilities. It is also costly, as many to a sanitary toilet. conventional sanitation programs promote durable, The main advantage of the total sanitation approach over well-built, and expensive toilets, and thus tend to offer conventional policies is that it is a community-wide significant hardware subsidies in order to persuade approach, which requires that every household in the households to pay their share of the considerable costs community stops open defecation and uses a sanitary of toilet construction. toilet. This approach involves even the poorest and most Few large-scale sanitation programs of this type have been vulnerable households in the community, and ensures successful. High hardware subsidies usually result in that the community and local government focus on sanitation programs being able to reach fewer people, and helping these households gain access to a sanitary toilet prove tempting for non-poor households. In addition, with a safe excreta disposal system. This process is households who build toilets under heavily-subsidized the reverse of most conventional sanitation programs, programs often feel less ownership for their facilities and which tend to favor those that can afford toilets, may be less inclined to make any lasting improvements to those that have land available to build toilets, and those their hygiene behavior. that are first on the list for subsidized facilities. All too often, conventional programs leave coverage of Over the last few years, non-governmental organizations the poor and the marginalized, that is, those most (NGOs) in Bangladesh1have been pioneering a new affected by inadequate sanitation, until long after everyone approach to sanitation development. It is known else has been served. as Community-led Total Sanitation2 and has several fundamental differences from conventional NGOs in Bangladesh state that they have used the total approaches, including: sanitation approach to support more than 1,000 rural nFocus on stopping open defecation (rather than communities in stopping open defecation, using building toilets); participatory techniques to raise awareness of local nNeed for collective action (to stop open defecation sanitation issues and assist communities to solve their within the community); own problems (see box on `Ignition'). The combination of nNo toilet subsidy (households must finance their internal community pressure and external NGO support is own toilets); and reported to have enabled hundreds of rural communities in 1Notably WaterAid Bangladesh and VERC. 2Kar (2003). 65 The total sanitation approach encourages rural households to use their initiative and funds to build basic sanitary toilets, without imposing standard external designs. Ignition ­ one way to stop open defecation? Open defecation is a practice that is centuries old in most rural areas. To many villagers, it appears to cost nothing and to do little harm. Given this situation, something dramatic is required to change people's thinking and behavior, as the dire record of most rural sanitation programs attests. In Bangladesh, NGOs (notably VERC and WaterAid) developed a participatory `ignition process' to begin this change, including the following components: nSocial mapping of the village; nDefecation map with defecation mobility (including `crisis' defecation); nWalk of shame (transect walk to open defecation areas and water points); nChanges and trend of village water and sanitation situation; nLivelihood analysis and well-being grouping; nPossession of toilets by different groups; nExcreta calculation (amount of excreta added to village by open defecation); nContamination mapping (pollution caused by excreta and fecal-oral contamination links); and nGroup discussions on diseases due to open defecation, emergencies, medical costs. Many of these steps will be familiar, but two of the elements, the walk of shame and the excreta calculation, are highly innovative and effective motivational tools. During transect walks to sites of open defecation, it is common for members of the community to be embarrassed to visit these dirty spots with outsiders, and attempt to move away quickly. But the facilitators like to stop and ask questions: which families use this spot for defecation? what happens during emergency defecation at night, or during diarrheal incidents?...these questions are often answered by people covering their noses with their hands. Normally, when outsiders are taken around a village, the community likes to focus on its positive aspects and achievements, and feel a sense of pride. These `walks of shame' reveal a different reality. Although everyone sees the filth and dirt every day, they seem only to awaken to the problem when visiting these sites with groups of outsiders that analyze the situation in detail. A collective calculation of the amount of excreta that open defecation adds to the local environment is an interesting and participatory method of helping communities to realize the magnitude and extent of their sanitation problem. Participants make their own estimates of the amount of feces contributed by one person in one day, then keep multiplying to calculate contribution per family, per week, per year and so forth. In Mosmoil village (Rajshahi district, Bangladesh) the community calculated that 50,000 tons of human excreta were being added to their village environment every year. The communities are usually horrified by these figures, and immediately begin to wonder about the various routes of fecal contamination. Flow diagrams are then drawn to trace contamination routes to ponds, household utensils, domestic articles and, most important, to food through hands, flies, chickens, household pets, and so on. After these intensive participatory exercises, a positive force to deal with the situation tends to emerge, with people voicing their eagerness to stop open defecation and to construct toilets. In this way, the `ignition process' triggers change and fires enthusiasm for sanitation development! After Kamal Kar (2003) Bangladesh to reach 100 percent sanitation coverage spent on important software activities such as within less than a year, without any hardware subsidies. sanitation and hygiene promotion. The total sanitation approach encourages rural However, it must be remembered that the total households to use their initiative and funds to build sanitation approach is a relatively new concept, which basic sanitary toilets, without imposing standard is now being employed by many different actors in external designs. This allows very low-cost toilets to many different ways. The theory looks good, but careful be built using freely available local materials, thus evaluation of the practice is required before the making toilets more affordable and accessible to the sustainability and effectiveness of this new approach rural poor. It also permits more program funds to be can be verified. 66 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Annex 2 Case Studies from Bangladesh 67 YTC 68 Lessons Learned from Bangladesh, India, and Pakistan Annex 2 Scaling-Up Rural Sanitation in South Asia Case Studies from Bangladesh Bangladesh is the smallest, poorest, and most rural of households have access to a safe toilet, while 47 percent the countries studied. It is regularly inundated by of rural households have no toilet facilities at all. catastrophic floods and typhoons, and has one of the SACOSAN was very important for developing consensus highest population densities in the world, creating fierce among stakeholders and support for the sanitation sector. competition for the limited land that is suitable for The widely-disseminated baseline survey provides a habitation and cultivation. In its favor, Bangladesh has a common and undisputed database for all to work from, thriving non-government sector, with non-governmental and the new approaches discussed at the conference are organizations (NGOs) reaching about 75 percent of rural now spreading and gaining legitimacy. Following general settlements, and devising innovative and widely-copied consensus on the effectiveness and speed of the approaches to development. community-led total sanitation approach, most of the major NGOs in Bangladesh have now decided to adopt the Bangladesh has been at the forefront of recent sanitation approach, and have incorporated it into their national developments in South Asia. As discussed in the main sanitation programs. report, the Government of Bangladesh recently hosted the first South Asian Conference on Sanitation (SACOSAN), At the end of SACOSAN, the Minister for Local with international recognition of the new approaches to Government & Rural Development announced that sanitation provision developed by NGOs in Bangladesh. Bangladesh would aim to achieve 100 percent sanitation coverage by the year 2010, some 15 years ahead of the In the run-up to SACOSAN, the government realized that MDGs (which include halving the number of people it needed more accurate and detailed sanitation data in without access to hygienic facilities by 2015, and order to develop a realistic strategy and implementation providing sanitation to all by 2025). plan. A rapid baseline survey was commissioned, using sector and government resources to cover the whole Reaching this ambitious target will involve increasing country in just three months. sanitation coverage by 68 percent in less than six years, covering at least 2.4 million households every year.3 This is More than 45 percent of the total population were thought an enormous challenge, but the government has signalled to have access to adequate sanitation, but the results of its commitment by issuing new guidelines on rural this baseline survey confirm that only 29 percent of rural sanitation and by earmarking 20 percent of the budget 2003 Bangladesh Baseline Sanitation Survey Population Toilet No Sanitary Unsanitary Toilet Rural 18.32 m hhds (87%) 29% 24% 47% Urban 2.75 m hhds (13%) 56% 29% 14% Total 21.07 m hhds 32% 25% 43% * m hhds = million households (average size = 6.5 members) 321.05 million hhds x 0.68 = 14.31 million hhds/6 years = 2.39 million hhds per year (without allowing for population growth of 1.7 percent per year). 69 According to the latest figures, the remainder of Kurigram district (another 284,000 households) is more typical of northern Bangladesh, with an average sanitation coverage of just 23 percent. of the Annual Development Program (ADP) for are famine-prone, and are poorer than much of the rest of sanitation activities.4 the country. Rajshahi division, in which both districts fall, also has the lowest rural sanitation coverage in the Unfortunately, it seems likely that this ADP funding will be country. It is difficult to attract senior government officials used to provide toilet subsidies to poor households, thus and program staff to posts in this remote and undermining the zero subsidy approach promoted by the disadvantaged region, which makes the development three Bangladesh case studies summarized below: challenges that much harder. Case study 1: Local Government (Rajarhat Upazila) Case study 2: NGO Forum (Dinajpur program) Population density in the northern districts is about 600- Case study 3: Plan Bangladesh (Chirirbandar program) 700 people per square kilometer. This is a high population density (more than double than that found in India), but These case studies examine three different approaches to remains some 30 percent below the national average. In total sanitation in Bangladesh. The three cases were these areas, the villages often consist of a number of studied in similar contexts in northern Bangladesh, separate paras (hamlets), clustered around a larger hamlet/ but each has very different institutional arrangements. village and linked by networks of footpaths. The first is a government-led project with no NGO involvement; the second is an NGO-led project with The 2003 baseline survey shows that sanitation coverage significant community involvement; and the third is a in Kurigram district (31 percent) is significantly higher than community-led project with significant NGO involvement. that in nearby Dinajpur district (18 percent). The higher As in all the cases, the approaches are evolving and these figure in Kurigram is largely due to the high coverage in case studies represent snapshots of the programs taken one sub-district (Rajarhat Upazila ­ see Case Study 1), which has increased sanitation coverage in its 36,000 in the period January-March 2004. households to 99 percent over the last two years. Case study context According to the latest figures, the remainder of Kurigram The case studies focus on three sanitation projects in district (another 284,000 households) is more typical of Kurigram and Dinajpur districts, which lie close to each northern Bangladesh, with an average sanitation coverage other in the north of Bangladesh. These northern districts of just 23 percent. Case Study Data Unit Name Population Literacy Sanitation Total Rural Coverage District 1 Kurigram 1.8 million ­ 22% 31% District 2 Dinajpur 2.6 million ­ 27% 18% Country Bangladesh 136 million 87% 41% 32% Region South Asia 1,401 million 72% 56% 34% Source: WDR 2004; GoI Census 2001; Baseline survey 2003; www.banglapedia.search.com 41996-97 ADP allocation to rural and urban water supply was only 2.4 percent (DANIDA, 1999). 70 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Case study 1: Local government Approach (Rajarhat Upazila) Local government officials and DPHE engineers promote a This is an independent sanitation project, enacted by the low-cost `direct' toilet model. This design is based around Upazila (sub-district) government with assistance and a standard toilet platform (all-in-one cement toilet slab and support from the Department of Public Health Engineering gooseneck pan) mounted directly onto a concrete ring at (DPHE) and UNICEF. The sanitation project was modelled the top of a single bamboo-lined pit. The toilet enclosure on a well-known pilot project conducted by the local is home-made, usually from bamboo, palm fronds or government in nearby Patgram Upazila (Lalmonirhat old jute sacks. The toilet components are sold by RSMs at district). In Rajarhat Upazila, the project was initiated by a US$ 2.90 for the standard package (toilet platform and one highly motivated and energetic local government official, ring). DPHE had already established an RSM in the the Upazila Nirbahi Officer (UNO), who is the chief Upazila, but the project led to several new RSMs being administrator of the sub-district. developed by DPHE, using funding from UNICEF. Key features The sanitation project involved considerable awareness nNinety-nine percent toilet coverage in entire Upazila raising, IEC, and social mobilization, but all of this work (sub-district of 36,000-plus households); was conducted by government staff under the control of nLocal government implementation (with UNICEF the UNO, including local administrators, Union Parishad5 support); members, extension officers, school teachers, and nRural Sanitary Mart production of low-cost toilet anganwadi (nursery) workers. In addition, the UNO enlisted platforms; and local Imams (religious leaders) to spread sanitation nLimited usage of toilets. messages and convince their followers to install toilets. In the initial stages, the UNO realized that the approach was not effective for very poor households. Therefore, savings schemes were introduced, in which Union Parishad members collect US$ 0.17 monthly contributions from groups of 10 households. Every two months, one of the 10 households receives the US$ 3.38 savings that have accumulated, which allows them to pay for their toilet components. Institutional model UNICEF DPHE Upazila Assistant Administration Engineer UNO Upazila Rural Sanitary Government Mart Extension staff Household 5Union Parishad = lowest active tier of local government (until Gram Sokha Parishad become functional). Typically, each Union covers about nine villages (or paras). 71 In many cases, the local government has coerced the rural population into building toilets, whether people want them or not. Performance that "we had to buy the toilet, otherwise the The Upazila authorities report that, in a little over two years police would come". Some of these women are now (September 2001-December 2003), the RSMs in the using their toilets, and are happy to list the perceived sub-district have sold more than 32,000 toilets, resulting benefits (privacy, less disease, fewer flies), but more than in a spectacular increase in sanitation coverage from 16 50 percent of the households in this village are not percent to 99 percent. The 2003 national baseline survey using their toilets, and do not appear to have improved confirms 99 percent sanitation coverage, with 35,565 of their hygiene behavior. the 36,077 households in the Upazila reported to be using There were also reports that everyone in a neighboring sanitary toilets. community bought toilet components (under pressure However, the rapid appraisal conducted for this study from the local government) but that none of them questions this unusually high usage figure, and suggests were installed and, as a result, open defecation is that both toilet usage and sanitation coverage are still prevalent. declining fast now that the intensive sanitation project is These findings represent outcomes in only two of the considered complete. In the villages visited, a significant many paras in the Upazila, but they do bring into question proportion of the new toilets are already damaged, the sustainability of the approach. The failure of inoperable or no longer providing safe excreta disposal. households to repair or replace broken toilet pans, the Toilet pans have broken while being cleaned; toilets have installation of unsanitary toilets, and the declining toilet been altered to discharge directly into nearby ditches; usage, all suggest that these communities are not some toilets were never installed; and there is visible committed to stopping open defecation, and have not evidence of continuing open defecation. made any major changes in their hygiene behavior. Sanitation promotion and demand There is clearly a lack of community involvement and an The UNO reports that US$ 6,800 were collected through absence of hygiene promotion in the process. In many the savings schemes, funding toilets for about 2,000 cases, the local government has coerced the rural low-income households. This approach helped to cover population into building toilets, whether people want them the last five percent of the Upazila population, but there or not. As a result, many of the households feel little are suggestions that many of these poor households ownership for their toilets, have little interest in using or were forced to become involved in the savings maintaining them, and are unaware of the impact of their schemes. In Baruapara, several poor women commented current hygiene practices on public health. Typical Toilet Components and Cost Item Description Cost Platform Cement slab and pan (RSM) US$ 2 Pit lining 1 x concrete ring (RSM) US$ 0.8 Bamboo casing US$ 0 Enclosure Home-made (thatch, jute) US$ 0 Total cost US$ 2.8 72 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Technical sustainability Upazila: community and religious leaders were organized The toilet model promoted is a low-cost (US$ 2.90) and to apply pressure to resistant households; school appropriate technology that is simple to install and easy to teachers, Union councillors, and Upazila officials relocate once the (single) pit is full. Most households conducted weekly monitoring; and the UNO and his DPHE manage to install the toilet themselves and report few engineers made regular visits to sites of open defecation technical problems, thus removing the need for trained and to problem villages. The unusually high intensity and masons or for technical assistance. effectiveness of this resource use would not have been possible without the high priority and constant monitoring Despite the fairly standard pit size adopted (minimum five afforded to the project by the UNO. feet deep), there were reports of pits filling in only six to 12 months. However, this did not appear to be a problem, Financial sustainability with several households stating that they had already dug The project has been very cost-effective, in that it used no new pits and relocated their toilets several times in the two additional government funds and provided no toilet years since the original construction. subsidy. However, there can be no doubt that this sort of intensive campaign cannot be run on a continuous basis Evidence of easily broken cement toilet pans suggests that without detracting from the other duties and some of the RSM components are badly designed, or not responsibilities of local government. The project manufactured to a high enough quality. Initially, there was was also lucky to attract significant UNICEF support, little alternative to the toilet components supplied by the including US$ 6,000 to establish four mobile production government-controlled RSMs, but there are now centers and operate them for two years. The cessation of several private production centers operating, which this funding has resulted in the closure of these should provide purchasers with more choice and production centers. As a result, the Upazila government more accountability. has encouraged private producers and an NGO to meet any future demands. Social sustainability A recent government survey classed 55 percent of Environmental sustainability households in Rajarhat Upazila as landless (that is, do not When properly used and maintained, the toilets own any agricultural land). Many of these households installed under this project should create few own only the land that their houses are built on, and environmental problems. However, there is evidence sub-division of this land between children often leaves that some of the users are not aware of the difference these plots cramped and inadequate. When combined between safe and unsafe excreta disposal, and that with an above average population density, as in Rajarhat others are abandoning their toilets and returning to open (population density = 1,169 per sq km), this leaves little defecation. Regular follow-up and monitoring is space in which the poor and the landless can construct required to ensure sustainable improvements to their toilets. environmental health. Local government officials address this problem by trying Scaling-up to persuade the larger landowners to donate suitable plots The Rajarhat sanitation project is completely independent, to the poor, but this process is difficult and can take with no special funding or support from government. No considerable hard work and mediation skills. regular monitoring of the sanitation project takes place at the district level, and none of the other Upazilas in the Institutional sustainability district are implementing similar projects, despite the This sanitation project has been driven by the enthusiasm positive demonstration effect. This suggests that the and commitment of the UNO. It has made great strides approach is entirely dependent on the UNO, and would using only the resources already available within the not be replicable in his absence. 73 The Rajarhat sanitation project managed to achieve almost universal toilet coverage for 36,000 households in only two years. Conclusion Key features The Rajarhat sanitation project managed to achieve almost nImplemented by a network of 635 partner NGOs; universal toilet coverage for 36,000 households in only nSanitation projects completed in 1,200 villages; two years. This is a commendable achievement, not least n900 toilet production centers; because, by implementing toilets in every household of an nSupply-driven approach (little technology choice); and entire sub-district without any hardware subsidy, it has nLimited local government involvement. demonstrated that even the poorest of the poor can afford low-cost toilets. However, the findings of this brief Approach appraisal suggest that toilet usage is already declining Since 1999, NGO Forum has been promoting an rapidly, and that the apparent success of near universal integrated WATSAN approach, with the objective of sanitation coverage will not be sustained and will not bring achieving 100 percent water supply and sanitation the expected public health benefits. coverage in a particular village over a two-year period. This approach combines provision of both hardware More detailed evaluation is required, but it seems likely (tubewells, rainwater harvesting structures, arsenic-iron that the high coverage has been achieved by an overly removal plants, sanitary toilets) and software coercive approach, which is strongly dependent on the (training, IEC materials, promotional activities). NGO direct involvement and commitment of the UNO. Forum found this approach effective, but it results Sadly, it looks as if this project, which was originally in a relatively slow increase in sanitation coverage, based on the Patgram pilot project, will end up in a similar and often struggles to reach the last 10-20 percent of state ­ with half the toilets abandoned and widespread the community. open defecation.6 Following general consensus on the effectiveness and Case Study 2: NGO Forum speed of the community-led total sanitation approach (Dinajpur program) developed by the NGO VERC and WaterAid Bangladesh, This is an NGO model, designed and supervised by the which demonstrated that villages can achieve universal NGO Forum for Drinking Water Supply & Sanitation. NGO access to sanitation without external subsidies, NGO Forum is a national NGO, which implements water and Forum decided to change its approach. Most of the sanitation programs through its network of partner NGOs have now been trained in the `ignition 635 partner NGOs. Sanitation is a high priority for process' (see Annex 1) and are using the zero-subsidy NGO Forum, and its hygiene promotion and sanitation approach in their sanitation projects. programs now consume more than 50 percent of its US$ 2.5 million annual budget. The target communities are selected by the partner NGO, with a focus on underserved and unserved villages. NGO Forum is an apex body, run through 14 regional Numerous IEC and hygiene promotion activities (courtyard offices around the country. The Dinajpur office covers meetings, processions, training) are conducted, using four districts and works with 20 active partner NGOs,7 community leaders, Imams (religious leaders), and each of which starts a two-year sanitation project members of the village development committee to spread in one village every year. This case study is based on the messages and reach reluctant households. the work of one of those partner NGOs (Uddog) in two Upazilas (Chirirbandar and Sadar) of The NGO then establishes a mobile production center in Dinajpur district. the village, which manufactures concrete toilet platforms 6The 2003 baseline survey shows that previously universal sanitation coverage in Patgram Upazila has now declined to 51 percent coverage; see also Dasgupta (2001). 7The Dinajpur office has another 20 partner NGOs that help to monitor progress. 74 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia and rings. Previously, cement pans were installed on the approach. NGO Forum has also established 900 toilet platforms, but NGO Forum now promotes plastic production centers8around the country, and its toilet pans, p-bends, and pipework, all of which are 635 partner NGOs begin work in another 635 villages supplied to the village by the partner NGO. each year. The village development committee undertakes community Since 1999, the Dinajpur regional office and its 20 monitoring of the sanitation project, with quarterly follow- partner NGOs have completed sanitation projects in more up visits from NGO Forum regional staff during the first than 80 villages. Sanitation coverage in these villages is year after completion. NGO Forum also has a central generally high, but toilet usage and sustainability appear monitoring cell in Dhaka, which collates information on the less good, particularly in those villages completed under progress and performance of the sanitation program. the old approach. Local government involvement is limited, apart from Sanitation promotion and demand attendance at district coordination meetings and informal Kornai village (Sadar Upazila) was declared fully sanitized discussions with Upazila Nirbahi Officers to resolve two years ago, but a brief survey suggests that only 50 any problems with local government officials. However, percent of the households are currently using sanitary the NGO Forum regional office reports that it is toilets. The remainder have either abandoned their toilets, planning to increase links between partner NGOs or have failed to maintain them in a sanitary condition and Union Parishads. (toilet pans were blocked or broken). Performance In Kismotboypara (Chirirbandar Upazila), the sanitation Nationally, NGO Forum report 1,260 villages (spread over project is ongoing. Lots of new toilets with plastic pans eight districts) fully sanitized using the total sanitation are evident, but several households have not bothered to install toilet components donated by the village Institutional model development committee, and others are reluctant to use the new toilets despite recent behavior changes by others in the village. International NGO Forum Local donors District donors Head Office Government (DANIDA, (Dhaka) Reaching the poorest remains a challenge. Several UNICEF, approaches have been tried: households are encouraged CAFOD, SCF) to share toilets with their poorer neighbors; the Partner NGO Upazila (Uddog) Government partner NGO provides loans; and some of the poorest households have had their toilets donated by the village NGO Union development committee or the Union Parishad. But toilet community Parishad usage remains low among these groups, and among male fieldworker household members. Technical sustainability Production Village The mobile production center approach, whereby a Center Development (temporary) Committee mason manufactures toilet platforms and concrete rings in the village and the partner NGO supplies the plastic pans and pipework, provides few technical options to Household the households building the toilets. The main deviation 8540 production centers run by partner NGOs and 360 run by private producers. 75 Many of the men from poor households leave for the fields early every morning, and do not return until late at night. As a result, they were unable to attend most of the hygiene promotion and IEC activities. Social sustainability One of the partner NGOs highlighted the difficulties associated with providing hygiene education to the men of the village. Many of the men from poor households leave for the fields early every morning, and do not return until late at night. As a result, they were unable to attend most of the hygiene promotion and IEC activities. The NGO resolved the problem by visiting the village very early, before the men left for the fields. However, it is clear that reaching this group, which is the most resistant to changing its hygiene behavior, remains a difficult task. Institutional sustainability Support from NGO Forum, including training and limited financial assistance, raises the profile of these partner NGOs and allows them have some say in local development forums. But there are few linkages to local from the typical low-cost toilet model is the government, or to other development processes. use of a number of concrete rings to line the single This allows the partner NGO little authority to enforce leach pit. bans on open defecation, or persuade reluctant households to improve their hygiene behavior or The older toilet models used cement pans, which appear invest in sanitation facilities. to break easily, and were rarely repaired or replaced. One recent immigrant in Kornai village had bought a new Each village sanitation project has a two-year cycle, after toilet from another local NGO, but several other which the partner NGO moves on to work in a new village. households had no toilet, or a toilet with a broken pan, The limited staff and resources of these small NGOs make were unsure how to go about repairing their toilets. it very difficult for them to monitor toilet usage or carry out Typical Toilet Components and Cost Item Description Cost Pan and trap Plastic (NGO) US$ 0.8 Floor slab Concrete (RSM) US$ 2.5 Connection Pipework (offset) US$ 0.8 Pit lining Concrete ring (RSM) US$ 3.3 Mason Installation and transport US$ 0 Enclosure Home-made (thatch, jute) US$ 0 Total cost US$ 7.4 76 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia follow-up visits to villages in which the two-year project necessary for structural reasons, means that most cycle has been completed. households are unwilling to construct a second pit. As a result, the partner NGOs recommend that local sweepers Financial sustainability (sanitary workers) should be paid to empty the leach pits The NGO Forum model relies on donor funding, from when they become full. This process involves digging international donors for its own operations, and from local another pit nearby, then re-filling it with the pathogenic donors for its partner NGOs. The strength of the model is solids from the leach pit, before sealing it with soil (at least the resource leverage achieved by NGO Forum, which uses a foot deep) into which a tree is planted. its relatively small budget to access much larger aggregate funds from its 635 partner NGOs. In return for technical Scaling-up support and political access, these partners utilize their Despite its huge NGO network, the NGO Forum has local donor funds to implement NGO Forum designed managed to cover only 1,200 villages in the last three sanitation programs. But it is not clear exactly how large years. This is a remarkable achievement, involving the these local funds are, or how much is spent on sanitation construction of sanitation facilities by many thousands of promotion by NGO Forum and its partners. households, but it still represents less than a one percent increase in national sanitation coverage. NGO-Forum report average software costs of only US$ 0.30 per household toilet, but this seems very low The NGO Forum network has been growing steadily, but considering the lengthy process involved. Assuming that now includes most of the rural NGOs with suitable 635 villages per year are covered, this software cost water supply or sanitation experience, making further equates to an annual expenditure of less than US$ increases in the size and scope of the network difficult. In 16,949.15,9 compared to an actual sanitation budget of addition, few of these partner NGOs have the capacity to US$ 1,406,779.6 per year. implement more than one village sanitation project annually, despite the training and support that they receive Given that this is a zero subsidy sanitation program, from NGO Forum. software and program costs will consume the majority of the funds available. An earlier case study (WSP, 2003a) Conclusion suggests that a Union-level NGO Forum program may The NGO Forum total sanitation approach has achieved spend US$ 5.10 per household, of which about 30 percent rapid increases in toilet coverage, but has yet to prove is spent on software (IEC materials, follow-up meetings, that its projects achieve regular toilet usage or sustainable training, and exposure visits) and the remaining 70 percent public health benefits. The approach remains supply- pays for basic program costs (salaries and logistics over driven, with little room for low-income communities the two-year project period). However, even these costs to develop their own toilet models or to choose exclude the inevitably high management costs and alternative designs. overheads associated with running 14 program Evidence of declining usage, and an inability to reach the offices and monitoring the activities of such a large last five percent of households, suggests that the national network. approach needs modification. NGO Forum admits that it Environmental sustainability has been slow to adopt new approaches, and is now in the The vast majority of the toilets installed under NGO Forum process of making its programs more participatory and sanitation projects have a single offset leach pit, which is demand-responsive, with assistance from VERC and often lined with concrete rings. The relatively high cost of WaterAid Bangladesh. But there are also other more the concrete rings, and the perception that the rings are structural problems. The current institutional model does 9US$ 0.27 x 635 villages x 75 households = US$ 12,858.75. 77 The Plan approach does not impose any particular toilet design on the community, although it does encourage the use of local materials and the construction of very low-cost designs. not provide for a sustained relationship with communities subsidy, and a participatory approach it calls `Child- after the sanitation project is finished. There is little centered Community Development' (CCCD). However, monitoring of long-term performance and inadequate even with these changes, toilet usage remained low and identification of weaknesses in the approach, with hygiene behavior change was elusive. few follow-up visits to support the village development In 2002, Plan turned to VERC for assistance and guidance. committee and scant effort to promote improved This collaboration led to a more software-oriented hygiene behavior. approach, which has a focus on stopping open defecation, The NGO Forum is a national body, and thus must address using the zero subsidy `ignition process' developed by national-level development challenges, but it is currently VERC and WaterAid (see box in NGO Forum case study), constrained by the limited size and capacity of its while embracing Plan's own woman and child-centered network of partner NGOs, and by its failure to utilize the approach. Pilot projects proved successful, with every resources of government to expand and institutionalize its community achieving 100 percent sanitation coverage sanitation program. within a year, and the total sanitation approach is now being used in all of Plan's sanitation programs. Case study 3: Plan Bangladesh (Chirirbandar program) The Plan approach does not impose any particular toilet The Plan Bangladesh sanitation program is relatively small, design on the community, although it does encourage the but uses a highly effective approach, and is in the process use of local materials and the construction of very low- of scaling up into a much larger program. At present, cost designs. Plan has begun promoting plastic toilet the Plan sanitation program operates in more than pans, but a range of other designs, from home-made sheet 100 villages spread over five Upazilas (sub-districts), metal pans to shop-bought ceramic pans, can be found in four of which are located in the northern districts. most program villages. Plan has been working in Chirirbandar and Khansama Upazilas (Dinajpur district) since 1994, but has only been using a total sanitation approach for the last two years. Like NGO Forum, the Plan field offices work closely with local partner NGOs, but Plan also employs its own facilitators to implement its sanitation program. Key features nUse of participatory `ignition process'; nVery low-cost toilet designs (less than US$ 1); nChild-centered community development; nFocus on small, progressive communities; nGood links with local government; and nApproach unproven at scale. Approach Until 1998, Plan Bangladesh provided free toilets through Social intermediation and IEC are carried out by Plan's its community development programs. Each of these field staff and by its partner NGOs. The participatory toilets cost US$ 50, but program evaluations revealed that ignition process is reinforced with exposure visits to less than 20 percent of them were being properly used. fully sanitized local villages, which also provides the Plan decided to revise its programs, adopting a lower participants with practical models for their toilet designs. 78 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia During the process, the community establishes a surrounding villages, toilet usage is relatively high, and monitoring committee, whose members check defecation there is evidence of improved hygiene behavior (for sites on a regular basis. The children of the village are example, basic handwashing facilities). also involved, as they often prove to be active and unembarrassed identifiers of those who continue with It is also clear that Plan has developed a good relationship open defecation. with the local government. The chief administrators (UNOs) of the Chirirbandar and Khansama Upazilas are Plan coordinates its sanitation programs with the Upazila keen to link government efforts with the Plan programs. government, and has supported workshops in 18 districts Plan also assisted the local government to complete new to develop a common understanding of approaches and baseline surveys in the 18 Union Parishads in which it is objectives. The Upazila Task Force brings together key currently working, helping to lower official coverage stakeholders from government and NGOs on a monthly figures from 42 percent to a more realistic 25 percent. basis, and is the main forum for planning and coordinating Sanitation promotion and demand sanitation programs. Toilet coverage and usage are generally high, with the new Institutional model total sanitation approach clearly more effective than previous approaches. However, toilet usage is already declining in villages declared fully sanitized only International Plan District 18 months ago, confirming the importance of constant donors Bangladesh Government Head Office monitoring and regular follow-up visits. (Dhaka) It was also apparent that some groups within the village are harder to reach than others. In several cases, one Plan field office Upazila Task Upazila (Chirirbandar) Force Government section of a village proved reluctant (or disinterested) in the sanitation program and, despite the best efforts of the village sanitation committee, quickly abandoned their Union Plan facilitator toilets and returned to open defecation once full coverage Parishad was proclaimed and the attention of NGOs and local authorities moved elsewhere. Partner NGO Village Development Committee Household Performance Very few villages have been completed under the new approach, with only three fully sanitized villages achieved so far in Chirirbandar and Khansama Upazilas. Further, most of these villages (paras) are very small, often containing less than 50 households. However, the results in these few villages are encouraging. Signs of open defecation are much less common than in 79 One of the key factors in the success of the Plan program has been the willingness to allow rural communities to utilize innovative local sanitation technologies that engineers normally frown upon. Most toilets were sanitary and contained some handwashing facilities, although usually no more than a coconut shell full of ash. But many of the owners of these apparently home-made toilets had little idea how their toilet worked, or of the importance of keeping the excreta sealed and isolated. In one village, every toilet ventilation pipe had been screened using scraps of the same pink cloth (to prevent insects from entering the pit and spreading fecal contamination). It transpired that these home-made insect screens had been added recently by the partner NGO, without the knowledge of many of the toilet Credit: WaterAid Bangladesh owners, who proceeded to remove the cloths when asked about their purpose. locally available materials are used) to US$ 0.93 (to purchase a plastic pan and pipe). The durability of these Technical sustainability very low-cost toilets is uncertain. One of the key factors in the success of the Plan program has been the willingness to allow rural communities to Some engineers argue that, while the use of more durable utilize innovative local sanitation technologies that materials may make the toilet three times as expensive, it engineers normally frown upon. In particular, many of the will function better and last at least three times as long. toilets installed do not have a water-seal toilet pan, which In Chirirbandar, where the toilets are in demand and have is usually considered essential among societies that use been constructed from freely available local materials, such water for anal cleansing. as bamboo and mud, it appears that basic repairs are easily and regularly made, in much the same way that many poor A typical toilet design has a home-made sheet metal pan, rural households make seasonal repairs and improvements with bricks for footrests and a mud floor. It flushes to their houses. However, there was little evidence of through a self-closing seal (made from plastic sheets) into spontaneous upgrading or rebuilding, with several a wicker-lined leach pit, and uses a bamboo ventilation households found to abandon their toilets as soon as any pipe (with a cloth insect screen) to reduce fly and odor serious blockage or damage occurred. problems. Toilet enclosures are almost always home-made, using bamboo poles and thatch or matting. The cheapest Social sustainability of these toilets range in cost from US$ 0 (when only Three of the households in Isamoti village (Chirirbandar Typical Toilet Components and Cost Item Description Cost Pan and pipe Plastic (NGO) US$ 0.93 Floor slab Home-made (mud/bamboo) US$ 0 Pit lining Bamboo wicker frame US$ 0 Enclosure Home-made (thatch, jute) US$ 0 Total cost US$ 0.93 80 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Upazila) had not built toilets, but were reported to be using approaches and programs promoted by NGOs such as nearby toilets owned by the family's relatives. Plan, but it seems likely that most of it will be used to fund toilet subsidies for poor and vulnerable households, thus The ban on open defecation in the village, and its disrupting and threatening the sustainability of zero enforcement by the monitoring committee, has forced subsidy total sanitation programs. these households to change their hygiene behavior, even though they are not yet ready to construct their own Environmental sustainability toilets. This approach appears to work well in small Most toilets installed under the Plan sanitation program cohesive communities, but may not prove viable in larger have a single offset leach pit. Little attention has been communities with weaker social networks. given to what will happen when these single leach pits fill. Toilet users in Chirirbandar Upazila intend to pay local Institutional sustainability sweepers (sanitary workers) to empty their leach pits. Despite strengthening links with local government, This process involves digging another pit nearby, then Plan's sanitation program is currently separate and transferring the solids from the leach pit, before sealing dependent on its donor-funding, with no indication that the pathogenic contents with a soil layer (at least a foot local government is prepared to involve Plan directly in any deep) into which a tree is planted. government programs. Plan is attempting to use its influence to improve the sanitation policy and practice of Scaling-up local government, but the Department of Public Health Plan is in the process of scaling-up its sanitation program. Engineering (DPHE) is resistant to the involvement of It is investing US$ 760,000 in a new program that will NGOs in implementation, and continues to promote its involve 60 Union-level facilitators and five Upazila government-run production centers. coordinators, with additional financial and policy support from the Water and Sanitation Program (WSP). The There is little systematic monitoring of performance or objective of this program is to achieve full sanitation progress by either Plan or the local government. Financial coverage in five Upazilas by mid-2007, as requested by expenditure is monitored by Plan's head office in Dhaka, the Government of Bangladesh as part of its drive to reach but the current institutional model does not provide for universal sanitation coverage by 2010. long-term monitoring of sanitation coverage, open defecation (or its proxy ­ toilet usage) or hygiene behavior. This increase in scale is already proving challenging, with evidence that key stakeholders have not reached Financial sustainability consensus on policy and practice. Despite the The Plan total sanitation approach is intensive and highly convergence in thinking achieved at SACOSAN, many participatory, requiring well-trained facilitators and government officials (and some NGOs) remain convinced multiple village visits. Software costs are high. An earlier that toilet subsidies are the only way to provide sanitation case study suggests software costs of US$ 5.40 per coverage to landless or extremely poor households. NGOs household10 without taking into account the program such as Plan can retain their unique approaches while costs and overheads at the regional and national levels. working in small, well-defined geographical areas, but this Plan can sustain the sanitation program at its current level, difference in understanding and approach becomes but does not have the resources to fund this sort of problematic when programs are scaled-up. program across all 64 districts. There is also concern about the limited spread effect The 20 percent of ADP budget allocated to sanitation from fully sanitized villages. The Plan approach could be used to reinforce and expand the new assumes that communities will solve their own 10WSP (2003b). 81 The initial outcomes of Plan's new sanitation program are encouraging. The approach uses current best practice, and appears to produce high sanitation coverage and toilet usage. But the starting conditions have been favorable. sanitation problems once confronted with them and government in its program, and to coordinate the planning made aware of affordable and appropriate solutions. of its scaled-up program with national and regional But there is little sign of this effect in the villages that bodies. But the starting conditions have been favorable. surround Plan's success stories, despite efforts to To date, Plan has implemented its sanitation program in encourage community-to-community learning. very small and cohesive villages, many of which are progressive communities with above average literacy, Plan would like to invest in capacity building within the and a long history of community development and Upazila Parishad (sub-district government), so that the cooperation with NGOs. local government can assume a larger role in the facilitation and monitoring of its sanitation programs. However, even under these conditions, there is evidence of But this investment seems of limited value until the declining toilet usage, and of failures to monitor or follow- national government rationalizes its sanitation policy and up effectively after achieving full coverage. provides some direction and coordination to existing Stopping open defecation in larger areas (Upazilas or sanitation programs. districts) will stretch Plan's resources and force it to tackle Conclusion more reluctant communities and more difficult physical The initial outcomes of Plan's new sanitation program are conditions. The current approach may work, but it seems encouraging. The approach uses current best practice, and likely that it will require better facilitation, more sustainable appears to produce high sanitation coverage and toilet monitoring and follow-up mechanisms, and far greater usage. Plan has also made efforts to involve the local cooperation and coordination with local government. 82 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Annex 3 Case Studies from India 83 YTC 84 Lessons Learned from Bangladesh, India, and Pakistan Annex 3 Scaling-Up Rural Sanitation in South Asia Case Studies from India In 1999, the Government of India introduced the Total nFive percent on start-up activities (baseline survey, Sanitation Campaign (TSC) alongside the long-running project preparation, awareness raising); Central Rural Sanitation Program (CRSP). The TSC was to nFifteen percent on IEC activities (demand creation); be more demand-responsive, using IEC (Information, nFive percent on rural sanitary marts and production Education & Communication) to stimulate demand, while centers (supply of toilet components); also promoting low-cost technologies and alternative nSixty percent on subsidies for individual household delivery mechanisms. The supply-driven CRSP was toilets and community sanitary complexes; completely phased out by March 2002, leaving the TSC as nTen percent on school and anganwadi (nursery) the main government program for rural sanitation. sanitation facilities and hygiene education; and nFive percent on project administrative charges (training, The most remarkable thing about the Total Sanitation overheads, monitoring, and evaluation). Campaign is the amount of money involved. The total planned outlay of the TSC is US$ 810 million, including as The TSC provides a subsidy of US$ 11 for the much as US$ 4 million per district in the more populous construction of individual household toilets,12but only to states. However, the TSC is not entirely publicly financed, those officially recognized as below poverty line as 19 percent of the planned expenditure will be from self- (BPL) households. This subsidy is considerably lower provision by the rural households that build toilets as a than the US$ 32-54 that used to be offered under the result of the TSC. CRSP, thus is expected to cover only the cost of the essential below-ground components of the toilet In part, this enormous investment reflects the huge rural (leach pit, cover slab, toilet pan) with the user population in India without access to sanitation. But the household responsible for providing a suitable toilet TSC budget is some 20 times larger than the equivalent enclosure (superstructure). national program in Bangladesh, whereas the unserved population in India (755 million) remains only 10 times The revised TSC guidelines (issued in January 2004) higher than that in Bangladesh (71 million) or Pakistan include several additions that directly reflect the (55 million). The size of the TSC reflects both the buoyant approaches adopted in Maharashtra (see Case Study 5 economy in India and a continuing preference for large- below). The old guidelines noted that `subsidy for scale government interventions. individual household latrines has been reduced' whereas the new guidelines state that `subsidy for individual The huge resources allocated to the TSC allow it to household latrine units has been replaced by incentive to dominate the Indian sanitation sector, both in terms of the poorest of the poor households' and adds: policy and implementation. The appeal of this large and lavishly-funded program is so great that some NGOs have `The construction of household latrines should be even dropped donor-funded sanitation programs in order undertaken by the BPL household itself and on to take part in local TSC projects. completion and use of the latrine by the BPL household, the cash incentive can be given to the The TSC is implemented through four-year-long BPL household in recognition of its achievement.' district projects, based on proposals prepared by district p.8 GoI (2004) governments in accordance with strict central guidelines. TSC project funding is split between six The new guidelines also formalize the Nirmal Gram Puraskar main components:11 (see box), a community-level financial incentive intended to 11Some components have funding ceilings: US$ 43,500 for start-up activities; US$ 76,000 for rural sanitary marts; and US$ 87,000 for administrative charges. 12US$ 8.15 fixed contribution from the Government of India; US$ 2.70 minimum contribution from the State Government. 85 The ban on dry toilets will limit options in drought-affected areas, where pour flush toilets are often abandoned because of their water requirements, and may also limit the promotion of the lower cost technologies that are likely to be attractive to poor households. Nirmal Gram Puraskar In October 2003, the Government of India announced the Nirmal Gram Puraskar, an award for administrative units (Gram Panchayats, blocks, and districts) that achieve 100 percent sanitation coverage, which has been defined as: n100 percent toilet coverage of individual households; n100 percent school toilet coverage; and nFree from open defecation. The Nirmal Gram Puraskar will be awarded to Gram Panchayats, blocks, districts, and any individuals or organizations that have been the driving force for effecting full sanitation coverage in the respective geographical areas. The Nirmal Gram Puraskar will be a minimum of: nUS$ 225 for individuals; nUS$ 450 for organizations; nUS$ 4,500 for Gram Panchayats; nUS$ 22,250 for blocks; and nUS$ 67,750 for districts. These awards should be used for improving and maintaining sanitation facilities, with a focus on solid and liquid waste disposal, drainage facilities, and maintenance of the sanitation standard in the relevant area. The State Government will identify and select Gram Panchayats, blocks, and districts that are fully covered and conform to the eligibility criteria. The Government of India will then engage independent evaluator(s) to confirm full sanitation coverage. Annually, a National Committee on Nirmal Gram Puraskar will draw up a list of those awarded the Puraskar. Adapted from GoI, 2004 reward the achievement of `fully sanitized and open States. Some State Governments disagree with the lower defecation free Gram Panchayats, blocks, and districts'. subsidy advocated by the TSC, thus have decided to provide larger hardware subsidies from their own funds. The new TSC guidelines include regulation against `dry' And some districts have been slow to prepare project toilets,13 stating that: proposals and begin implementation. `Construction of dry latrines is not permitted in the The following case studies examine four different rural areas. The existing dry latrines, if any, should be approaches to the Total Sanitation Campaign in India: converted to pour flush latrines.' p.8 ibid. Case study 4: West Bengal TSC This new policy is controversial. The ban on dry toilets will Case study 5: Ahmednagar Pilot, Maharashtra TSC limit options in drought-affected areas, where pour flush Case study 6: Andhra Pradesh TSC toilets are often abandoned because of their water Case study 7: Gramalaya sanitation program, requirements, and may also limit the promotion of the Tamil Nadu TSC lower cost technologies that are likely to be attractive to Case study 4: West Bengal (India) poor households. Total Sanitation Campaign While the TSC is a national program, largely funded by the This case study examines the unique approach to the Government of India, the uptake rate and approach Total Sanitation Campaign (TSC) adopted by the adopted varies considerably both between and within Government of West Bengal. Rural sanitation has long 13Non-flush toilets (that is, toilets without water seal pans) such as simple or ventilated pit latrines. 86 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia been a priority of the Government of West Bengal. When the Intensive Sanitation Program was launched in 1990, sanitation coverage in Medinipur District was barely five percent. Today, in what was the largest district in India (now split into two districts: East Medinipur and West Medinipur), the provision of more than 900,000 toilets has raised sanitation coverage to 60 percent. In 2001, Medinipur had the distinction of being the first district in the country to achieve 100 percent sanitation coverage in an entire block: namely, Nandigram II (population 104,600). These successes have led to global recognition of the Medinipur approach, thus it is no surprise that it has become the model for all subsequent sanitation activities in the State. Key features nBuilt on the success of the Medinipur Intensive Sanitation Program; nImplemented by local government through 322 NGO- run RSMs; nActive State sanitation cell (UNICEF-funded); reflected in strong local government institutions and their nUS$ 8.30 low-cost toilet design; commitment to provide basic services to the poor. This nUS$ 4.40 discount for BPL families; has allowed the sanitation campaign to involve people nToilet enclosure built by users (home-made); from all walks of life, and cut through political divides. n850,000 toilets constructed in 2002/03; and The government has also forged long-term partnerships n41 percent sanitation coverage in West Bengal. with UNICEF, and with an influential local NGO, the Ram Krishna Mission Lok Shikshya Parishad (RKM), both of General context whom deserve considerable credit for the sanitation West Bengal has a long history of socialist government, successes in Medinipur district. These enabling factors Case Study Data Population Unit Name Literacy Sanitation Total Rural Coverage District 1 Medinipur East 4.5 million ­ 69% 87% District 2 Medinipur West 5.3 million ­ ­ 39% State West Bengal 68.1 million 72% 58% 41% Country India 1,048 million 72% 56% 28% Source: WDR 2004; SIPRD 2003; Census of India 1991 87 Rural sanitation coverage in West Bengal is now significantly higher than in the rest of India, but the sanitation facilities remain concentrated in a handful of the 18 districts. West Bengal TSC 900,000 n Other 12 Districts 800,000 n North 24 Parganas n Howrah Mushidabad 700,000 n year) n West Medinipur n East Medinipur (per 600,000 n Burdwan 500,000 constructed 400,000 oiletsT 300,000 200,000 100,000 0 99/99 99/00 00/01 01/02 02/03 Source: SIPRD 2003 have combined to raise the profile of sanitation in West Two million toilets have been constructed in the last five Bengal, and to create unusually high political support and years, bringing State sanitation coverage up to 41 percent priority for investments in rural sanitation. (from 12 percent in 1991). Fourteen blocks now claim 100 percent sanitation coverage,14and progress is West Bengal has a high population density (765 people per beginning to be made in several previously non- sq km) and a reducing number of sites for open defecation. performing districts. It also has above average literacy rates, and a good record of community organization. These factors may contribute Monitoring of sanitation coverage is becoming more to above average: demand for sanitation; awareness of effective, with weekly progress updates being made by the health risks; and response to sanitation interventions. districts and reviewed at State level. Sanitation coverage This process is allowing State institutions to identify and Sanitation coverage is increasing rapidly in West Bengal. target weaknesses (such as non-performing districts). 14Verified in four blocks (Haldia, Nandigram II, Raina I and II) and claimed in a further 10 blocks (Ausgram I, Bally-Jagachha, Barrackpore II, Dantan II, Hasnabad, Mahisadal, Mohanpur, Nandakumar, Sankrail, and Sutahata). 88 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Case study context The State Sanitation Cell (housed in the State Institute This case study is based on: documentation collected by of Panchayats and Rural Development) provides WSP; interviews with key informants in Kolkata, and at the coordination, reporting, and technical advice. This State Institute of Panchayats and Rural Development allows the Department of Panchayats and Rural (SIPRD) in Kalyani; and visits to five villages in two Development (PRD) to focus on policy, funding districts (East Medinipur and West Medinipur). allocations, and overall monitoring. Rural sanitation coverage in West Bengal is now Institutional model significantly higher than in the rest of India, but the sanitation facilities remain concentrated in a handful of the 18 districts. Before 2001, the only districts making Government of UNICEF India progress were Medinipur (East and West) and Howrah. RGNDWM However, since the Total Sanitation Campaign (TSC) Total Sanitation Campaign started, three other districts (Burdwan, Murshidabad, North 24 Parganas) have rapidly accelerated their Government sanitation programs. of West Bengal Approach Local government officials and NGOs promote a standard low-cost latrine slab (including a cement mosaic pan and a Panchayat District District pour-flush water trap). In most cases, a single, unlined pit SIPRD Rural Administration Government is covered with a latrine slab, around which the users build Development District Zila Parishad Department Magistrate an appropriate enclosure. A network of Rural Sanitary Marts (RSM) manufactures the Block Block latrine slabs, and employs village-level motivators (on Administration Government commission of US$ 0.43 per toilet) to promote toilet usage Block Panchayat Development Samiti and collect up-front payments for RSM-supplied toilets. Officer After receiving full payment (US$ 3.77 from BPL families; US$ 8.09 from others), the RSM sends a mason to deliver NGO Local the materials and install the latrine slab. Rural Sanitary Government Mart Gram Panchayat The RSM then gets the Gram Panchayat to certify the number of discounted toilets installed by BPL families, and uses this certification to claim back the government NGO Household RSM motivator subsidy (US$ 4.31 per BPL family) from the block- level authorities (Block Development Officer and Toilet usage Panchayat Samiti). The rapid appraisal conducted for this study suggests that District authorities (District Magistrate and Zila Parishad) usage is high in villages that have reached 100 percent manage the local programs ­ providing funds to coverage. Most of the toilets appear to be in regular establish RSMs; involving government officials within use, with soap and water available within the toilet the district in sanitation and hygiene promotion activities; enclosure. In half of the cases, the users state that their disbursing subsidies; and monitoring progress latrine pits have already filled, and that they have relocated (financial and physical). their toilets by digging new pits and moving their 89 Landless households, and households living in congested villages, have great difficulty in finding a suitable location for their toilets. understanding of the importance of stopping open defecation; encouraging behavior change; focusing on toilet usage (rather than construction); and on wider environmental sanitation issues (drainage, solid waste disposal, and so on). However, it is less clear whether these messages have reached those without sanitation, or whether these messages are effective in stimulating demand for sanitation. Anecdotal evidence from the study suggests that toilet users from BPL households are aware of fecal- oral disease transmission, and of the benefits of handwashing, but that health and hygiene benefits are not Sign at ration shop: Rs 200 fine for open defecation strong factors in the decision to build a toilet. latrine slabs. In some of the areas visited, enthusiastic The main factors driving increases in sanitation coverage government officials organize patrols of well-known in West Bengal appear to be effective toilet promotion by defecation sites to enforce toilet usage. However, this NGO motivators; and pressure from government officials practice is occasional, usually linked to intensive to construct toilets. As sanitation coverage increases, so efforts to achieve full coverage, and there is little evidence does the challenge of motivating disinterested villages and of any formal usage monitoring once 100 percent households to build toilets. In some cases, this had led coverage is attained. those implementing the TSC to adopt innovative (sometimes coercive) approaches, including: In 2002, a detailed assessment of sanitation coverage15 nUS$ 4.31 fine for open defecation; in Nandigram II block (East Medinipur) confirmed that nSigns prohibiting open defecation in villages; sanitation coverage was 100 percent, but found that usage n`Open defecation' patrols by local authorities and was only 85 percent. The majority of the 15 percent still police; and practicing open defecation were reported to be working men. n`Toilet certificate' (from Gram Panchayat) required Demand for sanitation to obtain rations, birth/death certificates, and to apply In the successful districts, there is a good awareness of for bank loans. the benefits of sanitation, and of the political desire to Recent efforts to scale-up the provision of sanitation in increase sanitation coverage. West Bengal have led to a more supply-driven program. Among government and NGO officials, awareness has Enthusiastic officials are striving to meet ambitious been raised by TSC `start-up' activities: conducting coverage targets, such as the achievement of 100 percent baseline surveys; training of resource groups; setting of coverage within their jurisdiction, and this is reflected in block sanitation targets; and monthly review meetings. the more forceful approaches being adopted. NGO motivators, local leaders, and government officials now Substantial investments have been made in IEC talk about collecting (advance) payments for toilets, rather campaigns through different media at both macro (State) than convincing households to invest in toilets. In some and micro (household-to-household) levels. As a result, villages, BPL householders stated that a toilet was not a government and NGO officials display good priority, and that they were forced to make a standard 15Compiled by the Government of India review team (RGNDWM, 2002). 90 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia US$ 3.77 toilet payment in order to receive government surround the latrine slab with a toilet enclosure made from rations or placate a local leader. Toilets are being built, but local materials (sticks, woven palm fronds, jute sacking, many of the new owners are unaware of the TSC, unsure and plastic sheets). The low-cost design has significant of what they have paid for, and have little choice advantages when the pit becomes full. Another pit is dug in the process. nearby, and the latrine slab and enclosure are simply reinstalled above this new pit. Normally, this process does In areas where sanitation coverage has recently increased not require any additional materials, and most households rapidly, it is not yet clear whether the users are genuinely find that they can avoid paying the local mason for this convinced of the benefits of sanitation, or whether the task by moving the latrine slab themselves. poorer households will continue to use their toilets once the attention of local officialdom shifts to other villages. Some public health engineers have suggested that the promotion of toilets without solid-walled enclosures is Technical sustainability likely to undermine the sustainability (and appeal) of There appear to be few technical problems with the simple sanitation facilities. However, an impact assessment of toilet design adopted in West Bengal. Most villages in West rural sanitation in West Bengal16 found that as few as 20 Bengal contain ponds, which provide ready sources of percent households live in pucca (brick or solid-walled) water for toilet flushing. In many areas, favorable soil houses. Many families live in thatched or adobe houses, conditions allow the use of hand-dug leach pits with no and undertake frequent repairs using locally available lining. However, coastal and water-logged areas often housing materials. In West Bengal, the majority of toilet require more expensive lined pits (to avoid collapsing) and users have built kutcha (home-made) toilet enclosures, and more complex designs (to allow leaching), which has led to appear satisfied with their simple toilets even after several reduced sanitation uptake in these areas. The standard years of use. However, this may be related to the toilet pour-flush latrine slab contains a direct (gooseneck) water design adopted, which encourages the user to relocate the trap, which requires no pipework and can be easily toilet once the pit is full (thus discouraging investment in installed above a single pit. In most cases, the users then expensive toilet enclosures that will be difficult to move). Typical Toilet Components and Cost Item Description Cost Pan and trap Mosaic cement (RSM) US$ 1.51 Slab Reinforced concrete (RSM) US$ 4.74 Connection Direct (no pipework) ­ Pit lining None ­ Mason Installation and transport US$ 1.40 Motivator Fee US$ 0.43 Total cost US$ 8.08 16ORG, 2000. 91 As sanitation coverage increases, policy makers and local government officials can shift their attention to developing mechanisms and incentives for monitoring sustainability and effective use. No innovative or non-standard toilet designs were Social sustainability found in West Bengal. In theory, the RSMs promote Landless households, and households living in congested several toilet designs, but in practice almost all of the villages, have great difficulty in finding a suitable location toilets installed have the same below-ground for their toilets. In congested villages in West Bengal, components. The 322 RSMs in West Bengal clusters of individual toilets are often built on the outskirts manufacture cement mosaic latrine pans based on a of the village. Landless households usually have to rely on standard UNICEF design. These cement mosaic pans the benevolence of a local landowner, or seek permission are cheaper than conventional ceramic pans, but are to use communal land. Sanitation coverage is generally not available in local markets, and are more difficult to lower among tribal communities in West Bengal, and it has keep clean than ceramic pans. There are few private been reported that tribal households are often reluctant to suppliers in most areas, thus users are dependent on the install or use toilets. Sanitation coverage in West motivator from their local RSM for access to toilet Medinipur district, which has a high tribal population,17 is components, and for technical assistance. 48 percent lower than in neighboring East Medinipur RSM production data 18,000 n Nandakumar RSM 16,000 14,000 year) 12,000 (per 10,000 sets 8,000 Latrine 6,000 4,000 2,000 0 1998 1999 2000 2001 2002 2003 Note: RSM production was lower in 2000 because it was an election year 17Sankrail Block, West Medinipur: 27 percent Scheduled Tribes; 20 percent Scheduled Castes; 50 percent Other Backward Castes. 92 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia District. This difference in coverage reflects more general can shift their attention to developing mechanisms and development problems, such as the poorer, more remote, incentives for monitoring sustainability and effective use and arid situation in West Medinipur, but also derives from (including indicators such as open defecation, toilet usage, the decision of earlier sanitation programs to focus on the filling of leach pits, handwashing, and improved health `easier-to-cover' East Medinipur population. Interestingly, and hygiene behavior). recent intensive sanitation promotion among tribal groups Rising sanitation coverage is also calling into question the in West Medinipur has led to surprisingly quick uptake, sustainability of some rural sanitary marts. Most RSMs and several tribal communities now have 100 percent received substantial seed money (currently about US$ sanitation coverage (notably Sankrail Block). 5,396.07) and training, either from UNICEF (pre-TSC) or Institutional sustainability from the government. This assistance allowed them to The institutional model for the TSC in West Bengal is invest in the facilities needed to produce the standard TSC dependent on two key elements: local government toilet components. However, most RSMs offer few and RSMs. alternative products, and are starting to find that their income declines as local sanitation coverage approaches RSMs are situated at the block level (322 RSMs serve 341 100 percent. blocks), which makes the Block Development Officer (BDO) During 1998-2002, the Nandakumar RSM (East Medinipur) a key player in the TSC. In the districts visited, active BDOs produced and sold, on average, more than 11,500 latrine have mobilized all the resources at their disposal sets per year. Operated by a local NGO (Tamralipta Guchha (extension officers, PRI officials, teachers, government Samity), the RSM achieved these high sales by supplying vehicles) in intensive sanitation campaigns, and have used latrine sets to intensive sanitation programs in five their influence to motivate and assist the NGOs operating surrounding blocks, through a network of more than 2,000 their local RSM. motivators and 130 masons. Weekly monitoring of the TSC by the District The success of these programs has helped to increase Administration allows benchmarking across the different average sanitation coverage in the five blocks to 87 blocks, which provides recognition and incentive for the percent, with Nandakumar block recently achieving active and successful BDOs. These same BDOs are using universal sanitation coverage. As a result, demand is now the Nirmal Gram Puraskar to motivate the Panchayat easing. In 2003, sales dropped by more than 50 percent, to Samiti and Gram Panchayats within their jurisdiction. about 5,000 sets per year. Pockets of inactivity remain, but improvements in The RSM staff estimate that the five blocks in their service monitoring are beginning to expose these areas of area now contain only 23,000 households without toilets. weakness, and financial incentives to increase sanitation Clearly, the long-term viability of RSMs in this position coverage are providing motivation for previously is uncertain. disinterested government officials. Financial sustainability Unfortunately, both the monitoring and reward systems The low-cost and low subsidy approach results in few focus largely on physical progress (construction of toilets), funding or affordability problems. The provision of a with little emphasis on what happens after 100 percent subsidy lower than that advocated by the TSC frees up the coverage is reached. However, unlike many NGOs and central subsidy funds for use in other areas, such as project implementation units, local government has a additional IEC, sanitation promotion, and capacity building long-term mandate and responsibility for community activities. Meanwhile, the low-cost design means that sanitation services. Therefore, as sanitation coverage most households can afford toilets, despite the provision increases, policy-makers and local government officials of a below-average subsidy. 93 Further efforts are required to tackle the special technical and social problems associated with sanitation facilities in water-logged and water-scarce areas. Initially, the Medinipur Intensive Sanitation Program As discussed earlier, part of the block performance reflects provided no hardware subsidy, and allowed toilet the application and enthusiasm of the BDO. However, purchasers to pay the RSM in instalments. But these SIPRD note that below-average block coverage can also be approaches were dropped within a few years, as it proved the result of a badly-performing RSM. In most areas, the difficult for the RSM to recover the instalments, and there Rama Krishna Mission (RKM) is able to locate a suitable was local resistance to making poor households pay the partner NGO to run the rural sanitary mart, but sometimes full cost of their toilets (when subsidized government the local NGOs selected are ineffective. In this case, it can sanitation programs were running in other areas). be difficult to resolve the problem, especially if local interest groups are reluctant to relinquish their monopoly However, some recent increases in sanitation coverage of the supply of toilets to low-income households. At reflect additional (non-TSC) funding. In West Medinipur, present, there is very little private sector involvement in the the district administrator used discretionary (non-TSC) manufacture and distribution of low-cost toilets, and thus funds to make US$ 2,250 incentive payments to Gram little competition for the 322 established RSMs. Panchayats that achieved 100 percent sanitation coverage (similar concept to the Nirmal Gram Puraskar). In addition, Another constraint to scaling-up is the provision of toilets UNICEF funds the running costs of the State sanitation to groups living under unfavorable conditions, such as cell, which has been instrumental in improving monitoring landless households, extremely poor households, and and identifying weaknesses. those in water-logged or water-scarce areas. In West Bengal, the rising number of blocks with universal Environmental sustainability coverage suggests that communities are finding ways to There appear to be few environmental problems associated resolve the provision of toilets to the landless and extreme with the toilets installed in West Bengal under the TSC. poor (usually through cross-subsidy by the community, or Most toilets have single pits, which are backfilled once full. subsidy by the Gram Panchayat). Exposure visits to There was no evidence that the pit contents are being low-income villages with 100 percent sanitation coverage emptied or re-used. There was some awareness of wider are effective in overcoming persistent claims that these environmental sanitation issues, such as wastewater and landless and extremely poor groups should be provided solid waste disposal, but these activities generally receive with free toilets. However, further efforts are required to little priority. tackle the special technical and social problems Scaling-up associated with sanitation facilities in water-logged and Three broad scenarios are found in West Bengal: mature water-scarce areas. sanitation programs in the two Medinipur districts; In the last four years, more than 30,000 women's self-help recently scaled-up sanitation programs in four or five groups have been formed in West Medinipur. The 300,000 newly active districts; and relatively static sanitation women involved in these savings and micro-credit groups programs in the remainder of the districts. These have good local knowledge and are proving useful as differences generally reflect the interest and priority given voluntary health workers, and as a source of committed to rural sanitation by the respective district authorities. sanitation promoters. Some of the self-help groups have Tighter and more regular monitoring of TSC performance been lending money to their members for the purchase of is now increasing the pressure on less active district toilets, and have become involved in monitoring open administrators, but the challenge of energizing sanitation defecation, toilet usage, and hygiene behavior. This programs in weak districts remains a major obstacle to model may provide a useful alternative approach to scaling-up. sanitation promotion by RSMs, particularly in areas But performance also varies inside districts, with a number without experienced NGOs, or where RSMs are of blocks lagging behind even in more successful districts. proving unsustainable. 94 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Conclusions Key features The Total Sanitation Campaign in West Bengal is rightly nUS$ 100 million budget for TSC in Maharashtra (US$ 3 celebrated as a success story. There has been a long million per district); history of innovative and holistic sanitation development, nFinancial incentives paid to BPL households after although concentrated in a few districts. However, the community stops open defecation; program is now scaling-up across the State, with some nAwards to Gram Panchayats that stop open defecation 850,000 toilets (covering eight percent of the population) (achieve 100 percent toilet coverage); built last year alone. nNGOs used for social intermediation (`ignition' approach); Part of this success derives from the favorable conditions nUse of exposure visits and stakeholder consultation to and political context. But much credit must go to the achieve reforms; and approach adopted: the low-cost toilet design has proven nSant Gadge Baba Campaign (SGBC). simple to install, durable and easy to reuse; the low subsidy ensures affordability and frees up government funds for motivation and awareness raising; and, finally, the institutional model has encouraged cooperation between local government and NGOs, and laid the foundation for long-term support and monitoring. As sanitation coverage in West Bengal rises and spreads, new challenges and questions emerge. The highly standardized approach may prove too rigid to meet the demands of universal coverage in all situations, and may struggle to absorb the lessons from sanitation successes in other areas. And while monopoly supply by rural sanitary marts has probably helped to simplify implementation, it may have suppressed the development of more competitive and sustainable local services. General context It remains to be seen whether the rapid sanitation Maharashtra is a high-income State with high levels of developments of recent months will prove as sustainable and beneficial as the much-vaunted, but more slowly developmental expenditure, but there are significant developed, Medinipur toilets. differentials between the more industrial districts close to Mumbai and the remoter and more water-scarce Case study 5: Ahmednagar (India) eastern districts. Total Sanitation Campaign Sanitation This case study examines the innovative approaches to sanitation development being implemented through the The Government of Maharashtra (GoM) has made TSC of the Government of Maharashtra. The TSC works significant investments in rural sanitation in recent years. Since 1997, the number of rural families that have access through district-based projects, with a number of different to toilet facilities has more than tripled. But Maharashtra approaches utilized in Maharashtra alone. started its program from a position of very low sanitation This case study focuses on the new approach to the TSC coverage, thus more than 70 percent of households being piloted in the Ahmednagar district. remain without sanitary toilets. 95 Stopping open defecation requires collective action, which suggests that the financial incentives would be more effective if used to encourage the attainment of community, rather than individual, goals. More important, the GoM has realized that heavy Reform Project18(Amravati, Dhule, Nanded, and Raigad investment in the provision of toilet facilities does not districts), and had their TSC projects sanctioned some guarantee improvements in public health. Between four years ago. The remainder took time to prepare project 1997-2000, US$ 150 million was spent on the sanitation proposals, and the final 13 district projects were only programme in Maharashtra, with 70 percent of the money sanctioned within the last year. going on large subsidies (US$ 55-80 per household) to encourage the rural population to build toilets. It worked in The total budget for the TSC district projects in one respect: more than 1.6 million toilets were constructed Maharashtra is about US$ 100 million, with each project in only three years, and the program was hailed as a costing from US$ 2.2-4.3 million. success. However, subsequent surveys revealed that only In June 2003, a government progress report noted that 43 percent of these toilets were being used properly, with implementation of the TSC was slow in most of the the majority being used for purposes other than Maharashtra projects, and that physical performance was defecation, or not used at all. very poor in the four sector reform districts where projects Sant Gadge Baba Campaign were more than three years old. Another district has Faced with the evidence that more than half of this exhausted its IEC funds, but made little progress massive investment had been wasted, the GoM decided to otherwise. Since then, the State Government has given pilot new approaches. In 2000, it introduced the SGBC, an higher priority to the TSC, and invested considerable time annual contest in which villages compete against each and effort into the development of an effective strategy for other for prizes and prestige. The focus is on community- scaling-up the provision of rural sanitation in the State. wide sanitation and cleanliness, with points awarded based on numerous criteria (sanitary household toilets, Following a series of consultations, workshops, and study wastewater disposal, solid waste disposal, water source tours, including visits to examine successful sanitation protection, morbidity and mortality data, school sanitation, programs in Bangladesh, West Bengal (India), and IEC efforts, and so on). The top three villages from each Tamil Nadu (India),19 the Government of Maharashtra block are awarded a cash prize, and become eligible for the decided to pilot a new approach in two districts (Nanded sub-district, district, and State competitions. and Ahmednagar). The SGBC has proved popular. Every year the GoM spends Ahmednagar district contains two very different US$ 1.5 million on prize money, which the winning landscapes: the northern area, which falls within the communities have to use for community development. But Narmada irrigation command and is relatively rich; and the it appears that the prestige and recognition attached to the southern area, which is severely drought-affected and awards are worth much more, as the campaign has led largely poor. rural communities across Maharashtra to spend Approach considerable amounts on improving the infrastructure in There are three key differences between the standard their villages. TSC approach and that adopted in the pilot project Case study context in Ahmednagar: The TSC was slow to take off in Maharashtra. Four of the nUse of participatory approaches to trigger 33 districts in the State were already included in the Sector behavior change; 18Pilot project aiming to institutionalize community participation and demand-responsive approaches in rural water supply development, now covering 67 districts in 26 States. 19Faciliated by the Water and Sanitation Program-South Asia (WSP-SA). 96 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia nFocus on stopping open defecation (300 villages incentives would be more effective if used to encourage the selected in first phase); and attainment of community, rather than individual, goals. nPayments are not made until the village achieves 100 In Ahmednagar, every household has to fund its own toilet. percent coverage (community incentives). However, the BPL households do so on the understanding The new approach is built on lessons from Bangladesh20 that they will be paid US$ 8.10 if everyone builds a toilet (see Annex 2), where it has been shown that villages can and the community is declared `open defecation free'. achieve universal access to sanitation without external The remainder of the TSC subsidy (US$ 2.69 per BPL subsidies, using participatory approaches to trigger household), paid to the GP on achieving universal access, awareness and empower the community to solve its own thus acts as an incentive for the GP to assist in stopping sanitation problems. open defecation, including the promotion and facilitation of the construction of toilets by the landless, the very poor, This type of participatory process requires good and those unwilling to invest. facilitation, local knowledge, and long-term support. In Ahmednagar, the Zila Parishad (district government) A similar financial incentive is provided to the NGO trained 20 local NGOs in the `trigger approach', and working in the village. It is paid US$ 1.07 commission for contracted them to carry out the required social every household that builds a toilet (from the IEC funds), intermediation and community development activities. but does not receive any of this money until the village is Each NGO covers 8-10 Gram Panchayats and has an declared `open defecation free'. open-ended performance contract that allows expansion Institutional model (or termination) of their work, subject to output-based progress reviews every 15 days. TSC in Ahmednagar district, Maharashtra The new approach assumes that a village that achieves 100 percent toilet coverage and stops open defecation Government Water Supply completely will reap larger health benefits than two villages of Maharashtra and Sanitation Dept. (of similar size) that reach 50 percent toilet coverage, RSPMU because half the households in the two villages (more if toilet usage is low) continue to defecate in the open. Phase I of the pilot project aims to stop open defecation Ahmednagar Ahmednagar District CEO District and achieve universal toilet access in 300 villages. This Zila Parishad approach is in stark contrast to conventional sanitation programs, which spread their resources thinly across a large number of villages, but rarely reach 100 percent toilet Block Block Government NGO coverage (or usage) in any of them. Development Officer Panchayat Samiti Conditional financial incentives The major innovation in the Ahmednagar pilot project is in Gram Panchayat its use of conditional financial incentives. Most sanitation programs treat sanitation as a purely private good, with up- Village Sanitation front individual household subsidies used to assist private Committee toilet construction. Yet stopping open defecation requires Household collective action, which suggests that the financial 20Kar, 2003. 97 Incentives to encourage collective action for the rapid development of sanitation facilities are having a remarkable effect on toilet coverage in Maharashtra. Performance person that reports them). There have been some There has been significant awareness raising and capacity difficulties with the pilot project. Three of the 20 NGOs building in the district. Elected representatives, local involved have already withdrawn or had their government officials, extension workers, and NGO staff contracts terminated for non-performance, have been involved in sanitation promotion through and there is now a shortage of suitable NGOs with workshops, training, and exposure visits to other relevant experience. But perhaps the most important successful programs. After only six months, the indicator of performance is the national recognition Ahmednagar pilot project has made significant progress. afforded to the policies and practice used in the pilot The new approach has been introduced into at least three projects in Ahmednagar and Nanded. The revised TSC Gram Panchayats in every block, so that 50 GPs across guidelines (January 2004) include several additions that the district are now involved. Five villages have already been directly reflect the approaches adopted in Maharashtra, declared free of open defecation, and another 25 villages are including a move towards post-construction financial reported to be approaching universal toilet coverage. incentives and the Nirmal Gram Puraskar (see earlier), a community-level financial incentive intended to reward the The technology and implementation appear sound. In the achievement of `fully sanitized and open defecation free villages studied, toilet usage was high and there was no Gram Panchayats, blocks, and districts'. evidence of fly or odor problems. Efforts were also being made to monitor and control open defecation. Some Demand for sanitation communities have removed bushes in the vicinity of the The Ahmednagar pilot project has not been very demand- village to reduce the number of open defecation sites, responsive in village selection. Of the 300 GPs selected, and are imposing a US$ 5.39 fine on anyone caught 225 were chosen on the basis of their performance in the defecating in the open (with a US$ 2.15 reward to the Sant Gadge Baba Campaign, and another 84 were nominated by their primary health centers. While good performance in the SGBC indicates above- Incentives to Reuse Abandoned Toilets average sanitation and village cleanliness, it may also In Wadgaon Amli village (Ahmednagar block), one household was recently persuaded to rehabilitate their old toilet. It was an expensive brick-built model that cost about US$ 80 three years ago, when it was provided free under a previous government scheme. Sadly, it was never used, except as a private place for the women to wash themselves, because the family continued to defecate in the open even after the toilet was built. But then the community decided to stop open defecation in the village. As a result, the women of the household report that, "it has become difficult to go out; all the bushes have been removed and there is no shelter; now we have to use a toilet." This family decided to invest US$ 11 in deepening the existing leach pit and installing a new ceramic pan, and have all started using the rehabilitated toilet. The women say that everyone has a toilet now, and that they won't go back to open defecation...even if the bushes grow back! Abandoned demonstration toilet, Watephal 98 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Typical Toilet Components and Cost Item Description Cost Pan and trap Ceramic (market) US$ 3.23 Floor slab Reinforced concrete (RSM) US$ 3.23 Connection Pipework (offset) US$ 0.64 Pit lining Honeycomb brickwork US$ 4.31 Mason Installation and transport US$ 4.31 Enclosure Walls, door, and roof US$ 3.23 Total cost US$ 18.95 reflect favoritism by local government officials. Some relatively large, well-educated, and well-connected villages, often those with links to senior government population (more than 80 teachers reside in the village) officials or elected representatives, receive more than that is still hoping to receive government subsidies and their fair share of assistance and development assistance. Despite its previous SGBC performance, the expenditure, thus routinely out-perform their less village is no longer clean, and there is little willingness-to- favored rivals in the annual SGBC awards. pay for sanitation. Following recognition that the SGBC has little impact on Technical sustainability toilet coverage, its scoring system has been changed to Despite seeing the success of the very low-cost toilet double the weighting given to toilet coverage (to 30 models promoted in Bangladesh and West Bengal, the percent). However, while villages that have received SGBC GoM officials felt that these technologies were not well- awards are likely to have higher toilet coverage than their suited to the different culture, physical conditions, and neighbors, it does not follow that demand for sanitation is economic standing found in Maharashtra. higher, or that needs are any greater. As a result, a typical toilet in Ahmednagar costs In 2003, Watephal (Ahmednagar block) was placed third in US$ 17-22. There is no fixed model, but most toilets have the SGBC at sub-block level. As a result, it was selected a ceramic pour-flush pan and some form of honeycomb for the pilot project and an NGO began work in the village. brick lining in the leach pit. The materials can generally be The `ignition process' was carried out and materials for 10 found in local markets, but most households rely on toilets were provided, but the community showed little assistance from the NGO to make their purchases. interest. Only a handful of toilets were built, and the NGO Concerns about water scarcity and affordability have led withdrew from the pilot project. the authorities to promote single-pit toilets with direct There are a number of reasons for the problems in (gooseneck) pans, and to examine the import of low-flush Watephal village. Among them, the failure of the NGO to pans. This prescriptive approach to the problems may follow-up on the initial participatory activities; political adversely affect sustainability, and there is little evidence in-fighting between two factions in the village; and a that it will reduce water consumption. 99 The one area of real concern is the shortage of suitable NGOs working in the sanitation sub-sector. The participatory process is central to the new approach, and its success is dependent on good facilitation and social intermediation. Low-flush pans are often harder to clean than and that regular follow-up and monitoring of toilet usage conventional ceramic pans, and are not readily available in and open defecation are carried out, with particular focus Ahmednagar. Their supply may be a gap in the market, on `reluctant households'. which can be plugged by encouraging their manufacture Institutional sustainability or import, and including them in the range of options available to rural communities. Similarly, the promotion of The approach used in the pilot project scores highly on single-pit toilets with gooseneck pans will reduce costs, institutional sustainability. While much of the funding is but may discourage further user investment and reduce from the central government, the institutions involved in sustainability, as it is necessary to remove the toilet mobilization, implementation, and monitoring are local and enclosure and slab when the leach pit fills (in order to will be around in the long-term. The TSC has been given relocate them above a new pit, or empty the old pit). political support at both State and district levels. District Water and Sanitation Committees and Sanitation Cells Water scarcity is a serious problem in some areas of have been established in most areas, but there remains a Ahmednagar, with many villages reliant on government- bias towards water supply at State level, with little capacity funded water tankers for several months of the year. to monitor or influence the district TSC projects. Further research is required to find local technologies The State Government is now planning to establish a that households are willing to use during times of State Sanitation Cell (modelled on West Bengal), with severe drought. provisional support from UNICEF. Social sustainability The one area of real concern is the shortage of Incentives to encourage collective action for the rapid suitable NGOs working in the sanitation sub-sector. development of sanitation facilities are having a The participatory process is central to the new approach, remarkable effect on toilet coverage in Maharashtra. New and its success is dependent on good facilitation and incentives are being developed all the time: spiritual social intermediation. leaders are being used to encourage communities to stop open defecation; and public ceremonies are being used to Financial sustainability ensure transparent and effective presentation of financial The Ahmednagar program is well-financed through both awards. As a result, the number of fully sanitized villages is the Government of India TSC and contributions from the growing rapidly, and local government is playing an active Government of Maharashtra. It has received additional and positive role in the process. support from external support agencies (for example, Water and Sanitation Program-South Asia) during the pilot However, it is less clear how well this approach has phase, but program costs are relatively low compared to convinced those households previously reluctant to invest the other government programs (with the exception of the in sanitation facilities. In some areas, Panchayati Raj West Bengal TSC). Institutions (PRIs) and NGOs have resorted to supply- driven approaches to achieve their targets, with most Gram The decision of the Government of Maharashtra to Panchayats providing free toilets to at least a small promote a more expensive (US$ 20) toilet design reduces proportion of their constituents. It is argued that these the program's appeal to poor households, but it has kept households cannot afford to build their own toilets. This hardware subsidies relatively low (US$ 8 to BPL may be true, but there is already evidence from `fully households), thus increasing the number of households sanitized villages' that usage is declining among those that the program can cover. who were pressured, or assisted, to construct their toilets. Environmental sustainability Therefore, it is vitally important that PRIs and NGOs do Rural households have limited knowledge of how long it not stop hygiene promotion after achieving full coverage, will take for their leach pits to fill, or what to do when they 100 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia become full. This is a critical area, as it will affect both and assistance in formulating policy and building capacity sustainability and public health. In most of the pilot in the district. villages, none of the pits have filled yet, and the villagers Neither the exceptional management nor the external appear to believe that it will be many years before this problem arises. However, case studies from other Indian resources will be available in other districts. The key States suggest that pits can fill in as little as six months. elements of the pilot program appear simple, but the More attention needs to be given to this area, both in the contracting out of services to NGOs is still resisted by design of toilets to reduce the cost and difficulty of the some local governments, and there is a risk that rent- transition, and in ensuring the safe disposal of the seeking officials will attempt to capture the large financial pathogenic pit contents if the pit has to be emptied incentives. Several districts have not performed well in the and reused. TSC to date, thus it is clear that scaling-up this new approach will require careful monitoring and enforcement Several communities have removed scrub and low-lying by State institutions. bushes from their villages in order to reduce the possible sites for open defecation. The removal of this vegetation Conclusions may have an adverse environmental impact, and The Ahmednagar pilot shows great promise. The this practice should be investigated before being fundamental premise of the approach is that communities promoted further. need to stop open defecation, which has led to the development of innovative mechanisms to fully sanitize Scaling-up villages. The number of villages declared free from open The second phase of the Ahmednagar pilot aims to fully defecation is rising, and the approach is being refined as it sanitize 600 villages. Given the current shortage of evolves and scales-up. competent NGOs, this expansion will stretch district resources. In addition, having picked the SGBC winning Many State Governments have now recognized this villages in the first phase, the challenge of triggering approach as best practice, and the financial incentives change in the less active and developed villages involved used are being incorporated in national sanitation policy. in the second phase is likely to be far greater. However, the Ahmednagar pilot confirms that If successful, the first phase should provide at least one `self-ignition' rarely occurs. Even where there is good fully sanitized village in every block. It is hoped that these awareness and understanding of sanitation problems, model villages will help to convince local leaders of the most communities are not capable of solving them without effectiveness of the new approach, and provide good some form of assistance and support. Ignition can come examples for exposure visits. These villages may also from within, generated by the leadership of an energetic produce community resource people: community local champion, or from without, through outsiders catalysts, facilitators, and sanitation engineers with first- such as the Ahmednagar NGOs. But real change takes hand experience of the process, who can be trained further time, and sustained support and follow-up is essential and used to strengthen the pool of social intermediators. for the long-term behavior change that the TSC hopes to achieve. The Ahmednagar pilot has been led by a group of particularly energetic and competent government officials, This approach utilizes local government, NGOs, private who have been well-supported in the development of the sector workers, and communities, providing each of them innovative approaches used to implement and expand the with incentives to work together to stop open defecation project. In addition, a number of external specialists, and to introduce low-cost toilets. As such, the pilot project including the Water and Sanitation Program-South Asia, is developing sustainable institutions and making the WaterAid India, KfW, and UNICEF, have provided funding most of limited local resources. 101 The Gram Panchayat is responsible for collecting applications from eligible households and for sanctioning the construction of individual toilets. Considerable sums have been poured into previous sanitation programs in Maharashtra, with little long-term impact on health or well-being. This case study suggests that this new approach is more promising, and may provide a useful model for other sanitation programs in South Asia. Fieldwork Findings based on documentation collected by WSP-SA, and rapid appraisal during February 4-9, 2004, including: interviews with government officials, project staff, and UNICEF officials in Mumbai; with government and NGO officials in Mangaon; with Gram Panchayat officials in Dhatav; with government, Zila Parishad and NGO officials in Ahmednagar; and with household members in five villages in Raigad and Ahmednagar districts: 1. Maluk, Tala Block, Raigad (245 households; 20 percent have toilets). 2. Hadmalie, Mangaon Block, Raigad (51 households; 100 percent have toilets). 3. Dhatav, Roha Block, Raigad (1,316 households; nLow toilet usage (less than 50 percent of new toilets in use in some villages). 50 percent have toilets plus 183 community toilets). 4. Wadgaon Amli, Ahmednagar Block, Ahmednagar General context (169 households; 100 percent have toilets). Historically, Andhra Pradesh (AP) has been a middle- 5. Watephal, Ahmednagar Block, Ahmednagar income State with middling levels of developmental (200 households; eight percent have toilets). expenditure. However, under its former Chief Minister, Case study 6: Andhra Pradesh (India) Chandrababu Naidu, it made great strides. Total Sanitation Campaign It is now among India's forerunners in deploying This case study examines the huge investment in rural information technology, with Hyderabad's advanced sanitation being made by the Government of Andhra infrastructure making it one of the most sought-after Pradesh through the Total Sanitation Campaign (TSC). bases for software developers, business process outsourcers, and biotech companies. This progressive Key features outlook has also affected the rural areas. The State's n1.67 million household toilets built in eight months independent negotiation of loans with the World Bank has (May 2003-January 2004); resulted in heavy investment in rural infrastructure (notably nTypical design has toilet and bathroom and costs roads and water supply). But many of the districts are US$ 61; drought-affected, and some 50 percent of the rural nFull subsidy provided (250 kg food-for-work rice and population are classed as `backward castes'. US$ 16.18 cash); nSupply-driven approach with limited hygiene promotion Sanitation (no NGO involvement); In June 2003, former CM Chandrababu Naidu announced nSignificant technical problems (bad toilet designs; an action plan to benefit 10 million people in Andhra unsafe excreta disposal); and Pradesh (13 percent of the State population) within one 102 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia year. Started just a year before the general election, this eligible for US$ 8.09 central subsidy, so the State only has welfare package offered: to add US$ 8.09 to complete the promised US$ 16.18 nNew ration cards for one million households; cash subsidy. n`Pucca' houses for 0.5 million families; The FFW program provides rice from central government nPlots of land for one million families; stores to drought-affected districts. Normally, this rice is nSubsidized gas connections for one million families; used as payment for daily labor on government projects, nToiletsfor3.5millionhouseholds;and providing an important source of food and employment for nOther economic benefits to two million beneficiaries. the poor during periods of drought. However, the FFW The ambitious sanitation target was formalized by projects rarely produce much of value to the government, Government Order No. 178 (June 2003), which confirmed as the unpaved roads constructed (or similar) often wash that the State rural sanitation program would be extended away in the first rains. Therefore, the Government of to all people living below poverty line. Andhra Pradesh proposes to use the rice as an incentive for something that may have a more lasting benefit, to The Velugu survey (participatory identification of the poor) both the government and the rural poor: the construction was to be used as the BPL baseline, with Gram of sanitary toilets. Panchayats certifying eligibility where the Velugu survey is Case study context incomplete. In addition, ration card holders that do not Seven of the 22 districts in Andhra Pradesh were included have sanitary latrines are automatically eligible for toilets in the Sector Reform Project21(among them Nalgonda under the new program. The GO further states: district), and all districts are now covered by SRP's `The Gram Panchayat will sanction individual sanitary successor, Swajaldhara. By 2003, every district had its latrines [ISL] to the eligible families in the Grama TSC project sanctioned, with average project budgets of Sabha and sanction proceedings will be issued by US$ 3.5 million. the Panchayat Secretary concerned. No other All three projects (SRP, Swajaldhara, and TSC) are administrative or technical approval will be necessary. overseen by a project monitoring unit (PMU) established in The sanction list shall be displayed on the notice the State Water and Sanitation Mission of the Panchayat board of the Gram Panchayat. Raj and Rural Development Department. The TSC was `The unit cost of each ISL will be US$ 59.35. Of this launched in AP about four years ago, but because of the the food component will be 2.5 quintals [250 kg] of political impact of the problems caused by the recurrent rice and cash component US$ 16.18. Since higher droughts, the focus of the State Government and the PMU allocation for each ISL unit in terms of money and has been largely on rural water supply and progress has rice has been made now compared to the unit cost been slow. However, the recent sanitation drive has greatly allowed in the past, construction of bathroom may be accelerated implementation, and given more attention to encouraged along with ISL.' GO No. 178 the sanitation campaign. This new program takes advantage of two central Approach government-funded schemes: the Total Sanitation Local government officials and engineers from the Campaign (TSC), and the Food For Work (FFW) program. PRED-RWS22department promote combined toilet Under the TSC, every BPL household without a toilet is and bathroom models (usually two cubicles) with 21Pilot project aiming to institutionalize community participation and demand-responsive approaches in rural water supply development, covering 67 districts in 26 States. 22Panchayat Raj Engineering Department-Rural Water Supply Sector (PRED-RWS). 103 There have been few house-to-house activities, and insufficient attention paid to issues such as hygiene promotion, stopping open defecation, and toilet usage. Case Study Data Population Unit Name Literacy Sanitation Total Rural Coverage District 1 Kurnool 3.6 million 75% ­ 33% District 2 Karimnagar 3.5 million 80% ­ 38% District 3 Nalgonda ­ ­ ­ ­ State Andhra Pradesh 75.7 million 73% 61% 37% Country India 1,048 million 72% 56% 28% Region South Asia 1,401 million 72% 56% 34% Source: WDR 2004; GoI Census 2001; NCAER 1999; SWSM-PMU data offset pits. Because of the high subsidy available Institutional model to BPL households, the officials verify and pay for the Total Sanitation Campaign, Andhra Pradesh work in stages: nUS$ 8.09 cash plus 100 kg rice coupons23on excavation Government of of pit and procurement of materials; India TSC nUS$ 8.09 cash plus 50 kg rice coupons on completion Government of of basic structure with platform; and Andhra Pradesh n100 kg rice coupons on construction of pucca (solid-walled) toilet enclosure. Panchayat RWS District District District The minimum standard required to obtain payment Raj and Rural Section Administration Government varies from district to district, but the end result Development Superintending District Zila Department Engineer is fairly uniform ­ most toilets have offset pits Collector Parishad lined with concrete rings, ceramic toilet pans, and plastered block or brickwork toilet enclosures. RWS Block Project District Block Section Monitoring Water and Government Some districts have contracted block-level Dy. Executive Unit (PMU) Sanitation Mandal Engineer `resource officers' to work on community mobilization, Mission Parishad but these officers are generally very young and Local inexperienced, and most of the local decision- State Block Water and Mandal Production Admin- Government making and financial management is made by Sanitation Water centers istration Gram the block development officer (known as the Mandal MIssion and MPDO Panchayat Sanitation Parishad Development Officer, MDPO) and the deputy Committee `Resource executive engineer (head of the block-level water and Household person' 23Rice coupons have to be presented at fair price shops (as per drought relief works). 104 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia sanitation committee). The Gram Panchayat is responsible for collecting applications from eligible households and for sanctioning the construction of individual toilets. Construction monitoring is very high-tech. In most districts, the block governments have digital cameras, which are used to take photographs of each completed toilet (also capturing the house and owner, to avoid the reuse of photographs) and to store the images for online access. In Kurnool district, a digital video tour of each completed toilet is being recorded, with 125,000 such virtual tours already available through the district government's computer network. This high-tech approach also extends to State-level monitoring of implementation. Every Monday, the district heads (known as collectors) take part in a video conference much lower, as is the impact on public health. The State with the State Government, in which district performances Water and Sanitation Mission (SWSM) reports that 30-40 are discussed, benchmarking takes place, and Gram Panchayats are nearing 100 percent toilet coverage, constraints are highlighted. and are to be recommended for the Nirmal Gram Puraskar. However, there has been little attention to stopping open Performance defecation in these areas (one of the main criteria of the The massive rural sanitation program in Andhra Pradesh Nirmal Gram Puraskar), and proper verification of these echoes a similar program in Maharashtra during 1997- claims will await independent review by the GoI evaluators. 2000 (see case study on the Maharashtra TSC). Vast sums of money have been spent; enormous efforts have been There have been significant efforts to raise awareness about made by the officials involved; and huge numbers of the rural sanitation program at both State and district levels. toilets have been built in a very short time. But the New baseline surveys, incorporating the results of the program has been highly supply-driven, using large Velugu poverty surveys where available, have improved local subsidies and government pressure to persuade poor information databases and targeting. Further, the systems households to construct toilets. Initial reviews suggest introduced to monitor physical and financial progress have that the results mirror those found in the Maharashtra proved effective in increasing transparency, revealing program: low levels of toilet usage; significant technical weaknesses, and ensuring that the allocated funds are problems; many new toilets already abandoned; evidence being used to build toilets. of continuing open defecation; and little change in the Sanitation promotion and demand hygiene behavior of most poor households. The program has been less successful at the household TSC progress reports indicate that 1.67 million household and community level, where social intermediation and toilets were built in the eight months following the launch sanitation promotion are clearly lacking. Despite the high of the rural sanitation program (May 2003-January 2004). subsidy being offered, some Gram Panchayats have failed If all of these new toilets were now being used, rural to collect enough household applications to match the sanitation coverage would have risen to 37 percent (from limited number of toilets sanctioned. There is little 22 percent in 2002). Sadly, the findings of this case study accountability between service providers and poor suggest that actual sanitation coverage is likely to be households. In many cases, the GP arranges the 105 Local government is heavily involved in the implementation of the rural sanitation program, with the lowest tier of government, the Gram Panchayat, largely responsible for identifying the poor, sanctioning toilet construction, and distributing subsidies. were using them only as washrooms. Brand new toilets were found abandoned or used to store chickens, goats, and other household goods. No water or soap was found in the toilets, and there was little other evidence of handwashing. Where toilets were in use, it was often only by the women and elder children, as most of the men continue to defecate in the open. There was some evidence of demand for bathrooms. Many of the single-cubicle toilets have been converted to bathrooms, with their toilet pans covered, blocked, installed in an unusable position, left unconnected, or removed completely. In combined bathroom and toilet constructions there was often evidence that the bathroom cubicle was in use, even if the toilet cubicle had been abandoned. construction of the toilets (obtaining credit from suppliers, assisting with group purchase and transport of materials, Technical sustainability selecting the mason, instructing on the design) with scant No low-cost toilet models are allowed under the Andhra involvement or decision-making by the household. Pradesh TSC. The RWS engineers require that toilets built under the TSC look as if they cost at least US$ 43.16, with At State level, much is made of the massive IEC campaign minimum requirements including ceramic pans, masonry conducted for this rural sanitation program. There toilet enclosures, and lined pits. have been conventions, competitions, newspaper advertisements, and use of both folk and electronic media. The absence of low-cost models makes universal toilet Schools have been targeted, thousands of mobile coverage difficult to achieve. BPL households receive exhibitions have been held at GP level, 800,000 village only US$ 16.18 in cash (in instalments) but are expected posters have been displayed, and about two million to find more cash to buy materials and pay for the pamphlets have been distributed. construction of the expensive standard toilet model, as the remainder of the subsidy is in the form of rice But there have been few house-to-house activities, and coupons. In most cases, the GP has to assist at least insufficient attention paid to issues such as hygiene a few of the poorer households to finance and promotion, stopping open defecation, and toilet usage. Consequently, many poor households know little of the construct their toilets. sanitation program, and have built toilets for reasons other Despite the amount spent on the toilets in AP, the than safe excreta disposal. Some build for the free rice,24 speed of implementation has prevented those involved in some build to gain a convenient washroom, and some the program from developing the necessary technical build because the GP is paying. know-how and has limited their chances to learn from Toilet usage among poor households was found to be very early mistakes. Construction quality is generally good, low in eight of the nine villages visited for this case study. but neither the RWS engineers, nor the GP, nor the The vast majority of the poorest members of these mason, nor the household, have much understanding communities were either not using their new toilets, or of the sanitation technologies involved. 24Rice prices rose to US$ 0.20/kg in early 2004, making 250 kg rice worth about US$ 54. 106 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Typical Toilet Components and Cost Item Description Cost Pan and trap Ceramic (market) US$ 5.39 Floor slab Concrete (RSM) US$ 2.15 Connection Pipework (offset) US$ 5.39 Pit lining Honeycomb brickwork US$ 7.55 Vent pipe PVC pipe US$ 2.15 Mason Installation and transport US$ 3.23 Enclosure Brick walls, GI door, and roof US$ 33.45 Total cost US$ 59.31 Technical faults are common in many areas, with typical nLeach pits with overflow pipes (pathogenic liquid problems including: overflows near house); nLeach pits with solid linings (stops liquid from leaching nLeach pits with connecting pipe (pits cannot be dried into soil); out for safe emptying); nLeach pits situated 30 feet from toilet (more water required to flush; more expensive); Rangarao Palli, Karimnagar District nSecond leach pit not connected to toilet (or able to This drought-prone village recently reported achieving be connected); 100 percent toilet coverage, and is heralded as one of nVent pipes on pour-flush toilets (additional and the success stories in the district. However, further unnecessary cost); and investigation revealed that only 200 of the 225 nVent pipes without insect screen (allows insect entry and households have working toilets, and that fewer still are exit from pit). using their toilets. The technical faults in Andhra Pradesh range from minor TheGramPanchayatinthisvillagehastriedhardtoachieve flaws with little impact, to serious problems that give rise full sanitation coverage, even providing US$ 539.6 to to public health hazards and threaten the sustainability of help 25 of the poorer households to build their toilets. the toilets constructed. The wide range and extent of the But the Gram Panchayat leader (Sarpanch) admits that technical problems suggest that the RWS engineers, some households still prefer to defecate in the open, in part because this avoids having to use their limited water masons, and local government staff involved in the supply to flush the toilet. program should be made aware of the risks associated with current practices. A rapid survey of the village confirmed that less than 50 percent of the poorest households were using their toilets, In particular, attention needs to be drawn to two critical and suggested that many of these households have not bad practices: the provision of overflow pipes on leach changed their hygiene behavior, and feel little ownership pits, which release pathogenic material into the area for their toilets. around the home; and the installation of unnecessary vent 107 The proposed 100 percent cash subsidy may increase the affordability of toilets, but it will not improve toilet usage or health benefits under the current supply-driven approach. Technical Issues ­ Toilets are Not as Simple as They Seem? Sanitary toilets must be carefully designed to remove human excreta from the domestic environment and ensure its safe disposal, either on or off the household plot: nOn-site disposal (excreta stored in a sealed and isolated pit until safely degraded); and nOff-site disposal (excreta transferred to a central treatment works, for example, sewerage system). In most rural communities, a household toilet and leach pit provide the most appropriate and effective method of safe excreta disposal. The technology is simple ­ a leach pit is merely a hole in the ground, but the pit must be covered and sealed, as its primary function is to isolate the contents of the pit from the outside world. Leach pits dug in stable soils are normally unlined, but deeper pits, and those dug in unstable soils, often have a supportive lining (honeycomb brick or stonework; or perforated concrete rings). The toilet pan can be sited either directly above the pit, or offset in an enclosure beside the pit (with a connecting pipe). Either way, the toilet wastes are dumped or flushed into the leach pit, which is designed to retain the solid wastes while allowing both liquid and gaseous wastes to soak into the soil surrounding the pit. Solids begin to accumulate in the bottom of the leach pit, greatly reducing infiltration through the clogged soil pores in the base of the pit. For this reason, leach pits should always have permeable sides (except for the uppermost 30 cm, which is normally solid lined to retain loose topsoil and provide structural strength). Leach pits with solid-lined sides (for example, concrete rings with cemented joints) will prevent liquids and gases from being absorbed by the soil, leaving the pit contents smelly, wet, and difficult to empty. In more affluent rural areas in India, local masons tend to be more familiar with urban sanitation systems, and frequently make the mistake of trying to convert toilets with twin leach pits into septic systems. The usual practice is to provide a solid lining to the offset leach pits, then link the pits with a connecting pipe, and provide an overflow pipe on the second pit. In this way, the liquid wastes pass through both pits before being discharged from the overflow pipe. Badly designed `septic pit' systems allow floating `scum' and suspended solids to pass directly through the pits and discharge to the open. And even if these `septic pits' are well-designed and operating as intended, the effluent is likely to be highly pathogenic (disease carrying) and may contain viable hookworm and roundworm eggs.25 Septic systems require baffle walls or t-pipes between pits (or chambers), and the septic effluent must be safely disposed into a large soakpit or into a sewerage system. Septic pit systems that discharge pathogenic effluent in the vicinity of rural homes are not providing safe excreta disposal, and should not be considered as sanitary toilets. In addition, septic systems accumulate deep layers of pathogenic sludge, which require periodic removal and safe disposal. The most effective method of desludging is by vacuum pump and tanker, but this technology is expensive and rarely available in rural areas. Septic systems also require ventilation, as the anaerobic processes that take place produce gases that need release. Sufficient ventilation is often provided by the inlet and outlet pipework, but an additional ventilation pipe may be required in some cases. However, water-sealed leach pit systems do not require vent pipes,26 as their permeable sides allow any gases in the pit to percolate into the surrounding soil. When a vent pipe is necessary, it is essential that its outlet be covered with insect screen, as insects are attracted by the odorous gases emanating from the vent pipe. Without the screen, insects can enter the pit, lay eggs inside it, and fly directly from excreta to food. Unscreened vent pipes leave excreta exposed to the open air and lower the barriers to fecal contamination. 25Tests on septic tanks in rural India found that 90 percent of effluent samples contain viable hookworm and Ascaris eggs (Franceys et al, 1992). 26The water seal prevents smelly gases from re-entering the toilet enclosure (note: vent pipes are required in pit latrines that do not have water seals, for example, VIP latrines). 108 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia pipes on leach pits, as these provide an additional route project, but is accountable to the Chief Minister, who for fecal contamination (and raise the cost of the toilet). directs the program and makes the major policy decisions. Close monitoring by the State Government, through Social sustainability weekly video conferences and online reporting, allows Toilets with very similar (but unusual) flaws were observed them to benchmark performance and apply pressure to the in several of the villages visited for this case study. In each weaker districts. case, the toilet enclosure was placed in one corner of the household plot, the leach pits were situated in front of the Within the districts, the Panchayati Raj Engineering toilet (rather than at the back, as is more common) and, Department (PRED), the nodal agency for rural water supply most surprising of all, the two leach pits were dug in the State, has managed to retain control of the TSC. This some 15-30 feet away from the toilet enclosure. This institutional arrangement contrasts with other States, where arrangement increases the cost of the toilet, as a longer the ongoing decentralization process has combined with a pipeline is needed. The pipeline must also maintain a focus on low-cost technologies and hygiene promotion to minimum gradient, so the extra length will either reduce encourage a more central role for local government the working depth of the leach pits, or mean that the toilet and NGOs. platform has to be raised. It will also increase the chance of Despite the technical bias of the PRED, the training of the maintenance problems, as there is more chance of solids masons that build the toilets has been inadequate. The getting stuck in the longer pipeline, and it will be harder to PMU report that 50,000 masons have been trained in low- find and clear blockages. cost sanitation, but this training turns out to be little more Further investigation revealed that these practices derive than a one-day course run by the local PRED engineers. from `Vastu Shastra', the ancient Vedic science of building Few of the masons interviewed in the field had attended a (related to Feng Shui). The local Vastu practitioner had training course, and neither the engineers giving the advised these households where to site their sanitation training, nor the masons, recognized the major technical facilities based on astrological locations and traditional problems listed earlier. rules on how buildings should be aligned. In particular, the Apparently, the Chief Engineer of the PRED in Andhra Vastu recommended that water (toilet wastes in this case) Pradesh strongly resisted the involvement of NGOs in the should always drain to the north-east, and that leach pits implementation of the TSC. Instead, the PRED decided to must not be sited in line with the door to the house. recruit temporary `resource officers' to act as social The absence of effective social intermediation in this rural mobilizers in each block. The short tenure offered to these sanitation program means that important issues like temporary staff gives no job security, making it hard to this are rarely exposed or discussed, and there is no recruit experienced or locally respected personnel. mechanism for addressing them even when they do As a result, these resource officers are generally young and come to light. ineffective, with none of the qualities offered by an Institutional sustainability experienced and committed local organization. The Local government is heavily involved in the majority have no professional support, no community implementation of the rural sanitation program, with the development experience, minimal training, and little lowest tier of government, the Gram Panchayat, largely mandate or incentive to serve the target communities. The responsible for identifying the poor, sanctioning toilet current institutional arrangements provide no mechanism construction, and distributing subsidies. or incentive for follow-up after toilet construction, for monitoring of toilet usage and open defecation, or for Nevertheless, it remains a top-down program. The district assessment of the health and hygiene impacts. It appears collector (chief administrator) manages the district TSC that the program is designed to construct toilets as rapidly 109 The Andhra Pradesh rural sanitation program is already operating at scale, with more than 200,000 toilets per month being constructed during each of the last eight months. as possible, with little concern for their long-term (which can take anything from six months to three years, sustainability or effective use. depending on family size, diet, climate, and so on), the other full pit should be kept sealed and dry, so that the Financial sustainability contents can safely decompose. In this way, by the time Most of the district sanitation targets were based on rice the operational pit is full, the solid contents of the other pit availability, as the provision of the high toilet subsidy is have become dry, odorless, and harmless, and can be dependent on the continuing supply of food-for-work rice safely dug out by hand and used as fertilizer. When the by the central government. These rice supplies are now leach pits are inter-connected, it is not possible to isolate almost exhausted, forcing the Government of Andhra either of the pits, or to allow their contents to dry out and Pradesh to take out a US$ 2.3 million HUDCO27 loan that decompose. As a result, both pits remain wet, and the will allow it to provide an additional 50,000 households resting pit is likely to be contaminated by the live with US$ 45 cash in place of the promised 250 kg rice pathogens in the operational pit. component of the toilet subsidy. In AP, the leach pits have often been constructed in line Given that the high subsidy was originally justified as a with the toilet, so that the first pit lies between the toilet productive use of food-for-work rice, this forced change and the second pit. This arrangement means that the in approach brings into question both the State second pit cannot be connected directly to the toilet, thus Government's rural sanitation policy and the sustainability cannot be used independently of the other pit. This design of its current rural sanitation program. It also increases the is effectively a single pit toilet, as the two chambers cannot risk of the subsidy being captured by the non-poor, as the be used separately, which means that little benefit is government is now offering a significant amount of cash gained from constructing the second pit. Emptying the (US$ 59.35) in its toilet subsidy. contents of these connected pits will also be problematic, as the sludge will contain fresh excreta and be wet, smelly, The proposed 100 percent cash subsidy may increase the and pathogenic. In these cases, provision needs to be affordability of toilets, but it will not improve toilet usage made for safe desludging and disposal of the septic or health benefits under the current supply-driven sludge, or for re-design of the toilet layout so that the pits approach. Despite the present financial contribution, can be operated independently. households have negligible influence over design or construction and appear to feel little sense of ownership Little attention is paid to wider sanitation issues, such as for their completed toilets. In addition, the Government of hygiene behavior, open defecation, drainage and Andhra Pradesh cannot afford to sustain the higher cash wastewater disposal, and solid waste disposal. subsidy, making it extremely unlikely that those most in need will ever see the benefits. Scaling-up The Andhra Pradesh rural sanitation program is already Environmental sustainability operating at scale, with more than 200,000 toilets per The TSC in Andhra Pradesh may give rise to month being constructed during each of the last environmental problems. No attention has been given to eight months. This massive achievement is testament safe disposal of the solids from leach pits or the sludge to a genuine political commitment to the sanitation from septic systems, and some of the recently built program, and to the effectiveness of the systems discharge pathogenic effluent into the decentralized implementation. domestic environment. When a toilet has two leach pits, as in most cases in Andhra Pradesh, they should be kept The high priority and impressive intensity of the sanitation separate and used alternately. While one leach pit is filling program have generated huge awareness among officials 27Housing and Urban Development Corporation Ltd. (HUDCO). 110 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia and community leaders. Unfortunately, little of this interest monitoring. On the other hand, the rice supplies are and activity has trickled down to the villages. Senior running out, many of the new toilets are not being used, officials are aware of national initiatives such as the Nirmal and there is increasing evidence of technical problems that Gram Puraskar, but there is limited knowledge of these question the sustainability and environmental impact of incentives at or below the Gram Panchayat level. the program. Previous programs required district-level approval for all Progress has been driven by the high political priority and decisions and project sanctions. This led to lengthy delays massive funding attached to the program. However, the (and loss of momentum) while information was passed up close interest and involvement of the Chief Minister have through the three-tier Panchayat Raj system and, also created a reluctance to report or address problems. eventually, approval was passed back down. Under the At the heart of the matter is the top-down, supply-driven current rural sanitation program, the Gram Panchayat approach adopted for the rural sanitation program. (lowest of the three tiers) vets applications, sanctions toilet construction, and pays out subsidies. This greatly No effort has been made to find out what sort of toilet the improves targeting and speeds up the process, while rural poor are willing to pay for, and nobody has tried to frequent monitoring from above keeps the GP honest. understand why so many poor households are not using their highly subsidized toilets. There has been no effective Despite these achievements, there is evidence that the hygiene promotion, no attempt to stop open defecation, program has been scaled-up too quickly. Central and no focus on wider sanitation issues. This is an old- government-funding has not been able to keep up with fashioned toilet-building campaign in which: technocrats the implementation rate, forcing State and district decide the type of toilet the program should implement; governments to borrow and juggle funds from other bureaucrats arrange the finance and implementation; and sources. More critically, there has been little time to learn the rural poor have scant involvement, and little interest from mistakes or make incremental improvements to policy in the outcome. or to implementation guidelines. Government officials are starting to recognize that toilet usage is low, and that more Fieldwork resources need to be directed towards hygiene promotion Findings based on documentation (collected by WSP- and social intermediation, but most of the money has South Asia, and by the Project Monitoring Unit of the already been spent. State Water and Sanitation Mission) and rapid appraisal during February 24-27, 2004, including: interviews with There has also been strong resistance to new delivery government officials and project staff in Hyderabad; with mechanisms and to low-cost technologies. In particular, government, PRED, and Zila Parishad officials in Kurnool; the Panchayat Raj Engineering Department (PRED) has with government and PRED officials in Karimnagar; with resisted the involvement of NGOs and insisted on an government and PRED officials in Nalgonda; and with expensive toilet design. These problems can be linked in village leaders and household members in nine villages in part to a culture of patronage in the State, embodied by an Kurnool, Karimnagar and Nalgonda districts: almost universal reluctance to lower toilet subsidies, Kodumur, Kodumur block, Kurnool (5,000 households; despite awareness of the success of other rural sanitation 60 percent have toilets); programmes in the region with a zero subsidy approach. Pyalakurthy, Kodumur block, Kurnool (1,500 households; Conclusions 33 percent have toilets); The rural sanitation program in Andhra Pradesh is full of K Markapuram, Kallur block, Kurnool (282 households; contrasts. On the one hand, more than 1.5 million toilets 100 percent have toilets); have been built, with great political commitment, massive Bejjanki, Bejjanki block, Karimnagar (1,650 households; IEC campaigns, and innovations such as online 30 percent have toilets); 111 Sanitation coverage is very low in Tamil Nadu. No exact figures are available, but it seems likely that rural sanitation coverage is in the range of 14-17 percent, compared to about 28 percent coverage nationally. General context In general, Tamil Nadu has been successful in its efforts to address poverty. Within the last 10 years, the proportion of those living below the poverty line has fallen from above 30 percent to about 20 percent. Yet poverty remains pervasive. Tamil Nadu is eighth poorest among the 14 major India States, and has the highest rate of inequality among those 14 States. This uneven improvement in the quality of life within the State has left a large section of the population consistently unable to benefit from the economic and social development that the State has achieved. This is particularly pronounced in rural areas, and among scheduled castes and tribes, minorities, and women. Recognizing this, a good proportion of Tamil Nadu's planned budget is allocated to programs seeking to assist Veerapur, Bejjanki block, Karimnagar (202 households; vulnerable people. Yet these have tended to be 15 percent have toilets); inadequately targeted and inefficiently managed. Ramkrishna Colony, Karimnagar (690 households; This is a result of a number of factors, including limited 12 percent have toilets); incentives for government staff to address the needs of Rangarao Palli, Karimnagar (225 households; the poor, with limited accountability to these clients, and 100 percent have toilets); resistance to civil servants changing from service Yellareddyguda, Nalgonda (553 households; providers to facilitators. 50 percent have toilets); and Sanitation Gaddikondaram, Thipparthy block, Nalgonda Sanitation coverage is very low in Tamil Nadu. No exact (201 households; 90 percent have toilets). figures are available, but it seems likely that rural sanitation Case study 7: Gramalaya (Tamil Nadu, India) coverage is in the range of 14-17 percent, compared to Total Sanitation Campaign about 28 percent coverage nationally. The reasons for this This case study examines the pioneering approach to unusually low coverage are not clear, but the majority of sanitation promotion developed by a local NGO, State resources remain directed towards rural water Gramalaya, and its subsequent adoption by the TSC in supply, for example, through the Sector Reform Project,28 Tiruchirappalli district, Tamil Nadu. which operates in six of the 28 districts in Tamil Nadu, and its successor, the Swajaldhara program, which covers the Key features other 22 districts. nNGO implementation (Gramalaya); nSignificant support from WaterAid; Case study context nLarge investment in hygiene promotion and IEC; This case study focuses on the work of the Gramalaya nHigh coverage and high toilet usage; and NGO in Tiruchirappalli district in Tamil Nadu. This district nLimited involvement of local government is well known to water and sanitation practitioners in India, (below district level). as it used to be the base for WaterAid India, one of the 28Pilot project aiming to institutionalize community participation and demand-responsive approaches in rural water supply development, covering 67 districts in 26 States. 112 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia most effective and innovative of the international NGOs hygiene promotion approach. A key element of this approach operating in South Asia. WaterAid India recently shifted its is the formation and training of women's self-help groups head office from Tiruchirappalli to New Delhi, but it leaves (SHGs), which use rolling funds to provide toilet construction behind a network of well-trained and locally renowned loans to their members. Four years ago, Gramalaya began partner NGOs such as Gramalaya and SCOPE. working with poor women in 26 villages to develop handpumps, household toilets, and school toilets. Today, Since 1987, Gramalaya has worked on rural development Gramalaya employs 75 staff, of which about 35 work on its projects (initially health and social forestry) in two blocks rural projects, and has expanded its sanitation program to (Thottiam and Thathaiengarpet) of Tiruchirappalli district. 200 villages spread among 55 Gram Panchayats. By 1989, it had branched into the sanitation field, working on the Low Cost Sanitation program (LCS) in urban slums, By 2002, Gramalaya's sanitation expertise was nationally and two years later WaterAid India began supporting its recognized, and the Water and Sanitation Program (WSP) rural sanitation projects. Today, funding comes from three invited its Executive Director (S. Damodaran) to join a team sources: 60 percent from WaterAid (largely for sanitation conducting a sanitation needs assessment study in projects); 30 percent from Water Partners International (an Maharashtra. This team was led by Kamal Kar, Indian social American NGO); and 10 percent from the District Rural and participatory development consultant who developed Development Agency (the local government body the groundbreaking `community-led total sanitation' implementing the TSC in Tamil Nadu). approach in Bangladesh (see Annex 1). Gramalaya has been implementing three-year integrated This approach is radical in India, as the history of health and sanitation programs using a comprehensive heavily subsidized government sanitation programs has Tiruchi Village Cracks the Whip on Open-air Defecation Thandavampatti hamlet (population 276; 69 houses) at Araichi village Panchayat in Tiruchi district, Tamil Nadu, was officially declared the first rural habitation in India to totally prevent open defecation on January 26, 2003. Two months earlier, Tiruchi NGO Gramalaya staff went to the village to conduct a meeting for the local women's self-help group. The women reluctantly outlined their problem while the men who were quizzed about it stated that they faced a crisis, as they were unable to use either the nearby road or fields to defecate. The Namakkal-Thuraiyur single-lane road is used by men and children to relieve themselves during the day, and by women at night. As a result, the villagers face a torrent of abuse from heavy vehicle drivers that come close to hitting those squatting by the road; and local farmers resent stepping on the feces in their fields, and complain that the tether ropes of their animals become coated with feces when the animals graze. But what really changed the villagers' minds was when they were taken in a procession through areas they previously used for answering calls of nature and saw for themselves the shocking situation. Offered a choice, the villagers opted for their own toilets. A sanitation `ladder' was drawn up for the villagers, showing various toilet types from zero budget varieties to pour-flush toilets costing around US$ 64.75. The favored option was the water-saving dry pit latrine, based on a Bangladesh model. Work began on January 16 when 13 houses dug the necessary three-foot deep pits and covered them with a cement slab with a drop hole and wooden cover. Thatch, old mats, and used jute bags served as a superstructure, with an old cloth covering the doorway. The Panchayat president lauded the hamlet for its outstanding example, and said she would encourage residents of Araichi, the main village, and the remaining hamlets to follow their example shortly. Adapted from New Indian Express, January 25, 2003, at www.irc.nl/content/view/full/2574 113 Gramalaya has also been innovative in other fields, using a child-centered approach to implement its health and sanitation programs, and developing child-friendly school and anganwadi toilets. Case Study Data Population Unit Name Poverty Literacy Sanitation Total Rural Coverage District Tiruchirappalli 2.2 million 60% 27% 60% 25% State Tamil Nadu 62.1 million 56% 21% 73% 17% Country India 1,048 million 72% 35% 56% 28% Region South Asia 1,401 million 72% ­ 56% 34% Source: WDR 2004; GoI Census 2001 conditioned rural populations and program officials to which to set the poverty line. Clearly, this decision is think that low-cost toilets are not viable, and that the crucial as it will determine how many households fall more expensive `viable' models cannot be built without below the poverty line, and thus how many are eligible for subsidies.The Gramalaya Executive Director admits that the significant benefits (including TSC subsidy) provided the exposure to these new ideas, and the experience in to BPL households. Maharashtra, changed his perceptions. He returned to Tiruchirappalli determined to adapt the `open defecation The survey results have not been released pending a court free' approach and the low-cost toilet models for use in ruling on the poverty line score, but it is understood that Tamil Nadu. the survey suggests that the number of BPL households in Tiruchi district should be revised down from 130,000 to This process led to Gramalaya's involvement with the first 90,000 households (27 percent). open defecation free village in India, Thandavampatti. However, rising awareness and promotion of the TSC, Approach and of the US$ 10.79 toilet subsidy available under this In Tamil Nadu, the districts have been given autonomy to program, prevented the spread of the zero-subsidy implement their TSC projects as they see fit. There is little approach. Even in Thandavampatti, where the community State interference and ultimate authority for the project lies was proud of having solved the sanitation problem with the district collector. As a result, there are a range of themselves, many of the households have since used approaches and management models in use, depending the government subsidy to upgrade their toilets. on the views of the collector and the resources available. Gramalaya is now one of the NGOs contracted by the The district government in Tiruchirappalli has contracted district government to implement the TSC in 14 NGOs to implement the TSC in its 14 blocks, Tiruchirappalli district, and has adapted its approach to fit although Gramalaya covers two blocks as two of the the TSC guidelines. smaller NGOs work together in a single block. Gramalaya The TSC project intended to use a more accurate baseline works in 30 villages at a time, using a three-year program survey conducted last year, but the results of this and exit strategy: State-wide poverty survey are controversial. The survey nYear 1 ­ community mobilization and motivation; was carried out by local anganwadi (nursery school) staff nYear 2 ­ handpump and toilet construction; and using a proxy scoring system to determine relative poverty nYear 3 ­ development of community-based organization levels, and has led to considerable debate on the level at and handover. 114 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Gramalaya promotes several different toilet models, but Institutional model many of the poorer households now opt for a US$ 12.95 direct toilet (single pit covered with a `gooseneck' toilet Government of India platform). The TSC subsidy (US$ 10.79) covers most of the costs of the toilet, leaving the household to pay only Government of UNICEF US$ 2.20. Those who prefer a more expensive toilet often Tamil Nadu take a loan from their self-help group, with the usual amount being US$ 32 repaid with an up-front US$ 6.47 State Rural District District payment then 12 US$ 2.15 monthly instalments. Sanitation Administration Government Society District Collector Zila Parishad Gramalaya has provided moulds to a couple of private production centers to enable them to produce pre-cast District Rural Development Agency concrete toilet platforms, cover slabs, and concrete rings. The NGO community organizers then inform the communities and self-help groups of the availability of NGO Block Development toilet components from these producers, and often assist Gramalaya Officer them in organizing group purchase and transportation of NGO Block DRDA Block the components. Local masons, often from within the Coordinator Coordinator community, receive training in the construction and installation of sanitary toilets. Panchayat Community Federation organizer The Tamil Nadu Women Development Corporation SHG leader (TNWDC) supervises the formation and management of the SHGs. There are now 120,000 SHGs in Tamil Nadu Self-help Household Group (each with 20 members = 2.4 million women), with Panchayat Federation leaders representing clusters of 20-25 SHGs at block level. Performance The performance of the TSC in Tamil Nadu is reported to The District Rural Development Agency (DRDA) is vary widely between the districts. In some, NGOs are not responsible for managing the TSC and monitoring the used, with the BDOs and union engineers responsible for performance of the NGOs, but local government is not all implementation. In others the Gram Panchayats are otherwise involved in the program. The DRDA organizes given the money to construct the toilets using local monthly block coordination committee meetings led by its contractors. Little IEC or social intermediation takes place TSC block coordinators who report to the Block in most of these cases, resulting in low toilet usage and Development Officer (BDO) and attended by all of the limited impact on hygiene behavior. Panchayat SHG Federation leaders and the NGO's representatives. About 50 percent of the districts in Tamil Nadu are using NGOs to implement their TSC projects. However, it is At the State-level, the State Rural Sanitation Society reported that there is a shortage of NGOs with suitable meets monthly to monitor progress and discuss experience, and that many have a tendency to spend success stories and new approaches. This body heavily on IEC but have neither the health qualifications comprises State Government representatives, leading nor the technical background needed to effect hygiene NGOs (Gramalaya, SCOPE) and key donor agencies behavior change and develop sustainable toilets. (UNICEF, DANIDA). Gramalaya has performed well in Tiruchirappalli district. 115 Success seems to be strongly associated with the performance of the self-help groups (SHGs), with active SHGs able to construct toilets for all their members. been innovative in other fields, using a child-centered approach to implement its health and sanitation programs, and developing child-friendly school and anganwadi toilets. Children's self-help groups have been introduced. These take care of handpumps and manage small kitchen gardens, generating unusually high awareness of health and hygiene issues among the children in these villages. The Tiruchi DRDA has been active in monitoring and managing its TSC project, with some of the NGOs having been removed for non-performance, and several government officials suspended for failing to implement the TSC. Sanitation promotion and demand There was evidence of good hygiene behavior in the villages covered by Gramalaya, with soap and water kept in almost every toilet, and excellent knowledge of the public health risks associated with poor sanitation. However, open defecation was still prevalent among a small Drawing on its accumulated sanitation experience, and the proportion of each community (10-15 percent households). new approaches that it has been using for the last six months, it has managed to achieve both high coverage Both Gramalaya and the community leaders admit that it is and high toilet usage in its TSC communities. However, hard work persuading reluctant households to build toilets Gramalaya only works in 30 new villages every year, so and stop open defecation. There always seem to be a few despite its years of hard work, toilet coverage remains at household heads that are against toilets (some people feel only 23 percent within its working area (compared to 25 that defecating so close to the house is unclean and percent coverage across the district). Gramalaya has also improper), and others that oppose local leaders for political Typical Toilet Components and Cost Item Description Cost Pan and trap Ceramic (market) US$ 4.31 Floor slab Concrete (RSM) US$ 3.23 Connection P-trap US$ 1.07 Pit lining Stonework US$ 2.69 Mason Installation and construction US$ 1.61 Enclosure Home-made (thatch, jute) US$ 0 Total cost US$ 12.91 116 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia or personal reasons, thus refuse to take part in any scheme underneath the pit to improve drainage. Upon removing promoted by these leaders. the pit cover slab, the owner (and mason) were shocked to discover three feet of septic liquid and excreta in the Technical sustainability bottom of the pit. The most common toilet design under the Gramalaya programs is a two-cubicle toilet and bathroom model This proved to be a graphic demonstration that leach pit with a single leach pit and a blockwork toilet enclosure. bases can become sealed as the sludge layer accumulates The concrete blocks are manufactured by private production and the soil pores clog, and convinced the villagers and centers using moulds provided by Gramalaya, and were NGO staff present that leach pits must have permeable introduced to reduce the cost of a `pucca' toilet enclosure. sides. In water-logged areas, SCOPE (another WaterAid- supported NGO working on the TSC in Tiruchirappalli Perhaps 15 percent of households opt for the cheaper district) has been promoting above-ground composting (US$ 12.95) `direct' toilet, in which the gooseneck toilet toilets that cost US$ 90, but there has not yet been an pan and platform are mounted directly above a single independent review of the performance and sustainability leach pit. of these toilets. In this model, the toilet enclosure is usually home-made Social sustainability from thatched matting, which allows the toilet platform Success seems to be strongly associated with the and enclosure to be easily relocated above a new pit performance of the SHGs, with active SHGs able to when the existing leach pit is full. In one village, the local construct toilets for all their members. However, problems mason built solid-lined leach pits using the freely available remain in areas that contain no SHG members, or in which local stone. the women oppose the views of the SHG leaders or their families. In several communities, one section of the village The owner of one such pit disputed that infiltration would had been fully sanitized (100 percent toilet coverage and be reduced because of the solid walls, stating that the no open defecation) but, for a variety of reasons, little mason had installed a two-foot deep layer of sand progress had been made in another adjacent section of the village. In these cases, it was clear that the NGO and self-help groups were unable to achieve collective action at the community level, despite their best efforts. This suggests that some additional external pressure may be necessary to enforce bans on open defecation and persuade reluctant individuals and households to invest in toilets. It was also noted that, in the enthusiasm of the moment, many of the better-off households in these villages decide to build grand and expensive toilets, often with tiled brickwork enclosures and large septic tanks. Sadly, most of these toilets languish unused and half-complete, as the owners always appear to run out of money and lose interest before the project is finished. This problem reflects both the inability of the community to stop open defecation and the need for sustained follow-up, even in villages that have Solid-lined pit and undrained liquid apparently achieved 100 percent toilet coverage. 117 The Gramalaya approach to sanitation development received national recognition after the Tamil Nadu NGO helped Thandamavampatti to become the first village in India to be declared free from open defecation. Institutional sustainability advocated by Gramalaya is effective but expensive. Gramalaya's success is built on the quality and No exact figures are available, but Gramalaya estimates commitment of its staff, whose strength and capacity owe a total expenditure of about US$ 21,600 in promoting much to WaterAid's nurturing and support. The external 1,200 toilets, which is more than US$ 17 per toilet. funding from WaterAid (and others) allows Gramalaya to This figure is likely to include significant expenditure on pay above-average salaries on a timely and reliable basis. activities other than implementation (advocacy, staff This funding also covers Gramalaya's running costs, training, networking, reporting), but it indicates the level of including its up-to-date computer facilities and its software subsidy utilized by well-funded NGOs. vehicles, as well as investments in other local resources, such as Gramalaya's new technology center in The State and district government are planning to Kolakkudipatti, which showcases a wide range of toilet introduce a commission payment for NGOs, whereby the designs and technology options. NGOs receive US$ 1.07 per household that builds a toilet. Comparing this figure with the amount spent by WaterAid monitors its partner NGOs closely: requiring Gramalaya gives some idea of the gulf between what quarterly progress reports; conducting twice-yearly effective NGOs spend on community development and the evaluations; and providing direction through three-year amount that the government is prepared to spend. policy frameworks. WaterAid has also introduced partner- to-partner assessments in India, whereby its partner NGOs Gramalaya has been providing women's self-help conduct independent assessments of each other's groups with US$ 540 to start their rolling funds. It is not programs. In addition, WaterAid has helped to establish clear how much of this start-up funding is being WaterNet, a network of NGOs working in the water and recovered, or whether any of the SHGs have managed sanitation field in Tamil Nadu. Last year, WaterAid's partner to establish themselves without external funding NGOs provided training to 50 new water and sanitation and assistance. NGOs through WaterNet, and another 100 NGOs should Environmental sustainability be trained in 2004. The Gramalaya villages showed generally good Gramalaya has become professional and well-respected environmental sustainability. Attention was paid to wider through its involvement with WaterAid and, although sanitation and environmental health issues, with soak pits it is now attracting funding from other sources, its and kitchen gardens promoted for wastewater disposal. success is still largely dependent on WaterAid's support. The one area of concern was the emptying and disposal of However, there are elements of the Gramalaya leach pit contents. Most households appear to have approach that require neither external funding nor constructed single pit toilets, but few of them were aware external assistance. what to do when their pits become full. Gramalaya has been active in developing federations of Scaling-up women's self-help groups and involving these groups in Gramalaya has been reluctant to scale-up its operations, sanitation promotion and financing. A Panchayat-level despite repeated entreaties from State and district federation has been established in each of the 55 GPs, and authorities facing a shortage of suitable NGOs. However, these apex organizations are now being recognized by Gramalaya is now planning to take over staff from a failed local government and involved in the planning and NGO in a nearby district, and to start work in 100 more implementation of block-level development activities. villages in that district. Gramalaya admits that this expansion will be a challenge, but recognizes that larger Financial sustainability scale approaches are needed to reach the huge unserved The participatory and people-centered approach rural population in Tamil Nadu. 118 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia 119 It is increasingly obvious that if NGOs such as Gramalaya are to have a major impact on public health, they need to work more closely and cooperatively with local government. One of the key scale issues is the role of local government. Like many NGOs, another factor in its success has At present, NGOs such as Gramalaya often take the lead been its size. It works in just two blocks, covering only sanitation role in their block and report directly to the 200 villages to date and, despite current plans to expand district authorities. This tends to exclude the block and GP into another 100 villages, has yet to prove that it can work authorities from the process, and may be at the root of at a larger scale. Gramalaya's complaints about the slow provision of TSC The Gramalaya approach also neglects local government. subsidies by local bodies. The study also found that As an NGO, Gramalaya has neither the guaranteed Gramalaya lacked the authority necessary to enforce long-term presence, nor the funding and authority of local compliance with community rules, or the means to government. This makes it difficult for Gramalaya to tackle encourage and assist reluctant households and severely hard cases (reluctant households), or to monitor an ever- constrained households (landless, tenants, widows, enlarging portfolio of communities. Yet local government, and so on) in joining the collective action to stop for all its embeddedness and power, lacks the social open defecation. intermediation and sanitation promotion skills found in There is also a question over the long-term sustainability NGOs such as Gramalaya. It is not unusual for NGOs to of the NGO-only approach. Gramalaya, and its current value their independence from government and the approach, is dependent on its funding, which determines advantages that this status confers when working with the number of communities that it can work in at any time. rural communities. But it is increasingly obvious that if This rolling approach, whereby a new block of NGOs such as Gramalaya are to have a major impact on communities are tackled every year, does not allow public health, they need to work more closely and for long-term follow-up in an ever-growing number cooperatively with local government. of communities. Fieldwork Conclusions Findings based on documentation (collected by WSP-SA) The Gramalaya approach to sanitation development and rapid appraisal during February 29-March 1, 2004, received national recognition after the Tamil Nadu NGO including: interviews with district officials and NGO staff helped Thandamavampatti to become the first village in (Gramalaya and SCOPE) in Tiruchirappalli; India to be declared free from open defecation. Since then, a visit to the Gramalaya technology center in its approach has proved effective in the Total Sanitation Kolakkudipatti; and interviews with village leaders Campaign, achieving consistently high levels of sanitation and household members in three villages in coverage and toilet usage. Tiruchirappalli district: Keelakarthigaipatti, Thathaeingarpat block, Tiruchirappalli There is much that can be learned from the Gramalaya (116 households; 87 percent have toilets); approach, but it is not a typical NGO. Some 90 percent of its funding comes from international donors, and this Mettupalli, Thathaeingarpat block, Tiruchirappalli external funding has allowed it to recruit and retain (72 households; 44 percent have toilets); exceptional staff, and to invest well above the norm Cholampatti, Thathaeingarpat block, Tiruchirappalli (per household) in its sanitation development activities. (108 households; 42 percent have toilets). 120 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia Annex 4 Case Study from Pakistan 121 122 Lessons Learned from Bangladesh, India, and Pakistan Annex 4 Scaling-Up Rural Sanitation in South Asia Case Study from Pakistan Official figures suggest that Pakistan has considerably To its credit, the Government of Pakistan has recognized higher total sanitation coverage (62 percent) than either that it has fallen behind in sanitation development, and is India or Bangladesh, but these figures conceal large now making efforts to redress the situation. The Medium variations between the provinces, and between urban and Term Investment Plan developed by the Ministry of Water rural sanitation coverage. Further, recent government and Power aims to allocate 40 percent of new water sector planning estimates are based on dramatically lower investments to water and sanitation programs, and at the figures: the 2002 Pakistan Water Sector Strategy end of the first South Asia Conference on Sanitation assumes that rural sanitation coverage is currently (SACOSAN) held in Dhaka last year, the Minister of Health 27 percent nationally.29 from Pakistan offered to host the next SACOSAN in 2005. As a result, the government has since held several In the sanitation sector, Pakistan is probably the least active sanitation forums and stakeholder consultations, and is of the three countries covered by this study. Despite the starting to develop new sanitation policies, approaches, explicit inclusion of sanitation in both its 2001-11 Ten Year and programs. Perspective Development Plan and its 2003 Poverty Reduction Strategy Paper, Pakistan currently has very few Case study 8: active sanitation programs of national or provincial scale. Lodhran Pilot Project, Pakistan Water supply and sanitation programs receive just 0.2 This case study examines the low-cost sewerage schemes percent of current water sector finance, with the vast implemented by the Lodhran Pilot Project (LPP) in majority of investments going towards irrigation, drainage, southern Punjab, Pakistan. Initially, the LPP worked only and flood control programs. on urban sewerage schemes, following the Orangi Pilot At present, the funds that are directed towards water supply Project (OPP) model, but its success in improving the and sanitation programs tend to be spent on urban sewerage system in Lodhran City led to demand for similar sanitation projects, or on provincial rural water supply and schemes in nearby villages. Concerns about the sanitation projects that allocate most of their expenditure to applicability of the LPP sewerage schemes in the rural water supply schemes. context appear unfounded: the LPP is now working on 2002 Pakistan Integrated Household Survey Province Sanitation Coverage Rural Urban Total Punjab 33% 93% 50% Sindh 51% 98% 70% North West Frontier Province 64% 96% 69% Balochistan 44% 93% 52% Pakistan 41% 94% 57% Source: PIHS, 2002 29Government of Pakistan (2002): Pakistan Water Sector Strategy: Medium Term Investment Plan. 123 The negligible financial allocations made to the rural sanitation sub-sector have been exacerbated by recent changes in institutional arrangements. 12 village sewerage schemes (eight completed, four Sanitation ongoing); another 20 villages have applied for schemes; Accurate coverage figures for sanitation remain hard to and 100 more village schemes will be funded under a come by. In 2002, the Pakistan Integrated Household recently approved US$ 1.1 million grant from the World Survey (PIHS) found that only 41 percent of the rural Bank's Japan Social Development Fund (JSDF). households surveyed had toilets (compared to 95 percent coverage among urban households). Key features nThe LPP is an NGO Punjab is the richest and most populous province, yet (in process of registration); has the lowest rural sanitation coverage (32 percent) of nPeople-centeredprocess the four provinces. There are no obvious reasons for this (community contracting and management); weakness ­ poverty and literacy levels are at or above the nCommunity pay `internal costs' (50 percent total); national average, and the rural population ratio mirrors nThe LPP pay `external costs' (50 percent total); the national ratio. nLow-cost settled sewerage systems The negligible financial allocations made to the rural (average per household cost = US$ 70); and sanitation sub-sector have been exacerbated by recent nUntreated effluent used for irrigation. changes in institutional arrangements. Provincial Public General context Health Engineering Departments used to be responsible Mirroring trends at the national level, poverty in Punjab for implementation of most public or donor-funded has increased in recent years (from 25 percent to sanitation programs. In 2001, a Local Governance Ordinance created autonomous Tehsil Municipal 33 percent during 1991-99). There is also a marked Administrations (TMAs) and made them exclusively poverty gradient across the province, with Southern responsible for municipal services in both the rural and Punjab being considerably poorer than Northern Punjab. urban areas within their jurisdiction. This transition is In Pakistan, cultural and religious beliefs play an important incomplete, and many of the TMAs do not yet have role in determining behavior, particularly in the domestic the capacity or resources to fulfil their new roles sphere. Many women in rural Pakistan observe some form and responsibilities. of `purdah', which makes it difficult for women to have any meaningful participation in community decision-making or Removing the `rural-urban divide' through this radical new in community management of water and sanitation services. institutional arrangement is complex: it involves the Case Study Data Population Unit Name Poverty Literacy Sanitation Total Rural Coverage Tehsil Lohdran ­ ­ ­ ­ ­ Province Punjab 78 million 66% 33% 47% 50% Country Pakistan 145 million 66% 33% 45% 57% Region South Asia 1,401 million 72% ­ 56% 34% Source: WDR 2004; PIHS 2002; World Bank Pakistan-at-a-glance 2004 124 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia centralization of urban services from urban local councils to the Tehsil (sub-district) level, and the decentralization of rural services from provincial line departments to the TMA. Another key difference is that the head of this new local government body is an elected official (Tehsil Nazim) rather than a bureaucrat. Unsurprisingly, most TMAs are still finding their feet, and many of the reforms have not yet been put into practice. Case study context In assessing the importance of local context on the case study, two factors stand out: the relatively urban nature of the southern Punjab villages in which the LPP works; and the unusual level and quality of the support available to the LPP. The villages studied range in size from 50-400 Rather than sharing the costs of each component, the households, but almost all comprise tightly packed responsibility for providing the components is shared: settlements (several were planned villages with regular construction of the internal components is financed and street layouts) within which each household (or group of managed entirely by the community; provision of the households) lives in a brick-built house in a walled external components, technical assistance, and social compound. Most of the villages have brick-paved roads guidance are the responsibility of the LPP (and its donors). with cement-lined open drainage systems, and The technology is simple: each household toilet flushes approximately 60 percent of households have toilets, into a small interceptor chamber (known as a t-haudi); usually of the pour-flush variety with brick-built when this interceptor chamber fills, the liquid overflows enclosures. Very few households have any form of into a concrete sewer pipe; from there, a network of sewer septic tank or latrine pit, and most households flush pipes and manholes drains the settled effluent to a their untreated toilet wastes (sewage) and wastewater screening chamber connected to a large collection tank directly into the nearby open drains. (usually sited on the outskirts of the village); finally, the When these open drains block, which they frequently do, untreated effluent is pumped from the collection tank to an the streets are flooded with highly pathogenic sewage and irrigation channel feeding nearby fields. wastewater. As a result, there is strong demand for The LPP employs `social engineers', which it trains in improved sanitation. However, the relatively well- social mobilization, mapping, scheme design, and developed nature of the villages means that there is little construction supervision. Once a community (or demand for simple on-site sanitation solutions, such as pit individual) has applied to the LPP for a sanitation scheme, latrines. In these villages, people generally want a higher the LPP officials visit the locality and check the technical level of service, such as the low-cost sewerage schemes and social feasibility. When a sanitation scheme is found offered by the LPP. feasible, an LPP social engineer surveys the village and Approach prepares a preliminary design, which forms the basis of an The LPP uses a `component-sharing' approach modelled initial costing. The technical design is important, as it on that of the OPP. The challenge of providing sanitation determines what is `internal' or `external'. The LPP has a infrastructure is divided into `internal' components simple rule ­ any sections that require 12-inch diameter (sanitary toilet, sewer connection, and lane sewer) and sewer pipes (or above) are considered external works, up to `external' components (main sewers and disposal works). and including the disposal works. The rest (the smaller 125 Since 2001, the Lodhran Pilot Project has succeeded in developing a number of low-cost sewerage schemes in small communities in southern Punjab. Several are now in operation, greatly reducing the environmental and public health hazards that were previously common in these villages. diameter sewer pipes and manholes) is considered part of tank, so pumping is only required every few days. Thus the internal works.30 most of the villages have had little problem in finding someone willing to run the disposal pump (including paying Since the communities implement the sewerage schemes for the diesel) in exchange for the use of the effluent water. themselves, local market rates are used in the cost estimates, which detail actual material quantities (volumes Institutional model of sand and gravel; number of bags of cement; number of At present, the LPP operates like many small, successful bricks required) rather than engineering quantities (cubic NGOs. Its donors allow it to employ a small but feet of concrete, or square feet of brickwork). This enables committed cadre of staff, who are well-trained and well- the Village Sanitation Committees (VSCs) to understand looked after. One difference is that the LPP official in the cost estimates better, and helps them to price and charge of day-to-day operations is also a local source materials more confidently. government employee of the Lodhran TMA (Assistant Tehsil Officer, Infrastructure and Services Department). The cost estimate for the internal components This unusual and informal arrangement derives from the (including the purchase of any land required for the early phase of the project, when the LPP's work was scheme) is used to calculate the required contribution exclusively in Lodhran City. Today, most of the LPP's per household. If everyone agrees that they are willing work is elsewhere, which strains the TMA's tolerance of to pay this amount, then the VSC starts collecting the the voluntary work done by their employee (who receives household contributions and the LPP begins the a monthly honorarium from the LPP). necessary technical training. The LPP has received significant support from the As soon as the titles to the land for the disposal works National Rural Support Program (NRSP), a national NGO are transferred, and the full amount for the internal that has been working in Lodhran since 1998. NRSP works is deposited into a joint bank account, work begins on the external development (main sewers and Lodhran Pilot Project ­ Institutional model disposal works). Once the scheme is complete, the External donors community is responsible for all aspects of O&M (for both Lodhran TMA Local donors (WB-JSDF, CIDA, internal and external components). The main task at the WaterAid, UNDP outset is disposal of the untreated effluent. The LPP has Plus) developed a novel solution to this problem. Water is a precious commodity in these small villages, as NRSP Lodhran Pilot OPP most agricultural livelihoods are dependent on irrigation. Project The effluent water from the sewerage scheme is rich in nutrients and flows all year, thus it is valuable. In most cases, an individual from the village (normally from one of Union Council the richer families) is persuaded to donate land for the disposal works, and to agree to operate the diesel pump. In Village Sanitation return, this individual has the right to use the effluent water Committee to irrigate his fields (which are normally situated near the disposal works). The wastewater flow is relatively low for most of the year and the LPP provides a large collection Household 30The size of the sewer pipe is determined by the theoretical sewage flow (calculation based on the number of people connected to the sewer, and rules of thumb concerning typical household water use and wastewater/sewage flows). 126 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia started the process of registering the LPP, and has helped average community share of the costs is over 50 percent, the LPP to access external donors (CIDA, WaterAid, UNDP equivalent to US$ 38 per household. Even when someone Plus). NRSP has also been instrumental in the preparation in the community donates the land, the household of the JSDF proposal, and in advising the LPP how it can contribution averages US$ 28 (39 percent total). scale-up its activities to cover the 100 village schemes to One of the strengths of the LPP approach is that it be funded under the JSDF grant. leverages such high user contributions, despite operating Performance among rural households in the poorest part of Punjab. Since 2001, the LPP has succeeded in developing a However, further investigation reveals that, although the number of low-cost sewerage schemes in small schemes are intended to provide 100 percent sanitation communities in southern Punjab. Several are now in coverage, very few of the poorer members of the LPP operation, greatly reducing the environmental and communities use the improved sanitation services. public health hazards that were previously common in Most of the villages have a `katchi abadi' area on their these villages. outskirts, where tenant or seasonal farm workers and their The LPP reports that the community pay 30-35 percent of families are housed. These households are landless, poor, the total cost of the schemes, but a more detailed look at and without services. They are normally considered to be the data suggests that the community contribution is outside the community, thus are often excluded from actually much higher (see table). The LPP normally ignores community development activities. These excluded the cost of the t-chamber (interceptor chamber and sewer households often make up 10-15 percent of the connection) when calculating the community share of the population of the village, yet none of them can be served cost (as households are left to construct these chambers by the LPP sewerage schemes, as no sewer pipes have themselves, based on the standard LPP design). been laid in their streets. Incorporating the cost of the t-chamber and the cost of the Among those households with access to the sewerage land for the disposal works into the total reveals that the system, there are many who are not yet benefiting, Average Scheme Costs Component US$ % Toilet ­ ­ T-chamber 7 10% Internal works 21 29% Land 10 14% Internal sub-total 38 53% External works 34 47% Total 72 100% Source: Author, based on LPP data 127 Among those households with access to the sewerage system, there are many who are not yet benefiting, because they do not have toilets or sewer connections. because they do not have toilets or sewer connections. In part, this is because of the heavy household expenditure Basti Barati Wala required to obtain the scheme. In order that the scheme The sewerage scheme in Basti Barati Wala was completed could proceed quickly, some poor households were in late 2003, following collection of US$ 1,030 from its given the option of providing labor in place of their 50 households. Forty-five of the 50 households have contribution to the internal costs, but many of them have since built t-chambers and connected to the sewer since been unwilling or unable to construct the expensive network, but only 70 percent of these households own t-chambers and toilets used by their better-off neighbors. sanitary toilets. The remaining five households live alongside the sewer network, but have not built toilets Hygiene promotion or taken sewer connections. While the LPP approach encourages collective action and A transect walk revealed another two households living community development, it is a largely technical process. on the outskirts of the village. These families were not The focus is on financing and constructing low-cost mentioned among the 50 households in the community, sewerage schemes, rather than ensuring public health and were not included in the sewerage scheme. It benefits. The LPP's field staff carry out social mobilization transpires that they are seasonal laborers, and are not activities, but do not examine hygiene behavior or considered part of the community. Neither of these two households owns a toilet, and they remain excluded from undertake hygiene promotion. both the sewerage scheme and other community Awareness of good hygiene behavior is low in the LPP development activities. communities and, as remarked earlier, many of the poorer households do not own (or use) sanitary toilets. There is strong demand for wastewater drainage systems, Demand for sanitation based on the understanding that these technical fixes will NRSP found that rural communities in Punjab identify solve most rural sanitation problems, but there is limited sanitation as a major problem in their villages, naming the interest in building toilets, in safe excreta disposal, or in following specific issues relating to stagnant wastewater: stopping open defecation. Even in those villages where nEnvironmental pollution; there is a demand for sanitary toilets, the lack of low-cost nIncidence of disease among women and children (and toilet options is a significant constraint. The LPP estimates the cost of a typical toilet (ceramic pan, brick related medical bills); nGroundwater degradation; walls, precast concrete roof) at about US$ 90. Clearly, cheaper alternatives could be built, but they are rarely nDamage to buildings from water-logging; and promoted. As a result, many poor households feel that a nSocial degradation. toilet is beyond their means. These issues reflect the widespread drainage problems Technical sustainability found in Punjab, many of which stem from a failure to Despite the low average cost (US$ 71 per household), the maintain traditional open channel drainage systems. LPP sewerage schemes appear durable and well-designed. Typically, these open drains become choked with solid Much credit must go to the LPP engineers, and to the waste and excreta dumped or flushed into the drains by management and training process that produced them. the communities themselves. However, as more LPP schemes are developed and completed, some technical concerns are coming to light. Yet there is little recognition that many of the sanitation problems are linked to unhygienic practices, such as The first is a shortage of concrete sewer pipes of flushing toilets directly into open drains, or to the fact that reasonable price and quality, particularly in the more the drains are rarely cleaned. remote villages. The LPP has addressed this supply chain 128 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia issue by encouraging Village Sanitation Committees to committees currently have no role once the schemes are find local contractors willing to set up temporary pipe completed; LPP itself is not officially registered; and the manufacturing facilities in their village. Several VSCs LPP is dependent on uncertain funding from its donors, report favorably on this approach: not only are the pipes as the local TMAs cannot yet fund schemes that do not cheaper, the VSC also has more control over their quality comply with the current government procurement rules and availability. (which require that the official schedule of rates is used). The second is the sustainability of the sewerage schemes. In its favor, the LPP is well-embedded locally. It has In settled sewerage systems, the t-chambers must be a central office in Lodhran City, and four field units. regularly desludged to prevent the sludge from entering Its staff all originate from the area, and it is well-respected (and blocking) the sewer network. in local circles. It is also important that savings are put by for major repairs The LPP was fortunate to have help from both the OPP and replacements, as critical items such as the pump and and the NRSP in its early stages. The high quality of their its diesel motor need rapid attention when a problem guidance and support allowed the LPP to develop an develops. Unfortunately, the VSCs interviewed for this effective approach and a reliable team. These links also led study had little comprehension of the O&M tasks to interest in the LPP's activities from external donors and associated with their sewerage schemes, and had made no government, culminating in the approval of the JSDF grant plans to collect sewerage charges or to institute regular to provide 100 village sewerage schemes over the next cleaning and maintenance activities. three years. Social sustainability Financial sustainability In its rural program, the LPP deliberately focused on small The LPP's operational budget (salaries, vehicles, villages (eight of the 12 LPP schemes have less than 100 overheads) is currently about US$ 40,000 per year. households) because it found that social mobilization is Over the next three years, the LPP will be funded by the simpler in these cases, and external costs (per village) are JSDF grant, but it will have to source alternative funding lower. However, several larger village schemes (up to 250 beyond that time. There are also indicators that the households) have now been completed, using a phased financial sustainability of the village sewerage schemes approach to break the scheme development down into could be a problem in the future. In several cases, the smaller more manageable parts. transparent division of responsibility and increased In most communities, the poorest households are ownership conferred by `component-sharing' appeared to reluctant, or unable, to pay the required scheme be missing. And, as mentioned earlier, there was little contributions. Many of these households are also unable sense that any of the communities expected to have to to provide labor as an in-kind contribution, thus most fund major repairs or replacements in the future. VSCs have exempted several such households from In Gahi Mummar (Tehsil Kehror Pacca), the village payment (or provided the funds from elsewhere). This sanitation committee complained that two or three lanes in ensures that these poor households have access to the the village had no sewers, despite all the households sewer network, but does little to improve public health as having paid their contributions. It transpired that the they often remain without a sewer connection or toilet, scheme had been delayed (by rains and shortages of even after the scheme is completed. skilled labor) and that market rates had risen in the interim. Institutional sustainability As a result, the money collected by the community for the Institutional sustainability appears to be the biggest internal works (based on the original cost estimate) was challenge faced by the LPP: the village sanitation insufficient. However, despite the community agreeing to 129 The Lodhran Pilot Project is an undoubted success. It has developed a viable and low-cost approach to implementing rural sewerage schemes in southern Punjab. responsibility for funding and implementing all internal works, the community now felt that the LPP (or some Wastewater Reuse other donor) should fund the shortfall. If managed properly, wastewater reuse can have significant environmental and economic benefits. Treated It appears that the low level of technical and financial wastewater can be a better water source for agriculture know-how in these rural areas results in a pragmatic than fresh water sources. The flow is relatively constant, approach by the LPP: it does most of the work in and the nitrogen and phosphorus in the wastewater can planning and design, while the largely passive community provide higher yields than freshwater irrigation. waits to hear how much it will have to contribute towards the scheme. Inevitably, the community becomes The main health risks are from helminthic (worm) and more involved during the construction phase, but it microbial diseases contained in the wastewater, and from remains to be seen whether these communities are the contamination of shallow groundwater aquifers. The worst case is when untreated wastewater is used to genuinely committed to managing and maintaining the irrigate vegetable or salad crops that are normally eaten schemes themselves. raw, a practice that resulted in the 1981 cholera outbreak Environmental sustainability in Amman, Jordan. Two issues stand out: the safe disposal of settled sludge; The 1989 WHO `Guidelines for the safe use of wastewater and the use of untreated effluent to irrigate crops. and excreta in agriculture and aquaculture' identify the At present, none of the communities have realistic plans to treatment levels necessary, which depend on whether inspect or desludge their sewerage systems. However, irrigation will be restricted (used only on cereal, industrial, when it does become necessary to desludge the fodder crops or pastures and trees) or unrestricted t-chambers (or manholes, or collection tank), it is (irrigation of crops likely to be eaten uncooked, irrigation important that the highly pathogenic sewage sludge is of sports fields and public parks). safely disposed, rather than being dumped in the open The WHO guidelines also outline methods to protect somewhere in the village. public health through safe waste application and control The untreated effluent from the sewerage schemes is of human exposure. In most cases, sprinkler irrigation is discouraged, and where fruit trees are irrigated currently being used for `unrestricted irrigation' (see box with wastewater, irrigation should cease two weeks on wastewater reuse). It is important that the VSC before fruit is picked, and no fruit should be picked off understand the potential hazards associated with using the ground. untreated wastewater for irrigation, and that careful After Faruqui (2000) instruction is given on suitable crop types, safe application methods, and control of human exposure (particularly when wastewater is being used to irrigate fields close villages, and will involve far more complex and more to habitations). expensive schemes than those provided to date. And there Scaling-up is significant political resistance to NGOs such as the LPP. The LPP is planning to scale-up its activities through the Unfortunately, the LPP is caught up in the ongoing and JSDF grant, and is already using its high-level contacts to controversial decentralization struggle. This process has persuade local TMAs and provincial government bodies to greatly reduced the allocation of development funds to commit to funding schemes through this model in the both politicians (Members of National Assembly and long-term. But can the Government of Pakistan, or the Members of Provincial Assembly) and line departments Government of Punjab, afford to provide settled sewerage (such as LGRDD), creating considerable resistance and schemes in every village? Many of the settlements in the antipathy towards alternative models, particularly when Lodhran district are more like small towns than rural they are competing for the limited funds that remain 130 Lessons Learned from Bangladesh, India, and Pakistan Scaling-Up Rural Sanitation in South Asia available to vested political and government interests. This approach encourages user investment and ownership The LPP plans to expand its staff substantially. The project in their services, and delivers the long-term sanitation management team will be strengthened and another 150 solution that most communities aspire to. social engineers will be trained over the next three years, But there are drawbacks. The benefits of the LPP sewerage the best of whom will be recruited by the LPP to help with schemes, which are 50 percent funded by local or external the 30-40 sewerage schemes per year that it will soon be donors, accrue largely to better-off rural households. implementing. This rapid expansion in staff and activities Those who already have toilets and septic tanks can will be challenging. connect easily to the new sewerage system, and are more So far, the LPP has been able to train and recruit good likely to afford the expensive scheme contributions. In local talent, and the management have personally contrast, the poorest households are either excluded from monitored and supported their work. This may not be the sewer network (in the case of the seasonal workers), or possible in the next phase, with more staff, more schemes, unable to utilize it until they construct a costly toilet and and greatly increased reporting requirements. The LPP t-chamber (assuming they are willing and able to pay their recognizes that replication of its participatory approach scheme contribution). There are no alternative options, and has been slow in other localities, perhaps due little attention to whether the schemes are stopping open to limited dissemination and promotion of the model. defecation, improving hygiene behavior, and generating Therefore, it proposes to develop an IEC package that will health benefits. document and disseminate the lessons from the LPP. It also plans a program of exposure visits, in which 400 The sustainability of the schemes is also in question. elected councillors and local officials from nearby districts Rural communities often require long-term monitoring will visit the LPP schemes and discuss the approach with and support before they develop the capacity and local communities and officials. experience required to manage and maintain complex sanitation systems. Component-sharing is a good idea, Technically, the LPP approach is well suited to the but it looks a lot like cost-sharing in practice, and is no densely-packed villages, impermeable soils, and guarantee of sustainability. More emphasis needs to given associated drainage problems found in southern Punjab. to the long-term requirements of the LPP schemes, But the LPP offers only one option: settled sewerage. otherwise they are likely to go the way of the abandoned This option is relatively expensive, so may not be government sewerage schemes found in several of the affordable in all cases. And it is unlikely to be a viable surrounding villages. model in less urban scenarios, where households are more scattered. The basis of any demand-responsive There are also environmental issues. The communities are and participatory approach should be that it offers a range happy that the sewage and wastewater has been removed of options. These should include low-cost models from their villages, and that its disposal serves a useful suitable for the poorest, or for those not yet ready to purpose. But the LPP needs to look carefully at the long- invest heavily in sanitation infrastructure, and alternatives term environmental impacts of using heavily contaminated to cater for wide variations in local conditions. effluent for irrigation, and at practical methods of safely disposing of the septic sludge that will accumulate in the Conclusions sewer networks. Finally, it is not clear whether the approach The Lodhran Pilot Project is an undoubted success. is replicable. The approach appears simple, but as the It has developed a viable and low-cost approach to authoritative UNDP case study31puts it, `this project implementing rural sewerage schemes in southern Punjab. happened because some of the finest individuals in 31Haider & Husain (2002). 131 Many questions remain: Will the Lodhran Pilot Project model be effective when scaled-up? Is it an affordable model for use on a national scale? Pakistan got together to work on it'. Many questions 1. Chak 358 wb, Tehsil Dunyapur, District Lodhran (no remain: Will the LPP model be effective when scaled-up? scheme, but cash collected). Is it an affordable model for use on a national scale? 2. Basti Barati Wala, Tehsil Lodhran, District Lodhran (completed scheme in operation). Fieldwork 3. Gahi Mummar, Tehsil Kehror Pacca, District Lodhran Findings based on documentation collected by WSP (scheme 80 percent complete). Pakistan, and rapid appraisal during February 13-17, 4. Chak 205 wb, Tehsil Malsi, District Vahari (scheme 2004, including: interviews with LPP management and 40 percent complete). staff in Lodhran, with the Tehsil Nazim and TMA staff in 5. Kot Malikpur, Tehsil Malsi, District Vahari (first phase Dunyapur, with LGRDD officials in Lahore, with NRSP complete). management in Islamabad, and with the household 6. Chak 97 m, Ghariabad, Tehsil Lodhran, District Lodhran members in six villages in southern Punjab: (rehabilitation ongoing). References Faruqui, N (2000) Wastewater treatment and reuse for food and agriculture, Colombo, International Water Management water security, Ottawa, International Development Institute, Water Policy Briefing Issue 9 Research Center Kar, K (2003) Subsidy or self-respect? Participatory total Franceys, R, Pickford, J and Reed, R (1992) A guide to the community sanitation in Bangladesh, Brighton, Institute of development of on-site sanitation, Geneva, World Health Development Studies Working Paper 184 Organization NRSP (2002) Handbook: community-owned rural sanitation, GoAP (2003) Rural sanitation programme: Individual sanitary Multan, National Rural Support Programme, Lodhran Pilot latrines and school toilets in rural areas ­ guidelines for Project Rural Sanitation Cell implementation of programme, Hyderabad, Government of Andhra Pradesh, Panchayat Raj and Rural PIHS (2002) Pakistan Integrated Household Survey Round 4: Development Department 2001-02, Islamabad, Government of Pakistan, Federal Bureau of Statistics, Statistics Division GoI (2004) Guidelines on Central Rural Sanitation Programme: Total Sanitation Campaign, New Delhi, Government of RGNDWM (2003) Workshop on reform initiatives in water supply India, Ministry of Rural Development, Department of and sanitation sector: Maharashtra, Gujarat and Dadra & Drinking Water Supply Nagar Haveli, Mumbai, Government of India, Ministry of Rural Development, Department of Drinking Water Supply, Haider, M and Husain, T (2002) Accelerating the pace of Rajiv Gandhi National Drinking Water Mission, Processed development: a case study of the Lodhran Pilot Project, Islamabad, United Nations Development Program Shariff, A (1999) India Human Development Report: A profile of Pakistan, Local Initiative Facility for Urban Environment Indian States in the 1990s, New Delhi, National Council of Applied Economic Research, Oxford University Press Harriss, J (2000) How much difference does politics make? Regime differences across Indian states and rural poverty WSP-SA (2002) Jal Manthan 7: Making sanitation work, reduction, London, London School of Economics, LSE New Delhi, The World Bank, WSP-South Asia Development Studies Institute Working Paper Series No. 00-01 WSP-SA (2003) Component-sharing: up-scaling demand- responsive approaches in rural water supply and sanitation IWMI (2003) Confronting the realities of wastewater use in sector in Pakistan, Islamabad, WSP-SA, Field Note 132 Water and Sanitation Program- South Asia The World Bank 55 Lodi Estate New Delhi 110 003 India Phone: (91-11) 24690488-89 Fax: (91-11) 24628250 The World Bank E 32 Agargaon, Sher-e-Bangla Nagar Dhaka 1207, Bangladesh Phone: (880-2) 8159001-14, 8159015-28 Fax: (880-2) 8159029-30 The World Bank 20 A Shahrah-e-Jamhuriat Ramna 5/1, Islamabad, Pakistan Phone: (92-51) 9090150, 9090000 Fax: (92-51) 2826362 E-mail: wspsa@worldbank.org Web site: www.wsp.org May 2005 WSP MISSION To help the poor gain sustained access to improved water and sanitation services. WSP FUNDING PARTNERS The Governments of Australia, Austria, Belgium, Canada, Denmark, Germany, Italy, Japan, Luxembourg, the Netherlands, Norway, Sweden, Switzerland, and the United Kingdom, the United Nations Development Programme, and the World Bank. Author: Andy Robinson Photographs: Andy Robinson Created by: Write Media, India Printed at: Thomson Press (India) Limited