issue 12 • february 1999issue 12 • december ...waterfront issue 12 • february 1999issue 12 •...

ISSUE 12 • FEBRUARY 1999

WATERfrontISSUE 12 • DECEMBER 1998

A UNICEF PUBLICATION ON WATER, ENVIRONMENT, SANITATION AND HYGIENE

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unicefUnited Nations Children’s FundFonds des Nations Unies pour l’enfanceFondo de las Naciones Unidas para la Infancia

his issue of WATERfront is dedicatedexclusively to environmental sanitationand hygiene. Most of the content comes

from presentations by participants at theUNICEF workshop on these issues held inNew York in June 1998.

The week-long workshop, organized inpartnership with the UK Depart-ment for International Develop-ment and USAID, was attendedby over 70 professionals—30from UNICEF country andregional offices, 12 fromUNICEF headquarters of-fices and almost 30 frompartner agencies, govern-ments and NGOs.

The workshop focusedon practical field experiencesand the lessons we can learnfrom them. These are also thefocus of this WATERfront issue, whichreports on all 19 of the country case studiespresented at the workshop. We hope our read-ers will use thesecountry experiences as a tool to accelerate thepromotion of environmental sanitation andhygiene in as many ways as possible.

For it remains a sad fact that our efforts tosupply clean surroundings for the world’s poorhave consistently lagged far behind our effortsto supply them with clean water. And sanita-tion programmes have failed to keep pace withpopulation growth. The total without access tosanitation rose from about 1.7 billion in 1980to almost 3 billion in 1994 and is projected toreach 3.3 billion by the year 2000.

Rapid urbanization in developing countrieshas compounded the problems of people livingin cramped, fetid city slums. Over 2.5 million

Environmental sanitation: a globalchallenge for the 21st century

children still die each year from the diarrhoealdiseases largely preventable by sanitation. Agreater number survive, their physical growthstunted by the vicious cycle of frequent infec-tions and nutritional depletion, their mentalgrowth stunted by the loss of energy to learn,play, explore, go to school.

Why is sanitation nothappening?

How we dispose of our bodilywastes is a highly personalmatter, so private it is notdiscussed openly in manycultures, yet it affects all ofus. Faeces are allowed tocontaminate other people’sdrinking water; villages and

towns dump their solid andliquid wastes into rivers with-

out any compensation or concernfor those who live downstream. Com-

munal solutions, such as sewerage, still dependon individuals changing their behaviours andmaintaining their new habits lifelong. Thispartly explains why it has been so hard to solvethis fundamental problem.

Past efforts to promote sanitation oftengauged success solely by the numbers of la-trines set in place, without considering howthey were then used, if they were used at all.This hurry to impose increased ‘coverage’sometimes caused more problems than itsolved.

We now know that long-lasting behav-ioural change is a prerequisite to sustainedimprovements in sanitation. Change of thiskind calls for time-consuming approachesinvolving user participation, education, aware-

Table of Contents2 Environmental sanitation

and hygiene are UNICEFpriorities for 1998–2000

3 The impact of sanitation andhygiene on health and nutrition

5 Development of Uganda’snational sanitation policy

8 A new measure of disparities:Poor sanitation in Internet era

9 Dirty hands can have tragic,deadly consequences

Country briefs:10 Bangladesh: Designing a national

communication strategy11 Brazil: A better life for garbage

pickers12 Burkina Faso: Marketing hygiene

in a West African city12 China: Push and pull for rural

sanitation13 Guatemala: Helping squatters

back to their feet14 Honduras: Is low-cost sewerage

feasible for the urban poor?15 India: India’s rural sanitary marts15 Indonesia: The Clean Friday

movement16 Iraq: Rebuilding after war17 Mali: Tackling sanitation and

guinea worm17 Myanmar: Changing gear on

sanitation18 Nigeria: Keeping girls at school19 Nigeria: Turning garbage to profit20 Nigeria: Making SanPlats a

household word21 Tanzania: The hare and the

tortoise21 Uganda: Uganda’s sanitation

drive: the UNICEF context22 Viet Nam: Testing intensive

sanitation23 Zambia: Bringing sanitation to

the fore24 Zimbabwe: Participatory hygiene

education

26 New Publications

27 Useful resources

28 A global initiative for basicsanitation

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Issue 12 • December 1998unicef WATERfront

s part of its medium-term strategyfor the period around the mil-lennium change, UNICEF has

launched the Programme PrioritiesInitiative—an intensive effort to acceler-ate the pace of programme implementa-tion in specific areas and countries. TheInitiative’s objective is to help countriesreach the targets set by the World Sum-mit for Children in 1990—and to ensurethat this progress is carried into abroader vision of child rights in thecoming century.

Environmental sanitation and hy-giene are key concerns under the Pro-gramme Priorities Initiative, especiallywithin the goal of reducing under-fivemortality and morbidity rates. Action1.5 of the Initiative—support to inte-grated community-based approaches toimproving child health, nutrition, sani-tation and hygiene—specifies a range ofprogramme support activities includinghand-washing, hygienic preparation offood and sanitary disposal of humanexcreta. Action 1.6 of the Initiative fo-cuses on improved environmental sani-tation in urban areas and emphasizescapacity building in the fields of com-munication skills for behaviouralchange, solid and water waste disposal,and latrine construction.

Environmental sanitation and hy-giene are also underscored in the Initia-tive under the ‘emerging issue’ ofactions to improve early childhood carefor child growth and development.Under this heading the importance ofhygiene practices for young child careand development is stressed, as is theprovision of clean play areas. The role ofsanitation and hygiene in schools, too,receives special attention in the Initia-tive, especially in the context of improv-ing the learning environment for girls.

The Initiative’s spotlighting of envi-ronmental sanitation and hygiene wasone of the principal reasons for conven-

In UNICEF medium-term strategies,environmental sanitation and hygiene arepriorities

ing the UNICEF workshop on theseissues in June. Many of the recommen-dations made by the workshop partici-pants relate directly to specific Initiativegoals, and the experiences shared by theparticipants can be directly applied toprogramme acceleration.

A entry point has powerful advantages.Children at school can more easilychange to new behaviours as a result oftheir new knowledge, reinforced by well-designed sanitation facilities encourag-ing hand-washing and other soundhabits. The schoolchildren can theninfluence the behaviours of their familymembers, both adults and younger sib-lings, and thereby influence the wholecommunity to look after their immedi-ate environment and adopt hygienicpractices. Schoolteachers, as profession-als and influential individuals, can playan important part by training their pu-pils and providing a role model for theircommunities.

The absence of separate toilets forgirls has proved to be one of the mainimpediments to their attending school(along with their time-consuming choreof water collection, which can be light-ened by water points closer to home).Upgrading school sanitation will help tokeep children healthy and in school—especially girls.

Environmental sanitation andhygiene are key concerns under

the Programme PrioritiesInitiative, especially within the

goal of reducing under-fivemortality and morbidity rates.

Focus on schoolsOver the coming years UNICEF’s educa-tion and sanitation teams will be joiningforces regularly to focus water supply,sanitation and hygiene education onschools and the people connected toschools.

We believe that the school as an

UN reaffirms commitment to GESIIn October 1998 the Subcommittee on Water Resources, UN AdministrativeCommittee on Coordination, endorsed GESI—the Global Environmental Sani-tation Initiative first proposed by UNICEF two years ago.

This follows on the unanimous endorsement of GESI by the Water Supplyand Sanitation Collaborative Council (WSSCC) at its meeting in Manila in No-vember 1997. The participants at the Manila meeting—donors, UN agencies,NGOs and more than 80 developing-country professionals and decisionmakers—called for worldwide concerted efforts to promote sanitation underGESI, to accelerate the provision of hygienic conditions for all in the comingmillennium.

GESI activities will centre on helping all agencies to share information, fos-tering cooperative programmes, and initiating an advocacy campaign to raisepublic and political awareness of the urgent need for action. Participation byUNICEF staff at country level will be crucial.

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Issue 12 • December 1998 unicef WATERfront

Current UK policyhave been asked to speak on behalfof Dr. David Nabarro, Senior HealthAdviser of the UK Department for

International Development (DfID), whounfortunately was unable to be presenthere today. The fact that he had hopedto attend this workshop, and the pres-ence here of myself and two colleaguesfrom WELL at DfID’s behest, shows theimportance which DfID attaches tosanitation and hygiene. Environmentalhealth is one of the five global themes inDfID’s new health policy. DfID has alsofunded important research work in thisarea, such as the development of hygieneevaluation procedures and the recentstudy on user perceptions of on-sitesanitation in Ghana, Mozambique andIndia by Darren Saywell of the Waterand Engineering Development Centre(WEDC), University of Loughborough.However, the most forceful demonstra-tion of DfID’s commitment is last year’sundertaking by the Prime Minister,Tony Blair, to double DfID’s spendingon water, sanitation, hygiene and healthin sub-Saharan Africa.

DfID’s new policy framework em-phasizes partnership, with UK centres ofexpertise such as the London School ofHygiene and Tropical Medicine and theUniversity of Loughborough, our part-ners in WELL, and also with interna-tional organizations such as UNICEF.An increasing proportion of DfID’sbudget has been allocated to multilateralorganizations over the years; with anincrease in Britain’s aid budget likely tocome soon, much of the additional allo-cation will go to United Nations organi-zations. In particular, DfID is proud ofits past support to UNICEF and keen tosee its partnership strengthen in sanita-

The impact of sanitation and hygiene onhealth and nutritionWorkshop presentation, 10 June 1998, UNICEF New York

Dr. Sandy Cairncross, Director, WELL Resource Centre (Water and Engineering at London and Loughborough)

tion and hygiene. DfID knows how diffi-cult it is to do good work in this sector.

One reason for the difficulty is that itinvolves two-way communication withpoor people. It is relatively easy to talkto them, and offer them preconceivedsolutions; but it is far harder to listen tothem, and analyse their problems first.UNICEF is particularly good at thisdifficult work, largely because of itsunique and precious resource of techni-cal people based in the field. It is thanksto that cadre that most of the best andmost sustainable sanitation and hygieneprogrammes I have known were devel-oped or implemented with UNICEFsupport.

Health impacts of sanitationDiarrhoeal diseasesI have been asked to speak about thehealth impacts of sanitation and hy-giene. The chief impacts relate to thereduction of diarrhoeal diseases. Thankslargely to the efforts of UNICEF to pro-mote good case management of diar-rhoea, these diseases cause fewer deathsthan they used to; but over 2.5 millionchild deaths a year is still far too many.It is equivalent to the death of a childevery 10 seconds, or to a jumbo jet fullof children crashing into the sea everyhour. As oral rehydration therapy

(ORT) continues to bring the totaldown by tackling the lethal symptom ofdehydration, it will become increasinglytrue that only the prevention of diar-rhoea itself, for instance by sanitationand hygiene, can reduce the toll anyfurther.

For example, one diarrhoeal diseaseunaffected by ORT is bacillary dysen-tery, causing persistent, bloody diar-rhoea which, though not dehydrating,can be lethal to children and is also amajor cause of adult mortality. Sixteenyears ago, Dr. M.U. Khan showed thatthe simple measure of washing one’shands with soap could prevent six out ofseven cases of dysentery transmitted inthe home.

To assess what proportion of alldiarrhoeas could be avoided by im-proved sanitation and hygiene, I cannotdo much better than the estimate com-piled in 1990 by Steve Esrey and col-leagues from a thorough review of theliterature, shortly before Steve joinedUNICEF. They found that improve-ments in water supply, sanitation andhygiene were associated with a medianreduction of 22% in diarrhoea inci-dence, and of 65% in the rate of deathsdue to diarrhoea. Research tells us thatthe water benefit is due to the hygieneimprovements which water supplymakes possible, so that it would not beentirely wrong to attribute the entireimprovement to sanitation and hygiene.

It should be stressed, though, thatreviewing this literature is extremelydifficult. The published studies wereconducted in a wide variety of circum-stances, and it is obvious that the impactof sanitation will depend on the condi-

continued on next page

I …it involves two-waycommunication with poor

people. It is relatively easy totalk to them, and offer them

preconceived solutions; but it isfar harder to listen to them, and

analyse their problems first.

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tions prevailing before the intervention.In addition, the studies are of variablescientific rigour. Studies of diarrhoeaepidemiology are not for amateurs, asthere are many potential confoundingfactors and a host of other difficulties.Apparent demonstrations of a healthimpact can often be deceptive. For ex-ample, it would be easy, even with so-phisticated statistical controls, toconduct a study demonstrating thattelevisions protect one from diarrhoea,as those who own televisions are lesslikely than others to become ill for ahost of reasons unconnected with sani-tation. So it is with latrines….

In particular, and contrary to whathas recently been suggested, I know ofno firm evidence that the more expen-sive water-flush toilet systems requiringpiped water show a greater health im-pact than cheaper but well-maintainedfacilities such as pit latrines. On thecontrary, we know that a facility whichis too expensive for a family to installwill offer them no benefit at all.

Intestinal wormsThere are other important health im-pacts from sanitation, particularly thecontrol of intestinal worms such asAscaris (roundworm), Trichuris (whip-worm) and hookworm. Ascaris divertsabout one third of the nutritional intakeof a child with a typical worm burden,and is also an important cause of asthmain poor communities. Hookworm is amajor cause of anaemia. Trichuris is aserious cause of stunting in children,and of chronic colitis in toddlers, solong-lasting that their mothers rarelythink of taking them for treatment asthey tend to think that this diarrhoea isa normal condition for these children.The nutritional impact of these worms isevident from cases where children havebeen treated with deworming drugs, andhave then shown an immediate spurt ingrowth. Treatment, however, is not asustainable option to prevent reinfec-tion; the sustainable option is sanitation.

■ Impact of sanitation and hygiene from previous page

ExternalitiesThe impact of sanitation on intestinalworms was first demonstrated by thestudies of the Rockefeller Foundation70 years ago. An important conclusionfrom these and other studies relates tothe externalities of this impact. Theexternalities arise from the fact that mylatrine helps to protect you, my neigh-bours, from my diseases. Indeed, there isan impact on the health of the commu-nity as a whole from the overall level ofsanitation it enjoys. For advocates ofsanitation this is good news, as it meansthat sanitation is not only a privategood, but also a public good, and thatthere is therefore a case for public inter-vention, by subsidy or regulation, topromote it. No individual can be ex-pected to pay voluntarily for a benefitwhich others will enjoy.

It has been suggested that a piece ofbad news comes with this good news, inthat some threshold of coverage mustfirst be achieved before any health ben-efits will accrue. However, I can tell youthat there’s good news on both sides ofthe coin. In practice, there are healthbenefits to the individual householdswhich install latrines (indeed most ofthe studies showing health benefits haveconsidered just this case), with addi-tional benefits to the community whenoverall coverage is sufficient to prevent

disease transmission in the publicdomain.

Hardware is not enoughAnother result of the Rockefeller re-search is that the provision of sanitationalone is not enough. Changes in behav-iour are required for the full benefits tobe achieved. This is eloquently illus-trated by the following quotation fromCort, Otto and Spindler (1930), writingabout their work in south-western Vir-ginia in the USA. Their style reminds usthat this was written nearly 70 years ago:

“Several groups of negroes,one of which was extremely poor,as well as numbers of poor whitefamilies, showed little or no Ascarisinfestation because of the controlof the children and the use of priv-ies by all members of the families.On the other hand some of thebetter-off rural families with well-kept yards and good privies, andcertain families in very well-sani-tated mining-camps, had heavyinfestations. Such infestations werealmost always due to soil pollutionnear the houses by the young chil-dren, who were not taught to usethe sanitary facilities provided.”

Other benefits of sanitationOther benefits are less well documented,such as the impact on trachoma, thesecond most important cause of blind-ness worldwide. Studies from Mexicoand Malawi have shown the importanceof washing children’s faces in preventingthis disease. One study from Lombok inIndonesia suggests that even hand-wash-ing helps to prevent conjunctivitis. It isless well known that even latrines canhelp to control trachoma; where muchof the infection is transmitted by fliessuch as Musca sorbens, which breeds inscattered human faeces, latrines canprevent this transmission by deprivingthe vector of a breeding-site.

All these health impacts may be ourreason for seeking to improve sanitationand hygiene, but they may not be themost important factor for the users. Thefollowing were the responses of latrine

There are other important healthimpacts from sanitation,particularly the control ofintestinal worms such as

Ascaris (roundworm), Trichuris(whipworm) and hookworm.

Ascaris diverts about one thirdof the nutritional intake of a

child with a typical wormburden, and is also an

important cause of asthma inpoor communities.

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owners in the rural Philippines whenthey were asked why they were satisfiedwith their new facilities. Note the order:

1. Lack of smell and flies

2. Cleaner surroundings

3. Privacy

4. Less embarrassment whenfriends visit

5. Less gastrointestinal disease

The first four are not just selling-points; they are real benefits, for whichpoor people are willing to pay cash.Economists therefore can attribute amoney value to them. There may beother such benefits, which are still moreimportant though the respondents didnot mention them. For instance, theavailability of a household latrine maybe a major factor protecting womenfrom sexual harassment and even rape

on the way to or from the village defeca-tion ground; yet few women may feelable to mention this, and few men maycare to. We should study carefully whypeople may want sanitation; best of all,we should ask them. However differenttheir reasons may be from ours, weshould use them for promotion.

The quotation above from Cort andcolleagues illustrates the importance ofhygiene behaviour as a determinant ofhealth benefits, yet changes in behaviourare rarely measured in impact studies.If they were, it is likely that greater im-pacts would be found when behaviourchanges were achieved. By the sametoken, changes in behaviour are rarelypromoted effectively; if they were, manysanitation programmes could achievegreater health impacts than they havedone. Recent research has shown that, inthe same way that other benefits aremore important than health to most

■ Impact of sanitation and hygiene from previous page

In Uganda our operational definition ofsanitation involves:

1. Safe disposal of human excreta

2. Personal and public (including food)hygiene

3. Solid and liquid waste disposal

4. Vector control

5. Keeping drinking water safe untilconsumption (locally referred to asthe safe water chain).

The situation in Ugandan the 1960s and 1970s latrine cover-age was reported to be very high at90% to 95%. During that period,

Development of Uganda’s nationalsanitation policyWorkshop presentation, 10 June 1998, UNICEF New York

by the Hon. Dr. C.W.C.B. Kiyonga, Minister of Health, Uganda

public health legislation and by-lawsregulated food preparation in publicrestaurants and institutions, refuse dis-posal, and the numbers of latrines inhouseholds, institutions and publicplaces. Policy was strongly enforced bythe Health Inspectorate with the supportof parish chiefs. Other hygiene practiceswere generally poor; for example, veryfew people washed their hands with soap(or ash) after using the latrine or beforeeating.

Later political turmoil and thebreakdown of law and order in the1970s and 1980s saw a reduction inenforcement and a significant reductionin latrine coverage. The lowest recordedaverage level of latrine coverage was

30% in 1983, reported by UNICEF in1984. Latrine coverage levels had risento an average of 48% by 1993 but withsignificant regional variation, from 4%in the north-east and the Sese Islands ofLake Victoria up to 89% in Rukungiriand Kabale in the south-west. Manyhealth centres and schools still do nothave adequate numbers of latrines andhand-washing facilities for the numbersof clients and students. A recent studyby the Uganda National ExaminationsBoard of schools in several sample dis-tricts found that 67% had water supply;only 8% had an adequate number oflatrines, and only 33% had separatelatrine facilities for girls.I continued on next page

latrine owners, talk of disease, doctorsand death is a less effective lever to be-haviour change than messages based onwhat people know, do and want.

Let me finish with a quotation fromSir Ronald Ross, one of the founders ofmy institution and the man who, 100years ago, discovered that malaria wastransmitted by mosquitoes:

“Great is sanitation; the greatest

work, except discovery, I think,

that one can do…. What is the use

of preaching high moralities, phi-

losophies, policies and arts to

people who dwell in appalling

slums? You must wipe away those

slums, that filth, these diseases….

We must begin by being cleans-

ers.”

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Rural areas. Ninety per cent of Ugan-dans live in rural areas. Most rural peo-ple live in family compounds and invillages with less than 300 people inthem. Average household size is 4.8people. Not all family members uselatrines, and the excreta of young chil-dren are unlikely to be disposed ofsafely. Hand-washing with soap or ashafter defecation, after handling children’sexcreta and before cooking or eatingfood is rarely carried out. Drinkingwater collected from safe sources is oftencontaminated prior to consumptionduring handling and storage. Lack ofperceived responsibility, lack of knowl-edge and facilities, and certain culturaltaboos or myths together contribute tothese low levels of sanitation. In the east(Tororo) taboos exist whereby some in-laws are excluded from using the latrineof their host family. In the same area,some people believe that persons withdiarrhoea should not use a latrine butshould practise open defecation instead.Other myths existing around latrine useinclude fears of causing infertility inwomen, fear of pregnant women losingtheir unborn infants down the latrine,fear of being poisoned or bitten bysnakes in the latrine, and even fear ofcatching AIDS by using a latrine.

Urban centres. Ten per cent of Ugandanslive in urban areas, but their numbersare growing by more than 5.5% eachyear (nearly twice the national growthrate). The largest towns in Uganda wereconstructed with sewerage systemswhich are operated and managed by theNational Water and Sewerage Corpora-tion. However, the sewer network usu-ally covers a minimal area of the town,often the original commercial centreand colonial residential areas. High-income residential areas without accessto sewers have usually constructed septictanks. Lower-income residential areasare usually served with pit latrines. Solidand liquid waste disposal is also inad-equate. Kampala City Council estimatethat they collect and dispose of refusefrom only 20% of the population; the

rest is dumped indiscriminately. Mostother urban centres also have difficultiesin collecting and disposing of solidwaste. Conditions are worst for thehigh-density low-income informal resi-dential areas which may house 25% ofthe urban population. During the socialmobilization activities to combat thecholera outbreak in 1998, the communi-ties in Kampala singled out as especiallyvulnerable were found to have generalaccess to latrines (81% of households),but only 23% had a separate latrine, and30% were sharing one latrine with morethan four other households (more than21 people). The result was that 41% ofhouseholds had excreta visible in theircompounds, thus increasing the risk ofdiarrhoeal disease transmission. Fifty-two per cent of households had no fa-cilities for solid waste disposal, while57% had no facilities for liquid wastedisposal.

Displaced communities. Communitiesdisplaced by natural disasters and inse-curity experience different sets of prob-lems. Often forced to flee with little orno warning, they consider themselves tobe transitory. This brings a reluctance tocarry out any sorts of improvements totheir new environment. This is exagger-ated with poverty. Often wealthy dis-placed persons are able to relocaterelatively easily, but the poorer sectorsof the community will not have the cashto move long distances or purchaserequired services. In the course of anemergency, particularly following dis-placement, normal patterns of wateruse, excreta disposal and hygiene prac-tices are often disrupted, and individualsare rendered more vulnerable than usualto water and sanitation-related diseases,especially in overcrowded situations.Women may experience additionalproblems given their role as caretakersof the family and their requirement foradditional privacy.

Technological problems. Pit latrine con-struction is difficult in some parts of thecountry because of collapsing soils,

rocky soils and high water-tables. Thechallenge in this case is to produce adesign that is affordable and acceptableto the affected populations.

Effects of poor sanitationSocio-economic costs. Poor sanitation hasa significant negative effect on the na-tional economy. Hundreds of thousandsof education days and workdays are losteach month because of the diseaseswhich improved sanitation can prevent.On average, 2.7% of all students’ timeand 3.5% of all work time is lost to sick-ness or injury. Given that 49% of allreported sickness and injury in Ugandais related to poor sanitation, and estimat-ing that 8 million of Uganda’s 20 millionpopulation are between 15 and 60 yearsof age and working a 24-day month,some 39.5 million workdays are lost inUganda each year because of poor sani-tation. Expenditure on treatment of sani-tation-related diseases including malariacurrently amounts on a very rough esti-mate to about 27 billion Uganda shillings(some $22 million) a year.

Environmental impact. Lack of adequatesanitation is also a major threat to theenvironment. Examples include thedegradation of the urban environmentby indiscriminate disposal of solid andliquid wastes and the eutrophication offreshwater lakes by untreated humanwaste, the result being smaller, contami-nated fish catches. The costs of environ-mental damage include discouragementof the tourist trade, reduced overseasmarkets and revenue for fish products,reduced production from fisheries, andincreased purchase costs for chemicaland mechanical clean-up operations.The export value of Lake Victoria’s fish-eries is estimated at $320 million peryear (not including revenue from thehome market), but exports from sevenof the nine Ugandan processors havebeen banned. The causes of this are allsanitation-related, either from poorlakewater quality or poor hygiene duringcatching, storage and processing.

Impact on education. In 1995 there were8,531 government-aided primary

■ Development of Uganda’s national sanitation policy from previous page

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schools for a total number of 2,626,406students. Of these schools, 3,812 (44.5%)had a water supply and the reportedratio of students to latrines was 328 to 1(Ministry of Education Planning Unit).Many schools, particularly rural schools,had no latrines at all, and of those withlatrines, most did not have separatelatrine facilities for girls and boys. Lackof latrines, especially separate latrinesfor girls, was identified as the worstschool experience for girls. This drawsattention to the special conditions andexperiences which prevent girls fromfuller participation and achievement:privacy issues relating to sanitation are amajor factor forcing them out of school.Following the recent implementation ofthe policy for universal primary educa-tion, the ratio of pupils to latrines maynow exceed 700 to 1, and may encour-age further dropping out, especiallyamong adolescent girls.

Impact on health. Morbidity figuresavailable from outpatient diagnoses showthat diarrhoea, worm infestations, eyeinfections and skin diseases accountedfor 23.5% of all outpatient visits tohealth units in 1996, while malaria(another disease related to poor sanita-tion) accounted for a further 25.5% (i.e.a total of 49% of all outpatient visits areaccounted for by poor sanitation).

Undernutrition. The level of nutritionalstunting in Uganda is still among theworst rates of nutritional stunting inAfrica, and is partly attributable to thehigh incidence of diarrhoea—an averageof 5.2 episodes a year for childrenunder five.

Cholera and malaria epidemics. Follow-ing El Niño this year, Uganda was hit bycholera and malaria epidemics. By theend of April 1998, an estimated 35,000people had been taken ill with a total of1,500 deaths. This gives a case fatalityrate of 4.3%. Causes identified for thediarrhoeal outbreaks included over-crowding, lack of sanitary excreta dis-posal facilities, high water-tables, lack ofsafe drinking water, poor food hygienein markets (vendors and purchasers),

and inadequate solid waste disposal.Along with a higher incidence of diar-rhoea, slum dwellers in swampy areassuffer a greater incidence of malaria.

Special gender needs■ Women and girls in Uganda are the

caretakers of the home. In homesthey are responsible for cooking(86%), water collection (70%), fire-wood collection (73%), child care(62%), washing clothes (88%), andcare for the sick and elderly (62%).

■ In northern Uganda, women areresponsible for constructing homesincluding latrines. In other parts ofUganda, only men construct housesand latrines.

■ Women work an average of 15 hourseach day. No comparative figure isavailable for men, but it is estimatedto be significantly lower. While 70%to 80% of the agricultural labourforce is female, only 7% of womencultivate their own land and only30% have access to and control overthe proceeds, including the resourcesneeded for sanitation services. Twentyper cent of formal-sector employeesare women, and those women aremostly in the lowest-paid jobs.

Sanitation affects men, women andchildren to different extents, but is gen-erally worse for women. Problems of

privacy for urination and defecation areespecially acute for women and adoles-cent girls in urban areas, and are height-ened during menstruation.

Further study and gender analysisare required to determine the needs ofmen, women, boys and girls and to de-termine the optimum course or strategyto involve the active participation ofthem all.

Raising the profile of sanitationPresident Museveni’s 1996 electionmanifesto referred to the importance ofimproved sanitation in Uganda. Thenational Constitution states that it is theduty of every citizen in Uganda to createand protect a clean and healthy environ-ment. The first step in the process ofimproving sanitation in Uganda was togather all existing data on sanitation.The work on this developed into a con-cept paper entitled ‘Promotion of sani-tation in Uganda’ which was publishedin June 1997. This is the most compre-hensive statement on sanitation everwritten in the country. It covers theoverall situation in Uganda, both pastand present; discusses the effects of poorsanitation and the reasons for itsmarginalization; and calls for an acceler-ated national sanitation programme.

Empowering the people toimprove sanitationWe have decided to make sanitationimprovement a highly political processtargeting all elected officials in Uganda,starting with the President, who set theball rolling through his election mani-festo, and moving down through to thevillage level. Indirectly, therefore, weintend to reach the entire populationthrough the elected leadership and, bycoordination using a community-basedparticipatory approach, change thenorms in Uganda in regard to sanita-tion. A Cabinet memo based on theconcept paper was drafted, discussedand approved in July 1997.

The new approach to improvingsanitation will build on the grass roots:local government councils and develop-ment committees are to plan and main-


The new approach to improvingsanitation will build on the

grass roots: local governmentcouncils and development

committees are to plan andmaintain their own sanitationimprovement activities, and

promote individual action forchange, with the support oftechnocrats from all sectorsincluding health, education,

community development andwater.

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round the world, more people aregetting telephones and access tothe Internet while at the same

time an increasing number are withoutbasic household sanitation—toilets, oreven simple latrines—according to anew report.

The report, ‘’Vital Signs 1998,” waspublished on Saturday by the Independ-ent Worldwatch Institute, a Washingtonenvironmental group.

It is the latest in a series of annualsurveys pulling together a wide range ofdisparate indicators—crop yields, cli-mate changes, medical advances andretreats, military expenditures or theproduction figures for bicycles com-pared with cars—to spot new trends.

“There are a lot of important trendsthat never get reported,” said LesterBrown, who originated the survey in1992. It is now published in 21 lan-guages.

Looking at sanitation, an importantfactor in health crises in poor nations,the 1998 “Vital Signs” concluded that

What is the highest priority: Internet access or sanitation? In the article below, which appeared inThe New York Times on May 12, 1998, Internet and sanitation coverage trends are compared.

A new measure of disparities:Poor sanitation in Internet eraBy Barbara Crossette, New York Times*

the “sanitation gap” has become thegreatest risk to public health in somecountries. Using the latest availableWorld Health Organization figures, thereport says the number without facilitiesin the developing world increased by274 million in the first half of the 1990s.

“In some countries,” the reportreads, “less than half the population isadequately covered.” These includeAfghanistan, Brazil, Cambodia, China,Congo, Egypt, Haiti, India and Senegal.The report notes, however, that somecountries, like Brazil, have more exact-ing definitions of basic sanitation thanothers, so the statistics are not com-pletely comparable.

On telecommunications the num-bers are firmer and more recent. Theyindicate “tumultuous changes,” thereport said. International Telecommuni-cations Union statistics show that morethan 200 million telephone lines wereinstalled worldwide from 1990 to 1996,bringing total telephone lines to 741million. In 1960 there were 89 million.

Some countries have leapfroggedover the use of traditional telephonesinto the wireless era, the report found.In Cambodia, one of the world’s poorest

nations, where a national network oftelephone cables is considered a longway away, 60 percent of telephone sub-scribers use cellular phones.

Worldwide, cellular phone usershave increased an average of 52 percenta year since 1991, with 135 million usersby 1996. This trend accentuates thedifferences between the rich and thepoor in many under-developed nationswith poor communications networks.

As for the Internet, its use has grown“exponentially,” the report shows. Mostof the users are still in industrial coun-tries. Of the estimated 107 million peo-ple on line, about 62 million are in theUnited States and 20 million in Europe.

But the Internet has been harnessedto public services in a number of small,poor countries, the report found. Itmentions human rights work by theKuna indigenous people in Panama,agricultural marketing by cooperativesin Peru and shared medical expertise forcountries like Uganda and Bhutan.

“With 500 million people—8 per-cent of humanity—projected to be online by 2001,” the report reads, ‘we canbarely guess how the Internet phenom-enon will shape the 21st century.”

* Copyright © 1998 by The New YorkTimes. Reprinted by permission.

tain their own sanitation improvementactivities, and promote individual actionfor change, with the support of techno-crats from all sectors including health,education, community development andwater.

The approach is based on the prin-ciple of empowering people to helpthemselves. This process will start withparticipatory information collection,leading to action plans also developed in

a participatory manner. The plans willprovide people with increased knowledge(education) and increased understand-ing (free discussion), building on thecollective wisdom, strengths and bestpractices in the community around them.

In urban centres, pressure may needto be exerted on landlords and serviceproviders to comply with minimumservice standards. In rural areas, moreemphasis may have to be placed on

discovering positive images for promot-ing sanitation within the context of thelocal traditions and beliefs. At the sametime specific efforts will be made todiscourage negative taboos and beliefs.

The national sanitation forum. The hold-ing on 16–17 October 1997 of a nationalsanitation forum under the theme ‘Bet-ter sanitation: a responsibility for all’brought together the elected and civic

■ Development of Uganda’s national sanitation policy from previous page


A

9


Dirty hands can have tragic, deadlyconsequences

n the two recent years since the larg-est recorded outbreaks of Es-cherichia Coli 0157:H7 bacterial

infection made 501 Washington stateresidents ill, hospitalizing 151 of themand killing three children, the lastinglesson learned from the tragedy is this:“It’s best not to eat rare hamburgers”.But its forgotten lesson is more likely toplague our daily lives.

While public officials trace thesource of that E-coli epidemic to Jack-in-the-Box fast-food restaurants servinguncooked hamburgers undercooked, 16month old Riley Dewiler of Bellingham,Wash, had not eaten the tainted food.He died of complications after contract-ing E-coli at his day care center fromanother toddler who had suffered a mildillness after eating a Jack-in-the-Box.

Nor had two-year old Celina Shribbseaten tainted burgers before she died ofthe infection. In all ,48 patients got sicknot from eating hamburgers but bycoming in contact with someone whohad.

Most likely contributing to thosecases of secondary infection was un-washed or poorly washed hands. Some-body in their daily lives — at day care, atschool, at home, at work — passed onthe deadly bacteria by hand. “Washinghands can sound like a trivial matter”says physician Marcia Goldoft, and epi-demiologist with the Washington StateDepartment of Health who investigatedthe E-coli outbreak. “Very rarely it is afatal error, but it can be”.

Like many public health authoritieswho have watched with concern theresurgence of infectious and drug-resist-ant diseases in this country, Goldoftbelieves too many people don’t botherto wash their hands regularly and thor-oughly. “It is, unfortunately, a difficulthabit to get into” she says.

Medical statistics and the risingthreat of hand passed diseases should beconvincing enough. More than 80 mil-lion cases of food poisoning and 10,000deaths due to food-borne diseases occurannually in the United States, estimatesthe Food and Drug Administration(FDA). One in four (25%) of food-borne illness outbreak starts from poorhygiene, generally unwashed or poorlywashed hands, according to the USCenter for Disease Control (CDC) inAtlanta. The CDC calls hand washingthe single most important means ofpreventing the spread of infections frombacteria, pathogens and virusus causingdiseases and food-borne illnesses.

Besides the common cold and influ-enza, infectious diseases for whichproper hand washing is the first line ofdefense include strep throat, ear infec-tions and gastrointestinal disorders —

all of which have become routine inschool-aged children.

Some serious illnesses that can bepassed by unwashed hands are on theupswing in this country. The viral liverinfection Hepatitis A, for instance, istransmitted by feacal-oral contamina-tion. Someone infected does not prop-erly was his hands after using thebathroom and then passes along mi-crobes of his feces to someone else whois handling food, shaking hands, touch-ing the railing on the subway, directcontact. The virus ends up in the otherperson’s mouth and he gets sick.

A generation or two ago, societyseemed to be more aware of the risks ofunwashed hands. Parents cautionedtheir children coming from outdoors toclean up. The standard preamble todinnertime was “Did you wash yourhands?” Some families even held handinspections before meals.

But today, parents seemed to havewashed their hands of hand washingvigilance. In general, adults are in toomuch of a hurry or are too complacentto grasp what medical science the mostwidely available low-tech prevention toillness – scrubbing hand regularly withsoap and water. And children aren’tbeing thought how and why to washthoroughly.

“I don’t know if there are more rea-sons to wash your hands today thenthere were when we were children, butthe reasons certainly are equally as good.Germs haven’t gone away” says CharlesInlander, president of the People’sMedical Society, a consumer-healthadvocacy organization based inAllentown. Because his job alerts him of

I

©1996, The Washington Post. Reprintedwith permission.

“Hygiene, hand-washing and behavioural change are key issues, not only in developing countrieswhere UNICEF works, but also — as this article points out — in industrialised countries such asUSA where poor hand-washing practices are being blamed for an increasing incidence of certaindiseases.”


Most likely contributing to thosecases of secondary infection

was unwashed or poorlywashed hands. Somebody in

their daily lives — at day care,at school, at home, at work —passed on the deadly bacteria

by hand.

From The Washington Post*

10


C O U N T R Y B R I E F S

leaders of all the 45 districts of Ugandaalong with members of Parliament, theCabinet, the donor community, NGOsand concerned citizens. The forum spenttwo days discussing the issue of sanita-tion, all of it heavily covered by the localpress. The culmination of the forum wasthe signing of the Kampala Declarationon Sanitation by the chairmen of all thedistrict councils in the country as well asthe Ministers of Local Government andHealth and the representatives of theWorld Health Organization and

represents the boldest statement madeto date on sanitation in Uganda andincludes a 10-point strategy for action.A final agreement was a commitment bythe districts to return in a year’s time toreport on progress made in implement-ing their 10-point plan of action.

Legislation. A critical problem that hadbeen identified along the way was thelack of appropriate legislation policy andguidelines. The current public health actwas passed in 1965 and has been out of

■ Development of Uganda’s national sanitation policy from page 8

Note on Case Studies: A total of 19 case studies of sanitation programmes were presented at the UNICEF Workshop onEnvironmental Sanitation and Hygiene in June 1998. All of these case studies have been summarised here by WATERfronteditorial staff for the interest of our readers. To obtain the original case study, please contact the author as indicated.

Designing a national communicationstrategyCase study by Deepak Bajracharya, UNICEF Bangladesh

ehavioural change for a healthierenvironment is the goal of a com-prehensive new communication

strategy for sanitation, hygiene and safewater use, developed in 1998 for scalingup in 1999.

The strategy deploys multiple mediato reach the family, centring on mes-sages developed for, by and with children.Since primary schools are a natural focalpoint, the strategy features a stronghygiene education component for theschool water and sanitation programme.Students and teachers from both pri-mary and secondary schools will mapand monitor latrine construction andhygiene behaviours in the school catch-ment areas, complementing wider advo-cacy efforts using influential communitymembers. Support activities includeprovision of safe water in underservedregions, and fostering a decentralizedapproach to planning, implementationand monitoring.

Key elements of the strategy■ Establishing a campaign identity,

with a cartoon character—KamalChacha or Uncle Kamal—to createvisual linkage

■ A primary school package withgames, songs, comic books andchild-to-child activities to carry mes-sages to the home and community

■ A media package using TV spots and‘infomercial” and radio spots

■ Developing ‘sanimart’ stores,with lively selling aids toattract and educate, forlocal masons constructinglatrine slabs and rings

■ Information packages forinterpersonal communicationby those closest to families—health workers, religiousleaders and NGOs

■ Advocacy mate-rials for local government personnel.

Best practicesThese suggestions for best practicesderive from UNICEF’s experiences inBangladesh with social mobilization,social marketing, and the school sanita-tion programme.

Promoting hygiene in Bangladesh: Kamal Chachaand friends.

BBangladesh


continued on next page, top

This declaration, written by thedistrict council chairmen

themselves, represents theboldest statement made to date

on sanitation in Uganda andincludes a 10-point strategy for

action.

UNICEF. This declaration, written bythe district council chairmen themselves,

11



Communications■ Use private-sector expertise to de-

velop and test the campaign strategy

■ Establish standard operating proce-dures

■ Build communications capacity in-house and with government coun-terparts

■ Create intersectoral linkages to otherprogrammes.

Programming■ Approaches should be transparent

and accountable, with maximumcommunity participation and senseof ownership

■ Schoolchildren are an effective me-

arge numbers of families survive bypicking through garbage in themushrooming shanty towns

around Recife and its satellite cities inPernambuco state. Sanitation is precari-ous: exploitation and violence are com-monplace. This programme was spurredby the perception that for children andteenagers to have to live off garbagepicking is inhumane and unsustainable,both for society and for the environment.

Objectives■ To remove children and adolescents

from garbage dumps and help themreturn to school

■ To improve their living conditions

■ To organize them into associationsand generate jobs and income

■ To reduce the impact of carelessdiscarding of trash

■ To reduce the high mortality rates ofgarbage pickers and their families.

Start-up activities included seminarsand information gathering in the 60-plus shanty towns of the city of Olinda,bordering Recife. The aim is to create anadministrative model for managingurban solid waste which will take intoaccount the intersectoral nature of theproblem; strengthen the understandingthat education, health, social mobiliza-tion and promotion are all fundamental;consider the relationships between the

A better life for garbage pickersCase study by Fabio Atanasio de Morais, UNICEF Brazil

various actors involved; and respond tolocal needs. The approach expands onthe traditional role of public sanitationsystems, so that engineering solutionsare combined with other initiatives ad-dressing the community’s relationshipwith its living environment.

Challenges■ The community organizations, sanita-

tion services and UNICEF personnelall had difficulty reconciling the envi-ronmental solutions and the humandevelopment needs: the methodology

was thereforeadapted to allowfor continuous interactive participa-tion, learning and monitoring

■ Discussion between communitiesand decision makers is not customary

■ In general the population has beenapathetic, perceiving the public au-thorities as unreliable.

Lessons learned■ The goal can be reached only if eve-

ryone participates from the outset,including the growing number ofcommunity organizations; theproject should be seen as belongingto the city and not just city hall

■ The project was hampered by shiftsin political power. Political commit-ment has to be strong enough toweather such changes

■ Since projects of this kind are some-what controversial, good communi-cations are essential to ensureeffective and sustained commitment

■ Instruments to guarantee continuityshould be encouraged. This wouldinclude identifying further leadershipamong the relevant municipal de-partments, to plan work in partner-ship with the communities.

The 6-page case study is obtainable [email protected].

The city dump problem in Brazil: differentpartners, different priorities.

BrazilL

dium for prompting parents to build,use and clean sanitary latrines

■ Involve NGOs

■ Recognize the important role ofprivate latrine producers.


■ Bangladesh from previous page

12



igh diarrhoea and mortality ratesamong the young children ofBobo Dioulasso, the nation’s

second city, prompted a three-yearhygiene promotion project launched inlate 1995. It was intended to complementearlier water supply and oral rehydra-tion programmes, and to become amodel for future projects of this kind.

The primary target audiences werethe mothers of children under four,other caretakers, and children of pri-mary school age; the key messages werethat children’s stools should be safelydiscarded in potties or latrines, andhands should be washed afterwards.Preliminary work with women’s focusgroups showed that they rarely con-nected hygiene with diarrhoea but ratedit an important communal virtue. Themessages were therefore positioneddifferently for adults—hygiene is sociallydesirable—and for schoolchildren—hygiene helps to avoid diarrhoea.

Main activities■ The creation of responsables saniya

(hygiene workers)—women volun-teers, largely illiterate, elected bytheir community and working inteams to promote hygiene in some

Marketing hygiene in a West African cityCase study by Lizette Burgers, UNICEF Burkina Faso

15–20 households each. They weretrained in communication and insoap-making to generate revenue

■ Training of health workers to organ-ize hygiene discussions in the streetand at baby clinics

■ A street play performed in everyneighbourhood and in schools

■ Local radio spots, programmes andinterviews

■ Materials development: teachingmanual and posters (primaryschools); visual reminder sheets(volunteers); portable placards(health workers).

Problems encountered■ It took longer than expected to iden-

tify and formalize new forms of col-laboration between all the projectpartners

■ Project staff had trouble withUNICEF procedures, especially thetimely reporting required to justifycontinued funding. Training hashelped somewhat

■ Progress was hindered by changes ofpersonnel.

Lessons learned■ It is difficult to maintain volunteer

motivation in an urban setting. Therole of the responsables saniya istherefore being revised to one ofliaison between the local health cen-tre and its community, working insmaller teams of three or four, paidby the health centre under theBamako Initiative, and possibly as-sisting in other health campaigns

■ A strength of the programme was itsdetailed knowledge of the targetpopulation. The preliminary com-munity research spanning severalyears has generated a toolkit of tech-niques that could shorten such re-search to three months*

■ Instititutional clarity, especially onthe division of responsibilities, isextremely important for programmeimplementation.


H

* Details are given in the case study and inV. Curtis et al., ‘Dirt and diarrhoea: formativeresearch in hygiene promotion programmes’,Health policy and planning, vol. 12, no. 2, 1997.

Push and pull for rural sanitationCase study by Vathinee Jitjaturunt, UNICEF China

espite major strides in recentyears, over 600 million peopleare estimated to lack sanitary

latrines in China’s countrysides, wheresanitation is traditionally discountedand night-soil traditionally used un-treated to fertilize fields. High rates ofdiarrhoeal disease and intestinal wormsplace children in jeopardy.

UNICEF is currently assisting withenvironmental sanitation and hygieneeducation (and water supply whereneeded) in 21 poor counties of eightprovinces. To tackle the two fundamen-tal problems—absence of grassrootsdemand for sanitation, and the low levelof staffing assigned to this sector—theprojects use a combination push and

pull strategy. The‘push’ is to gaingovernment com-mitment at every level: the measuresinclude advocacy meetings, establishingregulations, and promoting intersectorallinkages with other national initiatives(in agriculture, education, poverty alle-viation, promotion of women, and pro-

ChinaD

Burkina Faso

13



tection of the environment). The ‘pull’uses social mobilization to motivatecommunities to want hygienic condi-tions: the measures include using massmedia and interpersonal contacts todisseminate key messages, using primaryschools as entry points for behaviouralchange, and strengthening the involve-ment of communities, especiallywomen.

Principal activities■ Advocacy meetings with national,

provincial, county and townshipofficials

■ Training—in project managementfor provincial and county officials,and in communication and appro-priate technologies for governmenttechnicians and trainers

■ Development of communicationstrategies, all media

■ Grassroots training, using participa-tory methods, of village leaders,health workers and other allies

■ Training of village masons in latrineconstruction and maintenance

■ Action research to design latrines fordesert and cold regions

■ Installing demonstration models ofaffordable latrines in project villages

■ Instituting school water supply andsanitation alongside the health andhygiene education now mandatoryin schools

■ Monitoring and evaluation of allactivities.

Factors for successStrong government commitment at alllevels is a factor for success, as is thedecentralizing of project planning andimplementation. Once the gains wereunderstood locally, local resources cameavailable: UNICEF’s seed spending onpromotion and on demonstration la-trines was a tenth of the money put upby villages to complete the latrines andthen build their own. Attitudes havechanged in many places, and reductions

have been reported (to be confirmed) inchild diarrhoea and worms.

Henan province launched its sanita-tion drive in 1989, independently ofUNICEF, and has raised the proportionof country-dwellers with improved la-trines from 1% to 55%. The provincecould be considered a model for bestpractices. These have included ensuringpolitical commitment; developing anaffordable, acceptable latrine designusing local materials; using small subsi-dies as an incentive; publicizing thebenefits of improved latrines; enlistingevery possible ally in the community;and patience and persistence, since be-havioural change takes time. Someproblems remain, chiefly with mainte-nance and proper use of the new latrines.

Henan and Anhui provinces recentlystarted preparations for going to scale inevery county. The lessons learned areexpected to supply the model for thenation.


Helping squatters back to their feetCase study by Julian Duarte, UNICEF Guatemala

his case study surveys a recentlyconcluded project to improveconditions for some 3,000 poor

families who settled in 1984, illegally atthe time, in the hills of El Mezquital onthe outskirts of Guatemala City. In Gua-temala as in other developing nations,massive migrations from the country-side have severely taxed the authorities’ability to provide safe water, drainage,sewerage and garbage collection.

In collaboration first with NGOs andthen with government, UNICEF’s pro-gramme for urban basic services sup-ported a variety of community-basedinitiatives. These included an innovativenetwork of health promoters selected bytheir community, and new models forcommunity day-care centres.

T From the start, the settlements ratedwater supply a critical need. Two mod-els, both community-managed, weredeveloped: households install their ownconnections from community-run wells,or from tanks kept fed by the municipalwater service for which the local com-munity association collects the fees,setting a portion aside for maintenanceand other expenses such as drainage,sewers and latrines. Volunteers receivedtechnical training in basic environmen-tal sanitation: public taps and dry la-trines were installed, existing latrinesimproved, and sewage drains and cob-bled sidewalks built in alleyways. Volun-teers planted trees to supply fuelwoodand prevent gullies eroding. Two plantsfor waste-water treatment are running

and three more inthe process of beinginstalled by theircommunities.

Lessons learned■ Community education and training

have been the nucleus activity, evenmore important than infrastructure.Over the years every family has beenbriefed on health and sanitation

■ Horizontal linking of different initia-tives, and the interinstitutional coor-dination to go with it, are helpful

■ Community participation is vital

■ Raising funds for projects in peri-urban settlements is not easy

Guatemala

14



Is low-cost sewerage feasible for theurban poor?Case study by Annemarieke Mooijman, UNICEF Honduras

he ‘Tegucigalpa model’ for watersupply in peri-urban settlementsbuilt its reputation on commu-

nity participation, cost sharing and useof a rotating fund to cover start-upcosts. After seven years the water needswere largely met and attention turned tosewerage in 1995: settlements housing300,000 people—a third of the city’spopulation—had pit latrines but nowaste-water systems.

By the end of 1997, four simplifiedsewage systems had been installed atcommunity request, with full coverageenvisioned for the end of 1999.

The households supply manual la-bour, some materials and an initial pay-ment for connection. The systems areinstalled by the national water serviceand run by the community’s junta deagua or water board, which makes thekey decisions on technology, tariffs,maintenance, operation, and speed ofloan repayments. During the first year ofthe first system, only one in five house-holds hooked up; a rotating fund is nowsupplying small loans to help familiesmake the investment, and four out offive are hooking up.

The water service provides hygieneeducation within three months of instal-lation, training schoolteachers, whopromote hygiene in the classroom, andcommunity volunteers, who visit about10 of their neighbours’ homes with flipcharts to help explain new behaviours.

The communities have so far chosena simplified conventional design (wide,shallow collector pipelines linkinghousehold pipes to the main sewers)over the locally more suitable small-boresolids-free design (solids settled on sitein a septic tank, with only fluids releasedto the system. Reassuring them that 4-

Honduras

T

Community participation in Honduras.

■ Success lies not only in a participa-tory methodology but rather inachieving integration: no single insti-tution has the resources to makesignificant inroads into the problemsof servicing poor settlements like ElMezquital, nor does anyone have asingle-issue approach that can ad-equately address the complex realitiesfaced by the inhabitants.

Problems encountered■ A lack of solid community organiza-

tion and participation

■ A rigid government structure makingit hard for communities to handletheir own solutions

■ Difficulties in obtaining financialsupport from international creditbanks

■ Intercommunity disagreements anddisputes.

Progress was slow overall, which ispartly inherent in work of this kind.


inch collector pipes are adequate hasbeen uphill work.

Challenges■ Even with hygiene education, some

misuse has led to partial breakdowns

■ The initial connection costs are toohigh for some

■ The city’s network of collector pipe-lines linking household pipes to themain sewers is nearly at capacity;massive investment is required toexpand capacity before the commu-nity systems can be added on alarge scale

■ None of the city’s waste water istreated before discharge into the riverdownstream of Tegucigalpa.

Are these low-cost sewage systemsfeasible? If we look only at the healthbenefits to the poor and the relativelysmall operating fees required of them, itis worth trying to raise the start-upfunds; but a proposed study of the over-all costs and environmental impact hasyet to be carried out. So the answer, fornow, has to be ‘possibly’.


15



erakan Jumat Bersih or the CleanFriday movement draws on thereligious and cultural values

of communities to promote hygiene.Starting as a district initiative in WestLombok and declared national policy inNovember 1994, the movement calls forcommunity self-help engaging all com-

The Clean Friday movementCase study by Y.D. Mathur, UNICEF Indonesia

Indonesiamunity members—individuals, families,organizations and government agencies.The nation’s religious leaders, who suc-cessfully promoted family planning inthe past, have been given materials onwater and sanitation according to Islamicteachings to help them promote hygieneduring prayer and other meetings on

Fridays, Islam’s holyday.

The objectivesare to promote healthy living throughreligious and other communal activities;to increase community awareness of theimportance of hygiene, specifically theuse of sanitary latrines, hand-washing,

G

India’s rural sanitary martsCase study by Rupert Talbot, UNICEF India

ural sanitary marts evolved fromindications that poor people willconstruct toilets without govern-

ment subsidy provided they have themotivation, the know-how, and avail-able, affordable materials. The marts areconceived as commercial enterprisesalbeit with social objectives, affiliatedwith rural production centres and creditmechanisms for the poorest, and sup-ported by social mobilization: the priva-tized system is collectively known as thealternate delivery system, and has swiftlybecome an integral component of thegovernment’s strategy for achieving 75%rural sanitation coverage by the year 2002.

The first experimental marts startedup in Uttar Pradesh in 1993. Strategicallylocated in public places like markets andstaffed by trained managers and motiva-tors, the marts showcase the health ben-efits of sanitation and hygiene, andcounsel potential users on choice oflatrine design and mason. Of threearrangements tested—high subsidy, lowsubsidy, or none—low subsidy workedbest. In Uttar Pradesh, manufacture ofthe cement or mosaic squatting slabs,pans and traps was undertaken by thelocal panchayat udyogs—rural industrialcomplexes run by groups of villagecouncils.

Key activities■ Training of managers and motivators

in sanitation and marketing

■ Selection and training of masons(including women, through women’sproduction centres, and youngpeople, through youth employmentschemes)

■ Mobilization—village contact drives,pamphlets, posters and films

■ Home visits by motivators. Bothmotivator and family receive a smallincentive, about $1.50, for each toilet

equipped fromthe mart.

When properly sited and run, therural sanitary marts have shown a profitwithin 12 to 18 months. Nearly 700marts are now active in more than 10states; NGOs, entrepreneurs, and evendairy and sugar cooperatives are offeringsanitation supplies; and zero subsidy isincreasingly the aim. Surveys show thatfor every toilet recently built throughthe main government programme, fourwere built by households on their own.

Best practices

■ Ensure a good balance between thesubsidized and self-financing compo-nents of any programme promotingsanitary toilets

■ Capitalize on the employment poten-tial offered by the construction oflarge numbers of toilets.


Handling of Drinking

Water

Disposal of Waste Water

Disposal of Human Excreta

Environmental Sanitation

Personal Hygiene

Village Sanitation

Disposal of Garbage

& Cattle Dung

Home Sanitation & Food Hygiene

Seven Components of Sanitation

India promotes ‘total sanitation.’

R India

16



Rebuilding after warCase study by Zaid Jurji, UNICEF Iraq

ater supply and sanitationsuffered severe deterioration

throughout Iraq following theGulf War in 1991. The nation’s high-technology, high-cost systems were hardhit by the dwindling of operating fundsto a trickle of humanitarian aid; by anexodus of skilled manpower; by theshortage of spare parts for sewage treat-ment plants and for the truck fleets thatcollect garbage and empty cesspools; andby prolonged power cuts causing sewermains to clog, corrode and back up.

After years of habituation to highlysubsidized government services, com-munities lack the knowledge to handlewater and waste rationally. Garbage iscollected erratically and dumped evercloser to homes. The result has been aresurgence of typhoid together with anearly threefold increase in underweightand an eightfold increase in diarrhoealdeaths among children under five.

From 1991 to 1997 only the gravestproblems could be tackled—preventingfurther breakdown, interim repairs for

Iraq

schools and hospitals, and temporarymeasures to keep sewage away fromhomes, schools and health centres. At-tention is now turning to permanentsolutions, as part of the emerging Oil forFood programme to meet humanitarianneeds. This programme is expected toinclude situation analyses to determinepriorities; a special focus on the poor—both urban and rural—and on schools;pilot projects to generate communityparticipation since no precedents exist;and local capacity building.

Current challenges■ Although the Oil for Food pro-

gramme will likely fund supplies andequipment, a key need will be locat-ing and training competent technicalpersonnel.

■ Ways should be found to interest theprivate sector in water and sanitation.

■ New legislation could be consideredthat would transfer some costs fromgovernment to users; increase profit

margins andencourage com-petition in theprivate sector; and stimulate commu-nities to make better use of water andsanitation services. The new ap-proach would have to be properlyplanned, justified and communicatedso as to win support and help thepopulation adapt.


W

consumption of properly handled drink-ing water, and proper garbage disposal;and to facilitate hygienic behaviours byinstalling sanitary latrines, water supplyand waste disposal in households and inpublic places such as schools and housesof worship. In West Lombok, activitiesincluded training the village womenvolunteers of the family welfare move-ment to deliver hygiene messages.

The movement has an establishedorganizational structure, growing latrinecoverage in the provinces with actionplans, and continuing political commit-ment. Though other factors may havebeen at work, West Lombok has experi-enced a noticeable decline in acute res-piratory infections, diarrhoeal diseasesand skin conditions.

Problems encountered■ Lack of commitment from regional

leaders

■ Most district heads have yet to drawup local action plans

■ Insufficient coordination betweenagencies, overcome in West Lombokby setting up an interagency team

■ Minimal data collection: detailedrecord-keeping has been a motivat-ing force in West Lombok, but for a1997 national sanitation survey, only12 of 27 provinces provided data.

Lessons learned■ The district head’s commitment is

key: these officials are close to thecommunities and also have the au-thority to influence budget alloca-

tions and issue regulations havinglegal force.

■ Agencies can improve sanitation ifthey approach communities in anacceptable manner, particularlythrough religious channels; for exam-ple, going to prayer meetings with areceptive attitude can provide oppor-tunities to impart hygiene education.

■ It remains difficult for women totake on non-traditional roles in mo-bilizing for hygiene.

■ General support gestures, such asvisits by distinguished figures, canenhance local authorities’ commit-ment.


A woman washes her pots in the EuphratesRiver near the city of Babylon.

17



he sanitation programmelaunched by Myanmar in 1982promised a free plastic latrine pan

to every family: by the mid-1990s cover-age was high in 25 townships, of 88 inthe pilot programme and 324 in thenation. Since supplying the plastic pans

Changing gear on sanitationCase study by Philip Wan, UNICEF Myanmar

Myanmarwas proving too expensive and did notensure proper use, UNICEF and theGovernment developed a low-cost self-help approach, designed to enable acritical mass of townships to achievecoverage fast enough to generate confi-dence and have an impact on health.

The new ap-proach shifts thecommunity frompassive recipient to active provider anddraws on existing strengths: a good healthinfrastructure of some 7,000 health cen-tres and subcentres, the vast school net-

T

Tackling sanitation and guinea wormCase study by El hadj Moustapha Diouf and Hamidou Maiga, UNICEF Mali

n the early 1990s, child mortality wasabove the national average in thelargely rural region of Mopti: only

14% of villagers had a safe and conven-ient water supply, and the region ac-counted for over half Mali’s cases ofguinea worm.

Earlier water supply programmeshad had little impact on hygiene, so the1993–1997 programme stressed hygieneeducation and sanitation in some 600villages, centred on women’s and chil-dren’s needs as well as schools; safe wa-ter was also supplied for the 150 villageswith the highest guinea worm rates.

Main activities■ Water supply. Drilling and recondi-

tioning wells; training villagehandpump caretakers

■ Hygiene education and sanitation.Training village animators andhygiene committees; introducinglatrines and hygiene education inschools; training village masons;helping households install simpletest latrines

■ Guinea worm. Close monitoring;training of health workers and com-munity agents; teaching householdsto filter pond water harbouring

Maliguinea worm; chemical treatmentof ponds.

Overall, the programme improvedcommunity understanding of water-borne diseases: more than double theplanned number of latrines were built,and the number of guinea worm casesfell from 9,200 in 1992 to 450 in 1997.Some problems require attention:

■ Lingering preferences for open-airdefecation and for using pond water,especially when handpumps mal-function

■ Difficulty in meeting the high demandfor latrines

■ Insufficient involvement of commu-nities, especially women, and espe-cially during planning and follow-up

■ Poor intersectoral coordination,since the public authorities are usedto vertical project management

■ Too few baseline surveys, and nooverall impact study

■ Low private-sector interest in sanita-tion, and low political commitmentin rural areas.

Factors forsuccessSuccess was greatestwhen the varied activities were inte-grated. Some interventions were decisive:

■ The monthly hygiene activities inevery village

■ Ensuring continued functioning ofhandpumps (even more than settingup new ones); together with filtering,this had particular impact on guineaworm

■ Monthly follow-up and surveillance

■ Improving village workers’ skills anddecentralizing project management.

The programme succeeded better withguinea worm than other water-bornediseases, but introduced tools and meth-ods that could be used elsewhere. Thenext phase is consolidation, and exten-sion to other regions of Mali. The focuswill be on decentralized managementand on meshing health and nutritionactivities with water supply, hygiene andsanitation.

The 10-page case study is obtainable [email protected] or [email protected].

I

18



Keeping girls at schoolCase study by Mohammed Kamfut, UNICEF Bauchi (Nigeria), Comfort Olayiwole, UNICEF Lagos,and Z. O. Agberemi, sanitation consultant

illage schools in Nigeria oftenlack a safe water source and

separate toilets for boys and girls.These are major reasons why fewer girlsthan boys attend school, especially in thelargely Muslim north where culturalnorms require girls to have privacy andnot share toilets with boys. In the aridnorth-east, the girls and women of vil-lages without water supply often have tosacrifice hours of their day—includingschool hours—to fetching water.

Spot checks of primary schools inthe north-east showed that barely aquarter had a latrine and water supply.In the rare schools with a pit latrine, ithad to service over 100 pupils, both girlsand boys. Children were defecating inthe playground and nearby compounds,adding the health hazard of exposedfaeces to parents’ reasons for withdraw-ing daughters from school.

Against this background, a projectwas launched in December 1996 to or-ganize a package of interrelated servicesfor 10 selected primary schools in eachof three north-eastern states: health andhygiene education to influence the chil-

dren, and hence their families and com-munity, to adopt hygienic practices; adouble-compartment latrine or twosingle-compartment latrines, with basinsfor hand-washing and a design ensuringprivacy; a well and handpump; and aschool garden around the handpump.

Construction was completed within15 months, with the communities andparent-teacher associations contributinglabour. The school principals supervisemaintenance. Students take turns toclean the latrines and fetch the water forhand-washing, while the handpump ismaintained by a teacher in term timeand a community member during

school holidays,both trained for the purpose.

Though there has been no formalevaluation, monitoring reports note thatthe school surroundings are cleaner.The pupils are maintaining hygiene andcomplaining less often of diarrhoea. Thecommunity benefits, too, as well as thechildren and teachers: water no longerhas to be fetched far afield, and theschool latrines are inspiring householdsin the vicinity to install their own. Thenew facilities have sparked considerableinterest from neighbouring villages andlocal authorities.

Privacy for girls: school latrines in north-eastNigeria.

V Nigeria

Since 1996 UNICEF has supportedthese social mobilization activities in 100townships. A 1998 survey of 22 town-ships showed that in two out of five,over 70% of families were now usingsanitary latrines. The majority of latrineswere new: a third had cost less than $4to build and another third less than $7.Poverty had been offset by using localmaterials, by families doing all the workthemselves (74% of households), and byoccasional help from other families.

A highly publicized national sanita-tion week in May 1998, headed by na-tional leaders and by key NGO andprivate-sector partners, set the goal of a

work, earlier experience in mobilizing foruniversal child immunization, growingprivate-sector activity, and communitysupport for sanitation.

The plastic latrine pans were phasedout in mid-1995; community self-helpwas promoted along with a workableminimum latrine standard (excreta to becontained in a covered pit). Social mobi-lization was moved to the forefront tomotivate behavioural change, tappingevery available resource—schools,NGOs, local health workers, villagemobilizers, the 10-household villageleaders, the government’s mobile com-munications team, local video parloursand the mass media, especially television.

School vegetable garden in north-eastNigeria: using handpump waste water toteach nutrition.

continued on page 24Latrine use in Myanmar

19



Lessons learnedChild-friendly water and sanitation invillage schools can serve as models forcommunity improvement, influencingvillagers to build household latrines andprotect water sources The project pro-vided an excellent opportunity to buildintersectoral linkage between pro-grammes (water supply and sanitation,education, nutrition, and health).

Turning garbage to profitCase study by Olushola Ismail, UNICEF Lagos, and Z.O. Agberemi, sanitation consultant

igeria’s recent economic trou-bles have brought massive mi-grations from country to town,

swamping the cities’ already overloadedsystems for waste disposal. In Lagos andIbadan, 1995 surveys of market neigh-bourhoods, which generate the mostrefuse, found that none of the marketshad adequate arrangements; 71% ofhouseholds were depositing trash in anyavailable open space, risking pollution ofnearby wells. Cholera breaks out regu-larly in both cities, and children, espe-cially, suffer high rates of diarrhoealdisease. The task of household wastedisposal falls mainly to women andchildren, who have to trek long dis-tances to a usable dump or pay refusecollectors from their mea-gre earnings.

The case study reviewsa pilot demonstrationproject which set up acomposting plant to makefertilizer of the 40 to 50tons of refuse discardeddaily by Ibadan’s largestproduce market. Thecomposted manure, saferand cheaper for localfarmers, sells at $3 a bag.The plant’s biogas pro-

Nigeriaduction is managed entirely by localwomen, and the community’s womenand schoolchildren earn further incomefrom collecting and sorting cans, plasticand glass for resale to industry, recyclingpaper for handicrafts, and raising seed-lings.

Training was provided for 42 stateand local government staff and for 60community artisans. Market women,schoolchildren and community leaders,educated to the value of environmentalcare, were actively involved in everyphase from planning onwards, and havebecome proud stakeholders. Costs wereshared—government 65%, community25%, and UNICEF 10%.

The project has not been formally

evaluated, but con-ditions in andaround the markethave visibly improved, and other Nige-rian cities have requested similarprojects. The key elements for replica-tion will include close liaison with all thekey partners; building capacity via on-the-job training; funding research anddevelopment of suitable technologies;involving the private sector; institutingworkable arrangements for cost sharing;and using revolving funds to empowercommunity-based entrepreneurship.


Bodjia market, Ibadan: a day’s workload at the composting centre.

N

Challenges

■ The huge number of schools still inneed, and the lack of funds for ex-panding the project

■ Overuse of the school latrines byvillagers lacking their own

■ Environmental sanitation and hy-giene are not yet officially on theschool curriculum.

UNICEF supplied two thirds of thefunding. Expanding the project willrequire systematic research and plan-ning around such issues as technologydevelopment, on-the-job training, andmeasures to make the services affordableand sustainable, such as revolving fundsfor sharing costs and stimulating com-munity entrepreneurship.

The 6-page case study is obtainable [email protected], [email protected] [email protected].

20



Making SanPlats a household wordCase study by Comfort Olayiwole, UNICEF Lagos, and Z.O. Agberemi, sanitation consultant

ecause incomes have been plungingin Nigeria for several years, acheaper alternative was needed to

the ventilated improved pit latrinespreviously promoted for the rural andperi-urban poor. After a 1995 study ofhygiene beliefs and practices nationwide,and a pilot project in the south-east totest and modify SanPlats for culturalacceptability, SanPlat latrines wereadopted as the new norm (see box).

In order to both achieve and sustainsound hygiene practices, the promotionstrategy emphasizes community leader-ship and management, with the federal,state and local authorities providing theenabling environment. Latrine construc-tion is supported by social mobilizationand hygiene education, by skills trainingfor the local manufacture of SanPlats,and by the setting up of community-runsanicentres (sanitation centres) to serveas promotion, counselling and salesoutlets.

Within three years more than a mil-lion people had acquired safe excretadisposal, increasingly paid for by thehouseholder, in 22 of Nigeria’s 36 states.Hygiene practices have improved, andSanPlats became a household word inthe project areas. Since demand was toogreat for the original production centressited at local government headquarters,SanPlat manufacture is now handledmostly by numerous communitysanicentres. Over 12,000 people havebeen trained. In the villages, the propor-tion of women receiving technical ormanagement training soared from 2% in1995 to 50% in 1997. On the 10-membercommunity sanitation committees, fiveare usually women.

Nigeria

Factors for success■ Conducting studies before starting

work

■ Setting up clear institutional arrange-ments for sustainability at everylevel—federal, state and local govern-ment as well as communities

■ Ensuring community participationand ownership, and increasing wom-en’s involvement

■ Using low-cost technologies compat-ible with local culture

■ Providing an initial subsidy for thevery poor

■ Using the earning potential fromsanicentres to spur interest andcommitment.

Active commu-nity participation,and building thelocal capacity for it, are key. The needsfor the future include continuous qual-ity control over the manufacture andinstallation of SanPlats; funding to ex-pand coverage while maintaining theexisting programme; and greater pri-vate-sector involvement and revolvingfunds to meet the demands placed onthe sanicentres. Roughly half of the na-tion’s rural population currently hassanitary excreta disposal: if the presentfunding and pace can be kept up, cover-age could pass 70% by the year 2000.


B

SanPlats at a glance

Drawings from Björn Brandberg, Latrine building: a handbook for implementation ofthe SanPlat system, Intermediate Technology Publications, 1997.

SanPlats or sanitation platforms are du-rable squatting slabs in finely mouldedconcrete that can be cheaply added toexisting pit latrines. The drop hole issmall enough to be safe for children; afitted lid controls fly and odour nuisance;slab and surround are easy to keep

clean. The slab design can be adapted tolocal conditions and the slabs manufac-tured locally. The upgraded latrine aswell as the slab may be called a SanPlat.

21



Sanitation and hygiene promotion inTanzania: The hare and the tortoiseCase study by Ken Maskall, UNICEF Tanzania

he 1990s have brought tighterfiscal policies in Tanzania andcuts in public-sector spending.

A 1995 survey of poor households con-firmed disturbing trends—significantnumbers with latrines in a state of col-lapse and not using a latrine regularly(especially children aged 7 to 14), andnot washing their hands properly afterdefecation or before handling food. Fourout of five local schools lacked sanita-tion, and only one out of two ruralfamilies discarded infant faeces safely.

Since the government’s subsidizedlatrine programme is now too costly andcannot maintain standards, attentionturned to developing a simple latrineimprovement package using SanPlattechnology (see box on previous page) tobuild partnerships with the growinginformal artisan sector and the growingnumber of community-based NGOs.

With the help of a national NGO,more than 230 artisans across the nationwere trained in SanPlat making during1996 and 1997. But demand remainedlow even though purchasers rated theslabs both affordable and highly satisfac-tory. SanPlats needed a clear, Tanzanianidentity.

After pre-testing, Sungura was cho-sen as the brand name in early 1998,sungura being Swahili for hare; the im-age exploits both the visual resemblanceand the hare’s reputation in Tanzanianfolklore as clean, honest and clever. Thehare logo appears on all the posters,information flyers, flags, comic stripsand stickers that boost promotion andmake SanPlat outlets more visible. Thepoint-of-sale materials target men, whocontrol the family budget; the messagesuse the slabs’ acceptability to children

Tanzania

The hare logo for Tanzania’s SanPlats. Inthe Tanzanian folktale, hare and tortoisecross the finish line together, the tortoisehaving held onto the hare’s tail. An emblemof teamwork, perhaps, for the multiplestakeholders in better health and hygiene?

and popular concerns about the growingincidence of cholera.

SanPlat sales rose during the pre-testing, a promising sign. Artisans’ wivesand daughters became involved on theirown initiative, and training for womenpromoters was scheduled to start inmid-1998, alongside further training ofartisans and distribution of promotionmaterials.

The Sungura promotion is one ele-ment in a comprehensive programmeto improve hygiene where it most affectschildren and mothers: other concernsare the home care of children underfour, home birthings by traditional birthattendants, and home care of familymembers with HIV/AIDS and cholera.The case study reviews the challenges ofworking in Tanzania’s new economicclimate and details the participatory

T A 1995 survey of poorhouseholds confirmed disturbingtrends—significant numbers with

latrines in a state of collapseand not using a latrine regularly

(especially children aged 7 to14), and not washing their

hands properly after defecationor before handling food. Fourout of five local schools lackedsanitation, and only one out of

two rural families discardedinfant faeces safely.

community research—notably a newtechnique for mapping individuals’perceptions—that has strengthenedunderstanding of people’s health needsand beliefs.


22



Testing intensive sanitationCase study by Nguyen Quang Quynh, UNICEF Viet Nam

tarting in 1986, the governmentfunded demonstration latrinesand issued leaflets on hygiene in

the hope of inspiring communities toupgrade their surroundings on theirown. Some 150,000 latrines were built inover 3,000 communes, but rural areascontinued largely unaware of the con-nection between a clean environmentand health.

A more intensive approach was triedout from 1993 to 1996 in the 39 com-munes of a rice-growing district in ThaiBinh province, preceded by over a yearof pilot activities in one commune todevelop the necessary experience. Themain elements were water-seal latrinesand well drilling: work was also done onbuilding bathrooms, garbage pits, ani-mal sheds and smokeless stoves. The

Viet NamS objectives were to educate communitieson sanitation; introduce affordable andacceptable technologies; develop amethodology to make the project bothself-sustaining and self-expanding; andengage the commune members, espe-cially women, in planning and opera-tions.

Every commune set up a projectmanagement board supervised by adistrict committee, and procedures wereestablished to manage funds and activi-ties. Local branches of the nation’s massorganizations—including the nationalfront and women’s and youth unions—helped with coordination. More than1,200 specially trained motivators pro-moted sanitation and other health meas-ures through meetings, home visits andthe mass media.

By final evalua-tion, 90% of com-mune membersunderstood the benefits of sanitary la-trines and safe water; 80% of householdswere using good water and over 60%were using hygienic latrines, new orrefurbished. Every school, kindergarten,day-care centre and government officewas properly equipped. Under-five sick-ness rates had been halved, and the ratesfor diarrhoea, trachoma and hepatitis(all ages) had fallen by about a third.

The principal constraint was com-mune members’ poverty (average percapita income $80 a year). They contrib-uted labour but were hard pressed toinvest in home improvements.

T he UNICEF five-year countryprogramme, 1995–2000, takes anintersectoral approach to the

needs described by Dr. Kiyonga. Tobreak down the vertical project thinkinghitherto prevalent in Uganda, needs andservices are handled on four levels: com-munity enablement, for actions villagerscan take on their own; service delivery,for the services villages need but cannotsupply; resource mobilization and man-agement, to ensure provision of services;and overall policy development andquality assurance. These levels corre-spond very roughly to the current tiersof government administration.

At all four levels, water supply wasreceiving priority at the expense of sani-

Uganda’s sanitation drive:the UNICEF contextCase study by Bill Fellows, UNICEF Uganda

Uganda

tation. Reversing this trend was tackledfrom both ends—by advocacy withnational leaders to give sanitation thehighest possible profile, and by commu-nity research and communications to setthe stage for new behaviours. The workin communities follows four main strate-gies:

■ Creating awareness through socialmarketing

■ Using knowledge of the communityas the basis for planning

■ Adopting participatory approachesto effect behaviour change

■ An integrated approach to schoolsanitation.

The President’s inclusion of sanita-tion in his 1996 election manifesto wasprobably the single most importantevent, as it initiated the accelerationprocess. Two workshops in early 1997on sanitation and on communications,attended by international experts as wellas key government personnel, were in-strumental in clarifying priorities andaction plans.

The cholera outbreaks from Decem-ber 1997 onwards somewhat sidetrackedthe longer-term planning process butbrought a new immediacy to popularperceptions about sanitation as a safe-guard for health. The recent districtelections were fought over sanitation



23



Bringing sanitation to the foreCase study by Isaac Mbewe, Chairman, WASHE

Over half of Zambia’s largely ruralpopulation lacks safe water and twothirds lack sanitation. With theeconomy in trouble, incomes have fallenand child mortality is on the rise, muchof it from diseases preventable by sanita-tion. Cholera breaks out every year, andthe drying up of dug wells from thedecade of drought that ended two yearsback still forces villagers to use distantor unsafe water sources.

Policy reform, first for water supplyand then for environmental sanitation,began in 1993: the resulting programmefor Water, Sanitation and Hygiene Edu-cation (WASHE) stresses decentraliza-tion to local authorities and privateentrepreneurs, and aims at eventualrecovery of all costs. A key role goes tothe district and village WASHE commit-tees, with concomitant upgrading of thecommunity members’ skills for theirnew tasks. Activities started up in Sep-tember 1995 in the nation’s 10 mostdrought-stricken districts:

■ Some 1,100 wells and handpumpswere installed or rehabilitated, free-ing girls to attend school instead oftrekking for water. With privateentrepreneurs working to improvedspecifications, the cost of newboreholes was nearly halved

■ 200 of these private-sector personnelwere trained in well drilling andhandpump repair, reducing pumpfailures from 40% to 15% within ayear

Zambia■ 200 community organizers were

trained to mobilize village house-holds for the five WASHE basics—hygienic latrine, hand-washing, safestorage of food and drinking water,garbage pit, and soakaway pit orsimilar provision for waste water

■ 200 masons were trained in latrinebuilding. Latrine construction startedslowly but by end 1997 over 12,000had been built. Some villagesachieved 100% coverage

■ Village and district WASHE commit-tees were trained in support skills—planning, maintenance,

management,rainwater har-vesting, andparticipatory communication tech-niques

■ A Zambian manufacturer developedfibreglass moulds for local casting ofZamplats, the national version ofSanPlat latrine slabs.

Among the factors for success wereenergetic government commitment andthe district committees’ pride in owner-ship. Frequent workshops involving allthe partners have helped to build a well-informed support network. The pro-gramme is now active in some 30districts.

Issues for the future■ Adapting WASHE to urban areas

■ Sustaining its high profile and sup-port

■ Maximizing impact on health bymeshing WASHE with other activi-ties such as income generation andschooling

■ Strengthening monitoring and evalu-ation, currently a weak area

■ Addressing gender concerns andwomen’s needs.

The 11-page case study is obtainable fromIsaac Mbewe c/o Sham Mathur,[email protected].

Lessons learned■ The key factor for success was com-

mitment by the commune People’sCommittees

■ The mass organizations proved veryeffective in social mobilization

■ Communities have to take part inproject planning and financing if newhabits are to take root

■ The staff of Thai Binh Medical Col-lege played an essential role in guid-ing, monitoring and evaluating theproject activities.

Handwashing in Zambia

The project is being expanded dur-ing 1998 to 10 more districts in 10northern provinces.


■ Viet Nam from page 22

24



iarrhoeal diseases and malaria areleading causes of child sickness,malnutrition and death in Zim-

babwe. The pace of latrine constructionhas slowed since the 1980s and has beenoutstripped by population growth: lessthan a third of villagers have access to ahygienic latrine. Although a majorityknow about washing hands after latrinevisits, the challenge is to convert suchknowledge into sustained behaviourchange.

Since 1993, an intensive programmein participatory hygiene education(PHE) has set out to replace didacticismby a teamwork approach more likely tohave lasting impact. Starting out smallin each district for demonstration, theprogramme is now active in 44 of Zim-babwe’s 56 districts.

Key activities■ Training. Supervisors are teamed up

in the same workshops as commu-nity extension workers. The three-stage training system generates asupport team for each province, asupport team for each district, and

Participatory hygiene educationCase study by Bijaya Rajbhandari, UNICEF Zimbabwe

ZimbabweD training of extension workers in eachdistrict. Most districts opt to train allextension workers regardless of sector.

■ Development of learning tools. Thecustom-designed learning modulesuse visuals to involve as well as in-struct. They were developed fromfield up rather than top-down sothat extension workers and villagerswould be comfortable with them;village women, in particular, havegained the confidence to contributein PHE sessions.

■ Support to households. The pro-gramme subsidizes family efforts tobuild latrines, upgrade wells andprovide for hand-washing. House-holders contribute 75% of the costs.

All the programme districts reportincreased latrine building and betterhygiene practices. Key tasks ahead areidentifying indicators for behaviourchange that can be used to gauge pro-gress, and incorporating PHE principlesinto the standard training for all exten-sion workers.

Lessons learned■ Participatory

hygiene educa-tion is a strong tool for changingindividual and community behav-iours

■ Impact is greatest when communitiesidentify and evaluate their ownhealth practices

■ Back-up support is crucial at everylevel for building confidence

■ Schoolteachers, church groups andother community activists shouldalso receive training: hygiene is morethan just a health issue

■ Training should distinguish betweenthe support staff who need only ageneral grasp of process, and theextension workers who need to befully trained and equipped with thelearning tools

■ Procedures should be built in forsystematic reporting, periodic reviewof activities, and impact assessment.


■ Myanmar from page 17

million new latrines (12% of the popula-tion)—a challenging but doable goal.Early indications are that the weeksparked a livelier interest in sanitation.Meanwhile, the successes achieved insome townships are boosting confidenceelsewhere.

The case study concludes with a briefdescription of WESNET, the regionalInternet forum for UNICEF’s water andsanitation staff in East Asia and the Pacific.


Communication strategy in action

25


ness raising and two-way communica-tion. While water supply projects canusually take community interest forgranted, sanitation and hygiene educa-tion have to create understanding anddemand, focusing intensively onindividual households and persons. Theapproaches that have traditionallyworked for water supply have failedwhen applied to sanitation, since theylack the flexibility to take account of thecomplex interplay between consumerwishes, behavioural change, and marketmechanisms.

In sum, sanitation programmes musttailor their proposals very closely to theusers’ socio-economic conditions,needs, desires and perceptions. Sanita-tion professionals need to listen to the‘clients’ and be sensitive to their priori-ties and habits. Local knowledge aboutsanitation and the environment has tobe incorporated into programme designs.

The way aheadCreating community demand is a firststep. Sanitation programmes also haveto be financially self-sustaining, at leastin part, given the present reliance onfree enterprise to shoulder burdens oncerelegated to government. Moreover,we now know that improved sanitationsystems and hygiene practices show fargreater longevity when communitiesdesign, manage, finance and generally‘own’ the services from which they ben-efit. Recent years have witnessed thedevelopment of a wide range of afford-able technologies, together with creativearrangements for credit and revolvingfunds that enable producers and usersalike to make the necessary investmentsin these technologies.

That said, the marketplace alonewill probably not provide the satisfac-tory technologies that are still needed.Despite the crucial importance of sanita-

tion, the private sector has shown sur-prisingly little interest. So experimentallow-cost technologies will therefore haveto continue to be supported, and func-tioning solutions continue to be repli-cated elsewhere as appropriate.

The workshop report will be avail-able shortly from the WES Section,UNICEF New York. For copies of thecountry case studies, please contact theauthors.

■ A global challenge from page 1

issues, and the national newspaperscarried over 400 articles on the topicduring the first six months of 1998.Home and school improvement compe-titions are being held; hundreds ofschools have built latrines; entrepre-neurs are setting up garbage recyclingbusinesses. In the meantime, more thanhalf of UNICEF spending for watersupply and sanitation is now dedicatedto sanitation, up from 4% two years ago.

Lessons learned

■ A few highly committed and politi-cally well-placed individuals can havetremendous impact

■ In particular, the President’s supportwas crucial, supplying both motiva-tion and credibility

■ Sanitation is not just a health issue

■ UNICEF should lead by example,promoting sanitation in every aspectof its work and showing personalcommitment.


■ Uganda from page 22

medical issue that effect the public, In-lander says that he washes his handtwelve times daily. He is convinced“`hand washing has slipped” because ofa misplaced public faith in modernmedicine and the risky belief that antibi-otics can thwart most infectious diseasesbefore they get out of hand. “We thinkwe are too smart for infections” he con-tends. “It is obvious we are not. Ourmothers were far more aware of thosekind of things than we are today.”

Marc Micozzi, a physician and direc-tor of the National Museum of Healthand Medicine points out that most ofthe usual suspect illnesses such as coldsand flu , primarily are transmitted bycontact — making them largely prevent-able with an old fashion dose of preven-tion. “Even today the simplest thingsreally account for keeping us healthy —good nutrition, simple sanitation wash-ing your hands” say the editor of Thejournal of Alternative Medicine. “Eventhe bacterial that aren’t killed by antibi-otics can be killed by soap if you can getthem on the outside before they get

■ Dirty hands from page 9

…most of the usual suspectillnesses such as colds and flu ,

primarily are transmitted bycontact — making them largelypreventable with an old fashiondose of prevention. “Even today

the simplest things reallyaccount for keeping us healthy

— good nutrition, simplesanitation washing your hands”

inside your body” — LA Times/Wash-ington Post.

26


hardware is the total package of sani-tary conditions and facilities availablein and around the school compound.The software is the activities aiming topromote the hygienic conditions andpractices at school, among staff andchildren, that will help to preventwater- and sanitation-related diseases.

For more information, or to order cop-ies, please contact the WES Section,UNICEF New York, [email protected]

Hacia una mejorprogramación: Manual sobresaneamiento

(Spanish version of Better sanitationprogramming: A UNICEF handbook,issued in April 1997)

There is an urgent need for develop-ment planners throughout the worldto give sanitation priority attention.The number of families without accessto adequate waste disposal in poorurban and rural areas continues togrow in many places, and the pro-gramming challenges for UNICEF andother partners are considerable. Thishandbook, prepared in collaborationwith USAID’s Environmental HealthProject, is designed to help workingprofessionals who are responsible forsanitation programming to preparerealistic and better sanitation pro-grammes. It is based on a broad defi-nition of sanitation as a process

whereby people demand, create, andsustain a hygienic and healthy envi-ronment for themselves.

To order copies, please contact the WESSection, UNICEF New York,[email protected].

Childhood lead poisoning:information for advocacyand actionLead poses an environmental andchild health hazard of global propor-tions, demanding urgent action. This20-page booklet published in 1997 is acontribution to reducing the adversehealth and environmental impacts oflead, particularly on children. It isintended as a tool for advocacy andaction in the hands of policy makers,communities and everyone caring forchildren.

The booklet is the first of an infor-mation series dealing with environ-mental pollutants and their effects onchildren, co-published by UNEP andUNICEF as part of a wider effort toraise awareness of the linkages be-tween environmental factors and thewell-being of children.

Copies can be obtained from the WESSection, UNICEF New York,[email protected] , or from theHuman Health and Well-being Unit,United Nations Environment Pro-gramme, PO Box 30552, Nairobi,Kenya.

Towards betterprogramming: A manualon school sanitation andhygieneThis manual, part of the UNICEFProgramme Division technical guide-lines series on water, environment andsanitation, is the result of collabora-tion between UNICEF and the IRCInternational Water and SanitationCentre in The Hague. Building onexperience from a number of countryprogrammes, the manual advocatesintegrated approaches towards a safeschool environment for all children,with linkages to community actionsand relevant education for healthy andsustainable development.

Children are agents of change. Ifwe focus on school-aged children,giving them the tools and knowledgeto change behaviours today, futuregenerations will be better prepared tocare for their families’ and communi-ties’ health and environment. This isan area long recognized as worthy ofsupport, and UNICEF has worked inpartnership with both donor andimplementing governments world-wide.

The manual deals with both the‘hardware’ and the ‘software’ neededto bring about changes in hygienebehaviour in students and, throughthem, in the community at large. The

New Publications

27


Useful resources

Training manual on women,environmental managementand sustainable developmentThis 1996 training package, preparedby Borjana Bulajic, Martha Dueñas-Loza and Adelina Guastavi, was pub-lished jointly by the United NationsInternational Research and TrainingInstitute for the Advancement ofWomen (INSTRAW), the UnitedNations, and the International Train-ing Centre of the International LabourOrganization. It consists of fourmodules:

■ Women and environmental health

■ Women as agents of change in thedevelopment sectors

■ Women as managers of the envi-ronment

■ Women, environmental indicatorsand capacity-building programmes.

The overall aim is to contribute tothe integration of women’s needs andtheir participation in sustainable de-velopment programmes, and to in-crease awareness among planners andofficials, as well as NGOs and women’sorganizations, of the need to involve

women in the planning, management,implementation and evaluation ofenvironmental programmes andprojects.

The package is intended for use byvarious target groups, such as seniorgovernment officials, developmentplanners, engineers, university profes-sors, trainers, and representatives ofNGOs and women’s organizations; itis also a good sourcebook for projectofficers on almost all issues relating towomen and sustainable development.

For further information or copies of thecomplete training package, please contactINSTRAW, 102-A, PO Box 21747,Santo Domingo, Dominican Republic,tel (809) 685 2111, fax (809) 685 2117 .

Jelly Jam, the peoplepreserverJelly Jam, created in 1972 by JudiFriedman, an American environmentaleducator, is a gentle, humorous car-toon rabbit who shows young childrenhow to help the environment—andhence themselves—in very practicalways. A teacher’s guide accompaniesthis activity book for children aged 3to 10, which uses colouring, puzzlesand other activities to spark children’sconcern for the planet.

Travelling under many guises,including Yeli Yam, el amigo de la gentey la naturaleza, Jelly Jam has recentlybeen adapted for children inAzerbaijan, Bermuda, Brazil, CostaRica, Kazakhstan, Romania, Russiaand Ukraine, with editions for China,New Zealand and South Africa soon tocome. Some of these editions weresponsored by UNICEF country offices.

For further information on Jelly Jam,please contact the WES Section,UNICEF New York, [email protected],or The Jelly Jam Program, 101 LawtonRoad, Canton, CT 06019, tel (860) 6934813, fax (860) 693-2822, e-mail:[email protected].

print since 1971. Additionally, it is basedon British legislation and clearly reflectsnormative behaviour in Britain and notUganda. Accordingly, draft legislationand policy on guidelines for environmen-tal health and sanitation have been devel-oped which more accurately reflectrealities in Uganda. These will be submit-ted to Parliament in the 1998 legislativesession.

ConclusionThe potential gains for Uganda fromimproved sanitation include:

■ Development of Uganda’s national sanitation policy from page 10

1. Reduced morbidity and mortalityfrom diarrhoeal diseases

2. Enhanced school education, par-ticularly for the girl child

3. Reduction of severe undernutrition

4. Millions of workdays saved eachyear, which will contribute to pov-erty eradication in the country

5. Savings of millions of dollars onenvironmental clean-up campaigns

6. Great potential for generating in-

creased revenue from tourism, fisher-ies and recycling of wastes.

The Government of Uganda is ac-cordingly highly committed to improvingsanitation. However, resources will berequired to sustain this process and wecount on our development partners tocontinue supporting us in this effort.

28


A newsletter for information exchange on Water,Environment, Sanitation, and Hygiene Education

UNICEFProgramme Division

Water, Environment andSanitation Section

Please send articles, illustrations and correspondence to:

The Editor, WATERfrontUNICEF Programme Division, WES Section

Three United Nations Plaza, TA 26ANew York, N.Y. 10017. U.S.A.

Telephone 1-212-824-6000Fax No. 1-212-824-6480e-mail: [email protected]

Printed on recycled paper

WATERfront

ver the years before and afterthe World Summit for Chil-dren in 1990, UNICEF has

learned much about how to work withcountries and communities in accelerat-ing action towards key goals for childrenand communities, especially in healthand education. We now need to draw onthis experience in accelerating action forsanitation and hygiene.

Six points1. We need a goal for sanitation and

hygiene—a global goal translated intocountry-by-country goals, perhapsregional and district ones. This is alesson for all, but especially for themany members of the WSSCC whohave major doubts about the valueof goals. UNICEF needs to share itsmore positive experience.

2. We need to mobilize behind the goal.Mobilization means leadership, ad-vocacy, and alliance building. Weneed to tap the energy and mobiliz-ing skills of the gender and women’smovement. Here there are lessonsto be learned for UNICEF field

A global initiative for basic sanitationNotes for workshop presentation, 12 June 1998, UNICEF New York

by Richard Jolly, Chairman, Water Supply and Sanitation Collaborative Council (WSSCC), and Special Adviser to theAdministrator, United Nations Development Programme (UNDP)

personnel. There is no need for con-flict with other goals. There are alsolessons to be learned by UNDP, espe-cially its resident coordinators, formobilizing theme teams aroundsanitation and hygiene.

3. We need to concentrate on low-costapproaches that can go to scale. Thiswas the lesson we learned from accel-erating to the 1980s goals for immu-nization and oral rehydration therapy,and the 1990s goal of eradicatingiodine deficiency. But water supplyand sanitation have made only asmall fraction of progress towardstheir targets. UNICEF, convey yourexperience to others: go low-costand go to scale.

4. We need to build on the success storiesof practical experience. Excellent ex-amples have come from Bangladesh,India, Thailand, Uganda, Zambiaand Zimbabwe, to name only a hand-ful. Here there are messages for all.

5. We need to mobilize the finance—byrestructuring budgets, by pushing forthe 20/20 initiative to dedicate 20%

of aid and 20% of government fund-ing to basic services, by mobilizingcommunity resources, by charges inappropriate cases. Here there is amessage for the World Bank and theInternational Monetary Fund,among others: do not be overly fix-ated on recovering the full cost ofprogrammes.

6. Country-by-country monitoring isvital. Detailed country monitoringproved critical to the success of thedrive to expand immunizationworldwide. Monitoring of watersupply and sanitation is at presentvery inadequate, and standards ofcoverage differ. It would be good tosee access to clean water incorpo-rated in the Human Poverty Index,published yearly in UNDP’s Humandevelopment report. This is a messagefor UNICEF and the World HealthOrganization.

The WSSCC remains ready to help,as a secretariat for sharing informationand for helping to mobilize interest andcommitment.

Royal accolade for WEDCuckingham Palace announced inNovember that one of the 1998

Queen’s Anniversary Prizes for Higherand Further Education had beenawarded to the Institute of DevelopmentEngineering/Water, Engineering andDevelopment Centre (WEDC), in recogni-tion of WEDC’s 27 years of teaching,research and consultancy in over 65countries worldwide, helping to ensurethat the world’s poorest people haveaccess to essential services. The prize willbe formally presented by Queen Elizabeth

at a special ceremony at the Palace on 11February 1999.

The official press release says ofWEDC: “Key strengths include the practi-cal, in-country experiences of its staff;its interdisciplinary approach coupledwith the appropriateness of its technolo-gies; and the huge network of alumniserving as development professionalsthroughout the world. Its proven expertiseand the humanitarian nature of its workmake it the first choice adviser of manyfront-line development organizations.”

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