Deciding to Flush: Motivators, Barriers and Knowledge Pathways Regarding Toilet Construction in the Western Region of Nepal
Sandra D. Umbach
Department of International Environment and Development Studies, Noragric Master's Thesis (30 credits) 2008
Deciding to Flush: Motivators, Barriers and Knowledge Pathways Regarding Toilet Construction in the Western Region of Nepal
By: Sandra D. Umbach May, 2008
A Thesis Submitted in Partial Fulfilment of the Requirements for a Master of Science Degree.
Norwegian University of Life Sciences (UMB)
Department of International Environment and Development Studies (Noragric) Ås, Norway
The Department of International Environment and Development Studies, Noragric, is the international gateway for the Norwegian University of Life Sciences (UMB). Eight departments, associated research institutions and the Norwegian College of Veterinary Medicine in Oslo. Established in 1986, Noragric’s contribution to international development lies in the interface between research, education (Bachelor, Master and PhD programmes) and assignments.
The Noragric Master theses are the final theses submitted by students in order to fulfil the requirements under the Noragric Master programme “Management of Natural Resources and Sustainable Agriculture”
(MNRSA).
The findings in this thesis do not necessarily reflect the views of Noragric. Extracts from this publication may only be reproduced after prior consultation with the author and on condition that the source is indicated. For rights of reproduction or translation contact Noragric.
Cover Photo: Partially Constructed Toilet Awaiting Completion. Bhujikot, Nepal (Nov/07).
All Photo Credits: S.Umbach.
© Sandra D. Umbach, May 2008 [email protected] Noragric
Department of International Environment and Development Studies P.O. Box 5003
N-1432 Ås Norway
Tel.: +47 64 96 52 00 Fax: +47 64 96 52 01
Internet: http://www.umb.no/noragric
Declaration
I, Sandra D. Umbach, declare that this thesis is a result of my research investigations and findings.
Sources of information other than my own have been acknowledged and a reference list has been appended. This work has not been previously submitted to any other university for award of any type of academic degree.
Signature………..
Date………
To the people of Nepal,
who never seem to be without a smile on their face, or gold in their hearts.
Acknowledgements
This study was completed in cooperation with many people, both in Nepal and in Norway.
Thanks to the faculty and staff at Pokhara Engineering College, in particular Mr. Cheej Gurung, Mr.
Som Nath Banstola, and Mr. Lekh Bahadur Gurung. Without the support and guidance of Mr. Lekh Sir, this study would not have been possible. You were instrumental in providing background information, in the formation of the study goals and methods and in determining the logistics of it all.
Your enthusiasm was contagious.
Thanks also to my colleagues and translators, Mrs. Bindu Sigdel Pokharel and Mr. Dipak Gautam.
Your support, perspective and interpretation made the field work possible, and your friendship made it enjoyable. Thanks also to Mr. Mahesh Panthi of Kotre Bazaar, for your excellent translation services and assistance.
Thanks to Dr. Keshab Awasthi and Dr. Binod Bhatta, for their input and support during the conceptualization and proposal stages.
Thanks to Noragric for a research stipend, which supported this work.
Many thanks to my supervisor at UMB, Dr. Cassandra Bergstrøm. Your guidance, input and
encouragement were vital to the creation and completion of this study. I have appreciated your insight and availability on so many occasions.
And to all the people in the villages with whom I lived and talked: thank you. Your willingness and openness in sharing your time, your lives and your opinions have formed the very foundations of this study. Dhanyabaad!
Abstract
The study identifies the perceived motivators, barriers and information pathways that contribute to household decisions about building toilets in rural Nepal. The study focuses on social aspects of sanitation at the local level, while acknowledging the greater complexity of factors contributing to the sanitation situation in a community. An ecohealth approach was used to conduct the study. While both the approach and the subject (sanitation) are focused on health as the ultimate goal (addressing policy-makers’ and program implementers’ concerns to improve health), the use of an ecohealth approach also facilitates the necessary comprehensive exploration of other factors contributing to sanitation (addressing the local people’s concerns), which are equally or more important in the actual practice of improving sanitation. Field work was completed in four rural communities in the hilly Western Region of Nepal. Sanitation-related decisions at the household level were explored using household interviews, key informants, group discussions, informal talks and observation.
The main motivators for (or benefits of) building a toilet were found to be: cleanliness; convenience;
status/for guests; fewer mosquitoes/flies; reduction of bad smells; and safety from leeches, snakes, and wild animals. The perceived barriers to building a toilet were found to be: lack of money; lack of time/labour; and other household priorities. The main modes of learning about toilets were found to be: observing and talking to acquaintances; working and travelling overseas or in cities; NGO or governmental training projects; and at school, or from their children. The government, NGOs, private sector, communities and individuals all have roles to play in promoting sanitation. The impact of social pressure, both within a community and from outsiders, was found to be instrumental in creating demand for improved sanitation. Active promotion of sanitation through school curriculum, home visit programs and sanitation clubs were found to be effective agents of change for sanitation behaviour. Health is a major driver for sanitation promotion projects by government, donors and NGOs, but if often not a significant motivator for improved sanitation at the individual/household level. In addition to improved health, significant benefits of improved sanitation include environmental cleanliness, convenience, comfort and dignity. Partly due to these reasons, the study finds justification for targeting 100% sanitation coverage in a community. While 100% sanitation coverage is not necessarily prerequisite for a reduction in diarrhoeal diseases, focussing on total sanitation (100% coverage) would ensure all the benefits of improved sanitation are equally accessible to the poor, who may well be unable to build toilets without external intervention.
TABLE OF CONTENTS
List of Tables... x
List of Figures ... x
List of Acronyms... xi
1 Introduction ... 1
1.1 Background ... 1
1.2 Objectives... 2
1.3 Significance... 3
1.4 Report Outline ... 4
2 Literature Review... 5
2.1 Sanitation and Environmental Health ... 5
2.2 Sanitation and Health ... 6
2.3 The Millennium Development Goals (MDGs) ... 8
2.4 The Sanitation Situation in Nepal ... 11
2.5 Community Led Total Sanitation... 18
2.6 Understanding The Demand for Sanitation... 20
2.7 The Ecohealth Approach... 23
3 Methodology ... 27
3.1 Research Design... 27
3.2 The Ecohealth-AMESH Approach... 28
3.3 Field Practicalities ... 30
3.3.1. Timing ... 30
3.3.2. Translation... 31
3.3.3. Record Keeping... 32
3.4 Pre-testing vs. Systematic Observation... 33
3.5 Location Selection... 34
3.6 Description of Sites ... 38
3.6.1. Observation Sites... 38
3.6.2. Study Sites... 40
3.7 Data Collection... 44
3.7.1. Scope ... 44
3.7.2. Sampling... 45
3.7.3. Tools... 46
3.7.4. Validity... 49
3.8 Data Analysis ... 51
3.8.1. Theoretical Interpretation of Data ... 51
3.8.2. Data Analysis Procedures... 53
4 Results ... 55
4.1 Effectiveness of Methods Applied in the Field... 55
4.2 Unit of Analysis ... 56
4.3 Local Classification Systems ... 57
4.3.1. Household Categorization ... 57
4.3.2. Toilet Categorization... 58
4.4 The Existing Sanitation Situation... 62
4.4.1. Observation sites ... 62
4.4.2. Study Sites... 65
4.5 Stakeholder Analysis... 74
4.6 Ecological Analysis... 78
4.6.1. Environmental Sanitation... 78
4.6.2. Drinking Water... 79
4.6.3. Water Availability... 80
4.6.4. Personal Hygiene... 81
4.6.5. Human Health ... 82
4.7 Social Analysis... 83
4.7.1. Leadership ... 83
4.7.2. Social Cohesion... 84
4.7.3. Gender ... 85
4.7.4. Other Cultural Factors... 86
4.7.5. Information Pathways ... 87
4.7.6. Previous Project Experiences ... 87
4.8 Governance and Policy Analysis... 89
4.9 Identified Motivators and Barriers ... 90
4.10 System Description and Issue-Influence Diagrams ... 94
5 Discussion ... 101
5.1 Research Approach ... 101
5.1.1. Study Scope... 101
5.1.2. The Usefulness of the AMESH Method for a Sanitation Study ... 102
5.2 Sanitation Indicators... 103
5.3 Social Capital and Social Heterogeneity... 104
5.4 Learning About Sanitation ... 107
5.5 Effect of Education... 110
5.6 The Water and Sanitation Users Committee ... 111
5.7 Room For All in the Sanitation Sector ... 112
5.8 The Demand for Sanitation ... 115
5.9 Money as a Barrier ... 117
5.10 The Issue of Optimal Sanitation Coverage ... 120
6 Conclusions ... 125
7 References ... 130
Definitions... 135
List of Tables
Table 2.1 – Definitions of improved and unimproved sanitation facilities... 10
Table 4.1 – Definitions of improved and unimproved sanitation facilities with respect to toilets found in Bhujikot and Istanthok. ... 60
Table 4.2 – Basic socio-economic and sanitation statistics for Bhujikot and Istanthok. ... 68
Table 4.3 – Stakeholder groups with respect to sanitation... 76
List of Figures Figure 2.1 – Potential reductions in diarrhoeal diseases due to improved water, sanitation and hygiene practices. ... 7
Figure 2.2 – Governmental bodies involved in water and sanitation policy and project implementation in Nepal. ... 15
Figure 2.3 – The nested eco-social system on which the ecohealth approach is based. ... 25
Figure 3.1– Schematic of the AMESH Method, used as part of the ecohealth approach. ... 29
Figure 3.2 – Site Locations: Observations Sites (Jagatpur and Lamiswarma, Shyangja District), and Study Sites (Bhujikot and Istanthok, Tanahu District). ... 37
Figure 3.3 – Jagatpur, Shyangja District (Observation Site)... 39
Figure 3.4 – Lamiswarma, Shyangja District (Observation Site). ... 40
Figure 3.5 – Bhujikot, Tanahu District (Study Site). ... 42
Figure 3.6 – Istanthok, Tanahu District (Study Site). ... 43
Figure 4.1 – Toilets in Bhujikot and Istanthok... 69
Figure 4.2 – Construction of permanent toilets in Istanthok (a, c) and Bhujikot (b). ... 70
Figure 4.3 – Concrete dishwashing stands, Bhujikot... 71
Figure 4.4 – Examples of household/environmental sanitation in Bhujikot... 72
Figure 4.5 – The drinking water source spring, Bhujikot. ... 80
Figure 4.6 – Motivators and barriers for building toilets and knowledge pathways for learning about sanitation in Bhujikot and Istanthok... 92
Figure 4.7 – Issue-influence diagram for villagers with no toilets or temporary toilets. ... 95
Figure 4.8 – Issue-influence diagram for villagers who have/use permanent toilets... 96
Figure 4.9 – Issue-influence diagram for community leaders, teachers, and health volunteers. ... 97
Figure 4.10 – Issue-influence diagram for NGOs and VDC/Government... 98
Figure 4.11 – System synthesis: combined issue-influence diagrams. ... 100 Figure 5.1 – Sanitation card games played with Class 1 and 2 children at Bhujikot School. 109
List of Acronyms
2064 BS The Nepali calendar year (BS = Bikram Sambat) running from mid-April 2007 CE to mid-April 2008 CE.
AACDC Andha Andhi Community Development Centre (local NGO) AMESH Adaptive Methodology for Ecosystem Sustainability and Health
CHV Community Health Volunteer
DDC District Development Committee
ENPHO Nepal Environment and Public Health Organization FAO Food and Agriculture Organization of the United Nations
GON Government of Nepal
HH Household
HH#5 Household #5 as identified during household interviews (lists of household identifier numbers are provided in the appendices)
MDGs Millennium Development Goals
NEWAH Nepal Water for Health (NGO)
NGO Non-Governmental Organization
NT No Toilet
PEC Pokhara Engineering College
PT Permanent Toilet
RWSSFDB Rural Water Supply and Sanitation Fund Development Board SDC Swiss Agency for Development and Cooperation
TT Temporary Toilet
UNICEF United Nations Children’s Fund
UNDP United Nations Development Fund
VDC Village Development Committee
VHP Village Health Promoter
WASH Water, Sanitation and Hygiene
Watsan Water and Sanitation
WHO World Health Organization
WSH Water, sanitation and hygiene
WSP Water and Sanitation Program (NGO)
WSUC Water and Sanitation Users’ Committee
Bhujikot, Tanahu District, Nepal
Photo taken Nov/07.
1 Introduction
1.1 Background
The international community has declared this year, 2008, the International Year of Sanitation. This declaration is a clear recognition of the importance of sanitation for the health and well-being of all people, and is an attempt to increase global awareness and commitment in the sector. There has been an overall increase in addressing sanitation issues in recent years due to efforts to promote improved sanitation in the developing world and increased commitment to funding for sanitation projects from the developed world. With respect to sanitation issues, Nepal is typical of a developing Asian country: the vast majority do not have access to improved sanitation facilities. The majority of the Nepali population lives in rural areas (85%1), where sanitation coverage is lowest. Open defecation, with its significant health impacts, is a common practice. Improved sanitation practices are spreading slowly in Nepal despite several successfully implemented sanitation projects. As a result, the country’s status with respect to the Millennium Development Goals (MDGs) for sanitation is reportedly
“making progress but insufficient” (WHO & UNICEF, 2006), with a national coverage of only 46%2.
The developed world enjoys much lower rates of incidence and mortality from infectious diseases than does the developing world (WHO, 2004). This is largely due to the widespread access to clean water, improved sanitation and proper hygiene practice in the developed world. In his study on the history of disease and mortality, Easterlin (2006) writes that the most significant advances in the history of public health and reductions in mortality have been made by public policy initiatives including advancements in public water and sanitation. He writes that the first major step in the breakthrough against infectious disease started with the
“sanitation revolution” in Great Britain and Europe in the 1840’s (ibid.). The 2006 Human Development Report (UNDP, 2006) also draws attention to the fact that only a few generations ago, Europe and the United States were also facing serious public health threats due to unclean water and unsafe sanitation. These issues only began to be adequately
1 WHO & UNICEF, 2006
2 According to Government of Nepal administrative data for 2006/07 (GON, 2007).
addressed in the end of the 19th century, with concerted political action at the national level (ibid.).
Poor sanitation is a major threat to public health, and as such provision of sanitation facilities and efforts to promote their use are responsibilities of national governments (WHO, 2007).
Accordingly, the Government of Nepal has been making efforts to increase sanitation coverage in the country. In addition, there are several organizations implementing water and sanitation, health and hygiene projects in Nepal in various capacities. These efforts by the government and other organizations are reaching many communities with improved water supply and sanitation, as well as contributing to the body of knowledge regarding sanitation in Nepal. There are still many villages and households that do not have improved sanitation, however. Given the vast population without improved sanitation and the limited resources available for sanitation programs, it may be years before the government or an outside organization identifies and initiates sanitation programs in each of these communities.
Individuals and communities also have roles to play in raising awareness, promoting sanitation and constructing toilets. In many communities some households have built toilets while other households have chosen not to or are unable to build one. There are potential consequences for public and environmental health that may affect the entire community when some people do not use a toilet. Ideally, the personal and public benefits of improved sanitation (e.g., convenience, dignity, community cleanliness, public health, etc.) would motivate people to talk amongst themselves, and construction of improved sanitation facilities and improved hygiene and sanitation practices would spread quickly regardless of external intervention by the government or an NGO. This is not reported to be happening readily in Nepal. This study addresses this issue by increasing understanding of how sanitation knowledge spreads in Nepal, why people choose to build toilets or not, and how to use this information to increase the rate at which improved sanitation is spreading in Nepal, in order to meet the MDGs.
1.2 Objectives
This work explores the motivators and barriers that influence why people do or do not build toilets. It also investigates information pathways for sanitation and hygiene knowledge: how people learn about toilets, and how they make decisions whether to build a toilet or not.
Ideally, the findings will provide useful insight into what can be done by organizations and
the government to increase the rate of spread of improved sanitation. The specific research objectives are:
To identify the reasons people choose to build a toilet, and the benefits they receive from having a toilet;
To identify the barriers or reasons why households have not built toilets; and To determine:
- the knowledge level about sanitation and hygiene in the community;
- how households obtain information regarding toilets; and
- how decisions are made regarding sanitation and the building of toilets at a household level.
1.3 Significance
Sanitation is a critical issue of interest to both governments and researchers because of its considerable impacts on public and environmental health (WHO, 2005; Esrey et al., 1991, Fewtrell, 2005). Furthermore, development initiatives to improve water supply and water quality will fail to achieve significant reductions in disease in the targeted communities if such projects are not accompanied by simultaneous improvements in sanitation (Esrey, 1996;
Wibowo and Tisdell, 1993). Despite the critical role that sanitation plays in public health, many donors and governments continue to prioritize drinking water, with less funding earmarked for sanitation. In addition, less central planning is usually targeted to sanitation, the responsibility for sanitation is often less clearly delegated within the government, and the lines of authority for sanitation decisions and policy at national, regional and local level is less clearly defined than for other development issues such as drinking water (UNICEF, 2006;
WHO & UNICEF, 2006; UNDP, 2006).
But it is not only a question of a clear delegation of funding and responsibility. Until recently sanitation promotion projects both by governments and non-governmental organizations have emphasised the technical aspects of providing and improving sanitation services (Nawab 2006). Lack of attention to social and cultural factors has often meant that systems may well go unused or be underused and poorly maintained. There are apt to be important differences between cultures, between different social groups in a society and other important factors such as local preferences that have gone unrecognized with respect to their influence on interventions being actively taken into use and maintained. In addition, the factors contributing to local demand for sanitation, that is, the motivators and barriers that influence
people’s decisions about building toilets, are still poorly understood (Jenkins, 1999 & 2004;
Cairncross, 2004). This study will identify and seek to understand the relative importance of such social, cultural and behavioural factors, and the factors affecting the demand for sanitation in rural Nepal. Doing so will provide insight to how toilet construction and usage rates may be increased both with and without externally intervention.
1.4 Report Outline
This document presents the methods and findings of field work conducted in rural Nepal relating to household sanitation. The following section (Section 2) provides a review of the literature relating to sanitation, environmental health, human and public health, national and international sanitation goals, and typical approaches used in sanitation projects. Section 3 outlines the methodology used in the study and provides descriptions of the study sites.
Section 4 presents the results of the data collected in the field. Section 5 is a discussion of the results with reference to the literature, and Section 5 presents the conclusions of the study.
Definitions of terms are provided throughout the text; as well, a list of definitions is provided at the end of the document.
2 Literature Review
2.1 Sanitation and Environmental Health
The sanitation practices of a community affect both environmental health and human health;
poor sanitation practices can contaminate the living environment, pollute food and water sources, and cause disease and discomfort. Furthermore, poor health caused by sanitation- related diseases (diarrhoea, dysentery, cholera, hepatitis, worms, schistosomiasis, to name a few) is a major barrier for improving the well-being and livelihoods of people in the developing world.
The World Health Organization (WHO) have underlined the significant impact of the environment (including sanitation conditions) on human health. Globally, at least one quarter of preventable ill-health and deaths are caused directly by modifiable environmental factors.
The contribution of the environment to child deaths is even higher: up to one-third (WHO, 2006c). Ninety-four percent of the global diarrhoeal burden of disease is attributable to environmental factors, such as water and sanitation (ibid.). The WHO Report on Health and Environment in Sustainable Development (1997) states that:
Environmental quality is an important direct and indirect determinant of human health.
Deteriorating environmental conditions are a major contributory factor to poor health and poor quality of life and hinder sustainable development... Impoverished populations living in rural and peri-urban areas are at greatest risk from degraded environmental conditions. The cumulative effects of inadequate and hazardous shelter, overcrowding, lack of water supply and sanitation, unsafe food, air and water pollution, and high accident rates, impact heavily on the health of these vulnerable groups (WHO 1997:35, italics added).
Continuing on to discuss actions taken to address these problems, the report states that:
...lack of basic sanitation, poor water supply and poor food safety contribute greatly to diarrhoeal disease mortality and morbidity. Curative measures have brought the number of deaths from diarrhoeal diseases down, but action that deals with the root causes of these diseases continues to be lacking (ibid.: 36, italics added).
While a lack of proper sanitation can degrade the environment and cause public health concerns, good sanitation practices can also potentially have a positive environmental impact.
Certain sanitation practices, if properly practiced have no negative effects on human health, while providing ecological benefits to a community in the form of fertilizers for crops.
Ecosanitation (ecosan) practices aim specifically to conserve nutrients by recycling human excreta for use as fertilizer, and have been shown to increase crop yields, reduce the need for potentially expensive chemical fertilizers, and improve food security (EcoSanRes, 2005;
WHO, 2006a). Care must be taken with these practices that the human excreta is properly treated so that diseases are not transferred between individuals via direct contact with the excreta, or by crop uptake. Based on personal observation, discussion with locals and available literature (Lamichhane, 2007), there is little practice of or reported interest in ecosan in Nepal, although demand may be increasing (ibid.).
While sanitation practice is individual and private, its consequences both for the environment and human health are public. Public health is defined as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals”
(O’Donovan, 2008:12). Several actors share the social responsibility for environmental and public health: individuals, communities, civil organizations and governments. It is therefore also the responsibility of each of these actors to promote improved sanitation practices.
2.2 Sanitation and Health
Human health is a strong driver for improving sanitation practices in a community, especially for donors and governments who aim to improve people’s health, livelihoods and quality of life. It has been well established that improved water and sanitation facilities can reduce disease, which in turn can help to alleviate poverty (UNDP, 2006; WHO, 2006c, Esrey, 1991;
Fewtrell, 2005). A WHO report on disease burden and risk factors (2004) estimates that in the year 2000 alone unsafe water, sanitation and hygiene (WSH) resulted in 1.73 million deaths:
88% of the global burden of diarrhoeal disease due to infectious diarrhoeal diseases. In the 2005 World Health Report (WHO, 2005), it was estimated that 18% of child-deaths in the world are due to diarrhoea. The report states that in developed countries, approximately 60%
of diarrhoeal disease is attributable to unsafe WSH. In developing countries not only is the incidence of diarrhoeal disease much higher, but as much as 85-90% is caused by unsafe
WSH, and the majority of this burden is borne by children (ibid.). Further, the diseases schistosomiasis, trachoma, ascariasis, trichuriasis and hookworm are fully attributable to WSH-related factors. According to the WHO, “this estimation of the global disease burden caused by unsafe WSH suggests a significant burden of preventable disease attributable to this cause in developing nations, and a non-negligible burden in developed countries”
(ibid.:1322).
The prevalence of diseases caused by poor sanitation and water quality, and the documented effectiveness in improving public health of even the most basic improvements (e.g., using pit latrines and hand washing) justify investment in these sectors (WHO & UNICEF, 2006;
Esrey, 1991, 1996; Fewtrell, 2005). According to a multi-country study on the impacts of sanitation on health (Esrey, 1996), incremental improvements in sanitation (i.e., from no facilities to a pit latrine to a flush-toilet) result in incremental improvements in health.
Reductions in morbidity rates of diarrhoeal diseases due to improvements in sanitation have been evaluated in several studies (Esrey, 1996; Wibowo and Tisdell, 1993 Bateman and Smith, 1991) and reviewed in two key studies (Esrey et al., 1991; Fewtrell et al., 2005). The percent reductions in diarrhoeal disease are shown to be as high as 32-36% due to improved sanitation, and 33-45% for improved hygiene practice. The results of the two review studies are shown in Figure 2.1. For the 1.8 million who die each year due to diarrhoea alone, 90% of whom are under 5 years old, these results are significant. Improved sanitation could potentially save the lives of more than half a million children every year. In addition, schistosomiasis, a disease that affects an estimated 160 million people and causes tens of thousands of deaths each year, may be reduced by up to 77% by improvements in sanitation (Esrey et al., 1991; WHO, 2005).
Figure 2.1 –
Potential reductions in diarrhoeal
diseases due to improved water, sanitation and hygiene practices.
Based on results of multi- study reviews carried out by Esrey (1991) and Fewtrell (2005).
30
15 20
33 36
39a
33 25
45 43
0 5 10 15 20 25 30 35 40 45 50
hygiene sanitation water supply water quality multiple interventions
% Reduction in Diarrhoeal Disease
Esrey (1991) Fewtrell (2005)
a) considers only household point-water-treatment methods.
Improved sanitation results in multiple benefits for the community in addition to disease prevention, potentially including nutrient recycling (in the case of ecosanitation), aesthetic improvements, safety for women, and social and psychological benefits such as privacy, dignity, pride in the community and general well-being. Studies have shown that the most important drivers in the adoption of a sanitation system by a community can be dignity, status, and convenience (WHO & UNICEF, 2006; Jenkins 2004; Cairncross 2004). These factors contribute to raising the quality of life according to the WHO Quality of Life (WHOQoL) indicators3, as well as improving the more broadly understood term health, as defined by the WHO4.
2.3 The Millennium Development Goals (MDGs)
The Millennium Development Goal (MDG) for sanitation is to halve the number of people without access to safe drinking water and basic sanitation by 2015 (Goal 7, Target 10) (UN, 2000). The Millennium Project Task Force on Water and Sanitation defines “basic sanitation”
as “the lowest-cost option for securing sustainable access to safe, hygienic and convenient facilities and services for excreta and sullage disposal that provide privacy and dignity while ensuring a clean and healthful living environment both at home and in the neighbourhood of users” (WHO & UNICEF, 2006, italics added).
While an admirable goal, it remains an imprecise definition, which makes monitoring and measuring sanitation coverage difficult. The WHO/UNICEF Joint Monitoring Program (JMP) report (2006) discusses many of the challenges in monitoring water and sanitation coverage.
For example, a typical approach to measuring “basic sanitation” coverage is to count how many people have access to sanitation facilities (WHO & UNICEF, 2006; Billig, 1999). In reality, however, the number of people using sanitation facilities is often lower than the number who have access. These shortcoming have begun to be taken into account.
3 The WHO defines Quality of Life as "an individual's perception of his/her position in life in the context of the culture and value systems in which he/she lives, and in relation to his/her goals, expectations, standards and concerns. It is a broad-ranging concept, incorporating in a complex way the person's physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment" (AWFC, 2007).
4 The WHO defines Health as “a state of complete physical, mental and social well-being, and not merely the absence of disease, or infirmity” (WHO, 2006b).
Increasingly, “usage” of sanitary latrines is being reported; until 2006, the JMP MDG monitoring report recorded figures for “access” to hygienic sanitation, subsequent to 2006 it began monitoring “usage” (ibid.).
Another example of the complexities in measuring sanitation is how to determine “safeness”:
how do you test in a village if a certain sanitation practice is “safe”? “Safe” may be interpreted in physical terms (no danger of children falling in or pit collapse), or health terms (no potential for disease transmission), or in ecosystem terms (contamination of well water from pit latrines). The difference in interpretation will affect how sanitation coverage is measured and reported. A “hygienic latrine” is typically defined as one that eliminates contact between humans and faeces, or where no faeces are present around the floor/seat (IRC, 2004;
Billig, 1999).
In summary, the establishment and usage of a latrine may not be simply equated with improved safety of the system. Even if people have access to facilities and the facilities are used, they may not be safe, hygienic or convenient (WHO & UNICEF, 2006). As discussed above, it is important that toilets are used, safe, and hygienic, because if they are not, human health can be directly impacted via the direct faecal-oral pathway, or by contamination of drinking water and/or food. In addition, environmental factors including soil porosity and groundwater flow affect the transport of pathogens and safety of the community’s water and sanitation systems. Nawab and Esser (2006) provide a review of the potential pollution and negative health consequences from pit latrines, and present a case in Pakistan where latrines were found to be the source of colliform pollution in well water. Simply installing and counting latrines is therefore over-simplified. The environmental context and design of the latrine are important considerations for environmental and human health. Provision of clean drinking water is useless if it is subsequently contaminated by pathogens from improper sanitation or hygiene practices. Classifying a latrine as ‘safe’ may require a broader consideration of the local environmental context5.
In monitoring the MDGs, sanitation coverage is expressed as the percentage of people with access to or using “improved” facilities, defined as shown in Table 2.1 (WHO & UNICEF,
5 As the objectives of this study focused on the social factors of sanitation instead of technological/ecological factors, the possibility of contamination of drinking water and other environmental consequences of sanitation were only cursorily investigated in the field.
2006). Similar definitions are found in IRC (2004) and Billig (1999). The MDGs set fixed targets as a means of monitoring if there is a change in sanitation conditions regionally and globally. Internationally agreed upon definitions are required to enable comparisons to be made across national boundaries. As there is a continuum of sanitation conditions ranging from open defecation to fully-sewered systems, defining what constitutes “improved” and
“unimproved” sanitation within that continuum provides a basis from which to assess and monitor access to and usage of facilities that meet a minimum standard required for human and environmental health. The JMP Report (WHO & UNICEF, 2006) states that “improved sanitation facilities are more likely to prevent human contact with human excreta than unimproved facilities” (pg.4); they should also prevent contact with human faeces by animals and insects to intercept such disease transmission routes (O’Donovan, 2008). Even once these definitions for sanitation facilities are set, there can be great variation in sanitation systems encountered in the field. Discrepancies in monitoring and classification criteria may result in inaccurate statistics and comparisons. These difficulties in both defining and monitoring improved sanitation imply that sanitation statistics should be viewed critically (UNDP, 2006).
Table 2.1 – Definitions of improved and unimproved sanitation facilities.
Adapted from WHO & UNICEF (2006).
IMPROVED SANITATION FACILITIES UNIMPROVED SANITATION FACILITIES
Flush or pour –flush to:
- piped sewer system - septic tank
- pit latrine
Flush or pour–flush to:
- elsewhere (street, yard, stream, ditch, open sewer, other drainage way, etc.)
Simple pit latrine (with slab) Pit latrine without slab or open pit Ventilated improved pit latrine Bucket latrine
Composting toilet Hanging latrine
Public and shared facilities6 No facilities, bush or field
South Asia was classified in 2006 as “making progress but insufficient” for meeting the MDGs for sanitation (WHO & UNICEF, 2006). According to Hutton et al. (2006), failure to
6 The WHO & UNICEF Joint Monitoring Program (JMP) report (2006) acknowledges there is debate about the inclusion of public and shared facilities within the definition of improved sanitation. While they recognize the increasing number of such facilities and acknowledge that some shared/public toilets do provide “clean, safe and affordable shared services” (ibid: 23), they state that “well-maintained public or shared facilities represent an improvement over rudimentary forms of sanitation, the likelihood of poor hygiene and unsustainable use of these facilities, especially by children and women, argues against counting them as improved facilities” (ibid.:23). The report informs that the issue will be further investigated.
meet the water and sanitation MDGs would have a global cost of about US$ 38 billion per year, with sanitation accounting for 92% of that amount7, reflecting the greater impact that improvements in sanitation have on health than improvements in water supply. In addition, they estimate that the global return on investment in low-cost sanitation may be as high as 9:1, and 6.9:1 in South Asia. The main contributing factors to these returns are a reduction in healthcare and associated costs, and increases in productivity due to improved health. The cost associated with achieving the MDGs for water and sanitation in South Asia is estimated to be around US$802 million, while the benefits are estimated to be around US$5,507 million (ibid.). In his paper prepared for WaterAid on the economics of meeting the sanitation MDGs, Kemeny (2007) cautions against interpreting these results too literally, although he agrees that most researchers find that the benefits of sanitation far outweigh the associated costs. Thus, improving the effectiveness of sanitation programs is a sound and justified investment and research effort not only from health, social as well as economic terms. Considering all these factors, effort in improving sanitation and renewed commitment to meet the sanitation MDGs is worthy of attention by researchers, policy-makers, donors, communities and individuals.
2.4 The Sanitation Situation in Nepal
UNICEF (2006) completed a study on the Situation of Children and Women in Nepal, in which they estimate that about 13,000 children under five die in Nepal every year due to diarrhoea8. In addition, they report that 65% of children have hookworm and 43% have roundworm, and 79% of pregnant women have hookworm, and 56% have roundworm.
Worms and diseases such as typhoid, as well as diarrhoea, are passed via contact with faeces.
Contact with faeces may by direct (hand/foot) contact, via rain runoff (there is a generally acknowledged increase in diarrhoea with the monsoon season), other water such as streams or household wastewater, flies and cockroaches, or other pathways. Studies have shown that
7 The cost estimates are based on a detailed cost-benefit analysis studies prepared for the WHO by Hutton and Haller (2004) and Hutton et al. (2006), and further discussed by Kemeny (2007). The calculations of the overall benefits of meeting the water and sanitation MDGs, and the costs of not meeting them, include averted DALYs, direct economic benefits (e.g., averted transportation and treatment costs), indirect economic benefits (e.g., productivity gains, averted missed-days at work, increased life expectancy), and non-health benefits (e.g., reduced waiting time at public latrines), as well as costs of hardware and software (e.g., materials, equipment, labour, maintenance, training).
8 As their data on death rates are not disaggregated by cause, this estimate is based on WHO calculations for the proportion of child deaths due to diarrhoeal diseases.
proper excreta disposal and handwashing are more effective in reducing the prevalence of diarrhoea than water quality and quantity (UNICEF, 2006; Esrey, 1991; Fewtrell, 2005). In their study on diarrhoeal diseases, water and sanitation in Nepal, Pokhrel and Viraraghavan (2004) state that there are a minimum of 30,000 deaths due to diarrhoea in Nepal every year (based on data from the Department of Health Services). They also write that most diarrhoeal cases in Nepal are not reported as hospitals/health posts are often far away from communities.
This has two consequences: the health post staff do not stay long in these positions and so the posts are often unstaffed, and people often lack of money to pay for transport to the health posts, for medicines, and hospital stays (or they fear high costs), so they do not use the health posts. The authors state there may also be a reluctance to report illness due to illiteracy and social embarrassment. Thus, the prevalence of diarrhoeal diseases is likely much higher than the reported rates.
The first commitment to sanitation in Nepal was evident in the government’s 8th Five Year Plan (2049-2054 BS, or 1992-1997 CE), when large increases were budgeted for water and sanitation. In 1994 Nepal adopted the national Sanitation Policy Guideline for Planning and Implementation of Sanitation Programs, and in 1995 the National and District Water Supply and Sanitation Coordination Committees were formed (Karn, 2006). The budgeted allocation for sanitation decreased from the 8th to the 9th Plan. In the 10th Plan (2059-2064 BS, or 2002- 2007 CE), the budgeted amount and the growth rate of expenditure on water and sanitation went up, although it has fluctuated (NPC & UNICEF, 2006), and more responsibility for water and sanitation was transferred to communities, NGOs and the private sector (UNICEF, 2006; GON, 2002)9. A majority of the budget transferred to local levels of government is unconditional, and the majority of the funds transferred are not spent on basic social services (including water and sanitation) (NPC & UNICEF, 2006). Given national goals to increase social services, this reflects a discrepancy in national and local governmental spending priorities. The 10th Plan’s logframe states the drinking water and sanitation sector objective to
“improve public health and increase productivity by supplying drinking water and sanitation services in a sustainable manner”, along with a with a strategy to “mobilize local resources to the maximum” (GON, 2002:Annex3, Section 3.17). Stated under the heading “risks and obstacles” for the sector was “priority on sanitation by communities”. The major sanitation
9 The amount and percentage of the budget dedicated to sanitation is difficult to determine as it is usually generically included with the water budget and/or under “social services” (UNICEF, 2006).
initiatives listed in the document were vague: sanitation as an integral part of the drinking water programs, urban sewerage construction, rural sanitation program, health education and public awareness programs.
By the end of the 10th Plan period (2007), the national goal of 50% sanitation coverage (83%
urban, 43% rural) was not met; coverage estimates at the time were 46% of the total population, according to administrative records (GON, 2007). Despite not meeting its published goals, the sanitation situation in Nepal has been improving, with estimates of overall sanitation coverage increasing from 11% in 1990 to 35% in 2004 (WHO & UNICEF, 2006). During the same period, coverage in urban areas increased from 48% to 62%, and in rural areas from 7% to 30% (ibid.). These 2004 figures compare closely with the average figures for all of South Asia, which are 63% (urban) and 27% (rural) (WHO & UNICEF, 2006). The estimates from the 2006/07 Nepal Population and Health Survey (GON, 2007) are much lower (37% urban and 20% rural coverage) than the other estimates presented here.
They are also lower than the alternate statistics presented in the same document but from a difference source: 46% total coverage by 2007, from administrative records. This difference may reflect inconsistencies in monitoring criteria and sanitation indicators (such as what counts as “improved sanitation”), as discussed in other places in this document.
In the current Three-Year Interim Plan (2064-2067 BS, or 2007-2010 CE), national focus has remained on shifting responsibility for water and sanitation to communities and NGOs. There is still provision for federal budget allocation to drinking water and sanitation programs, some of which is transferred to local levels of government and organizations for water and sanitation projects. The new targets for sanitation coverage have been increased to 60%
overall coverage by the end of the Interim Plan period. The Approach Paper for the Interim Plan (GON, 2007) states that previous failures in the sector were due to weak supervision and coordination of agencies working in the drinking water and sanitation sector in Nepal, as well as inadequate attention paid to drinking water quality and to maintenance of constructed systems. The Interim Plan again includes sanitation as an integral part of drinking water programs, with a focus on sewerage projects with recycling in urban areas, and “appropriate technology” in rural areas. Women will be involved “institutionally and at all levels”
(ibid.:55). The document states that continuing challenges in the sector during the Interim Plan are rehabilitation and maintenance of constructed systems, duplication of efforts by the
government and other involved agencies/organizations, and a lack of trained and motivated personnel to serve in remote locations.
In Nepal, the water and sanitation sector is led by the Ministry of Physical Planning and Works, which formulates policy plans and monitors progress. The Ministry of Physical Planning and Works has formed a National Sanitation Steering Committee, which has been instrumental in creating awareness about sanitation (UNICEF, 2006). The Department of Water Supply and Sewerage provides technical skills and support to the rural water and sanitation sector in cooperation with the Ministry of Local Development. Under the Department of Water Supply and Sewerage are Water Supply and Sanitation Divisional Offices, which serve communities with populations over 1000. Under the Ministry of Local Development are District Technical Offices, which serve communities with populations of less than 1000. In addition, there are District Development Committees, which formulate and manage district-level water and sanitation plans. The Divisional and District Offices mentioned above may, in the future, be merged into units under the DDC. According to UNICEF (2006), while this move may help clarify power and responsibility delegation in the sector, it “will not address the policy issue that is compelling government technical agencies in water and sanitation to restructure their organization to assume the function of a
‘facilitator’ rather than the traditional role as ‘implementer’” (pg.93). Increasingly, water and sanitation projects are being identified and implemented by local levels of government (Village Development Committees) and Non-Governmental Organizations (NGOs), with funding and technical expertise channelled from higher levels of government.
Village Development Committees (VDCs), serving several small communities (villages) within their area, often provide support, contacts, training and/or financial assistance for sanitation projects, as seen in the field during this study. On a local level, Water and Sanitation Users’ Committees (WSUCs) have been formed to facilitate community participation, and are often assisted by NGOs in project formation, implementation and management of water and sanitation related funds. Some WSUCs have recently come together to form the national Water and Sanitation Users’ Federation, which is anticipated to expand and eventually provide monitoring and auditing of rural water and sanitation projects.
In a scheme supported by the World Bank since the early 1990’s, funds from the World Bank, the Government of Nepal and international donors are channelled through the autonomous
Rural Water Supply and Sanitation Fund Development Board (RWSSFDB), to support organizations who implement projects10. According to UNICEF (2006), this scheme has been effective at delivering services to communities, but has “ignored the government’s role in the sector and has not been particularly effective at reaching the most remote and deprived communities” (pg.93).
A schematic showing the relevant governmental bodies involved in water and sanitation in Nepal is shown in Figure 2.2. It is apparent that he approach is very top-down, with no channels for feedback or information to go from the communities up through the levels of government who are creating policy and making funding decisions. There is also a noticeable lack of links between the departments designated as responsible for water and sanitation promotion, shown here, and other sectors that should be involved in such projects, such as public health, education, and finance departments.
Figure 2.2 – Governmental bodies involved in water and sanitation policy and project implementation in Nepal.
10 Water and sanitation projects funded through this system were encountered in the observation sites (Jagatpur and Lamiswarma) during this study, with Andha Andhi (a local NGO) acting as the support/implementing organization.
Ministry of Physical Planning & Works (Lead) -formulates sector policy and plans
-institutional mechanisms to monitor progress in the sector National Sanitation Steering
Committee -promotes sanitation awareness
Ministry of Local Development -provides technical skills and support
Department of Water Supply & Sewerage Water Supply and Sanitation Divisional Offices -provides technical input and services to communities >1000 people)
District Technical Offices -provides technical input and services to communities <1000 people)
District Development Committees (DDC) -formulate and manage district-level plans
Village Development Committees (VDC) -support villages/households with funds, materials, training, etc.
Water and Sanitation Users Committees (WSUC) -ensure community participation in all stages of projects -assisted by NGOs in formulating and implementing projects and managing funds
Non-Governmental Organizations (NGOs)
Water and Sanitation Users Federation Rural Water Supply and Sanitation
Fund Development Board (RWSSFDB) -autonomous organization to channel funds from WB/international donors/GON to NGOs and implementing/support organizations
Ministry of Physical Planning & Works (Lead) -formulates sector policy and plans
-institutional mechanisms to monitor progress in the sector National Sanitation Steering
Committee -promotes sanitation awareness
Ministry of Local Development -provides technical skills and support
Department of Water Supply & Sewerage Water Supply and Sanitation Divisional Offices -provides technical input and services to communities >1000 people)
District Technical Offices -provides technical input and services to communities <1000 people)
District Development Committees (DDC) -formulate and manage district-level plans
Village Development Committees (VDC) -support villages/households with funds, materials, training, etc.
Water and Sanitation Users Committees (WSUC) -ensure community participation in all stages of projects -assisted by NGOs in formulating and implementing projects and managing funds
Non-Governmental Organizations (NGOs)
Water and Sanitation Users Federation Rural Water Supply and Sanitation
Fund Development Board (RWSSFDB) -autonomous organization to channel funds from WB/international donors/GON to NGOs and implementing/support organizations
In addition to the government institutions, several organizations are active in the sanitation sector in Nepal. Among them are international and national NGOs: Red Cross Society Nepal, WaterAid Nepal, Plan Nepal, World Vision Nepal, Nepal Water for Health (NEWAH) and Nepal Environment and Public Health Organization (ENPHO). In addition, there are several local organizations and agencies, such as Andha Andhi Community Development Centre (based in Shyangja) and Udaya Consultancy Service (based in Pokhara), which implement projects and/or support larger organizations and government in technical, monitoring and evaluation capacities. Some of these organizations conduct research as they work (ENPHO, NEWAH), and have carried out studies on the sustainability of completed hygiene and sanitation projects or new technology (e.g., NEWAH, 2004).
The barriers to implementing sanitation programs in Nepal have been documented to be largely organizational and political. WHO & UNICEF (2006) identify the major obstacles to sanitation improvements to be a lack of:
political will;
finances;
strong institutional frameworks;
consultation and understanding of people’s (consumers’) preferences; and consideration of cultural beliefs.
According to UNICEF (2006), more involvement is needed in general in the sanitation sector by all stakeholders including the government, particularly in remote areas. In addition, they report that a sector-wide approach is needed, as is a separate sanitation budget. Nepal’s national planning currently include the sanitation budget as a part of the water budget. The main idea behind introducing a separate budget for water and sanitation is to distance the engineering solutions typical of water supply solutions, to bring increased focus to the health needs and benefits of improved sanitation, as well as draw attention to and highlight the significance of improved sanitation, and not allow sanitation projects and achievements (or failures) to become lost within the array of water projects planned and completed. A report by the National Planning Commission (NPC) and UNICEF (2006) adds that more investment is needed in the social services, including sanitation. They also recognize a need for an alignment of national and local institutions’ priorities and spending, based on past experiences that show that while social services including sanitation are stated priorities for the national
government, the majority of funding transferred to local levels of government (e.g., the VDC) are not spent on social services.
According to Karn (2006), who works with the NGO Plan Nepal to implement water and sanitation projects in the country, failure to meet the sanitation goals in Nepal is due to lack of financial allocation, management and political problems, and lack of institutional interest and priority. Similarly, WaterAid, an international NGO working in Nepal in the water and sanitation sector, cites the two major obstacles to be the lack of a single institution responsible for sanitation, and the lack of a budget dedicated solely to sanitation projects. They also mention that sanitation is not typically a donor priority (WaterAid, 2006).
On a more local/individual level, a data-gathering survey in Nepal (“BCHIMES”) reported that the main reason respondents gave for not building a toilet was that they could not afford one (UNICEF, 2006). The next most common reasons were lack of habit (i.e., prefer open defecation) and lack of space (especially in urban and peri-urban areas). Similarly, a study by Nepal Water for Health (NEWAH, 2004) revealed that the reasons people did not construct latrines were cost/poverty, lack of land and/or ownership of land, negative perceptions associated with defecating where others or oneself has previously defecated, uncomfortableness in sharing a latrine between men and women, and that the river was considered convenient enough. The same study revealed that the reasons people did build latrines were privacy, night time convenience and safety, convenience for the sick and elderly, and a reduction in road and river pollution. Note that none of these reasons are directly related to health.
The BCHIMES study revealed that although lack of sanitation facilities is often attributed to lack of awareness, 98% of people did know about the excreta-disease link. Only 20% realized that worms were also contracted via excreta. People did not generally realize that dirty hands or water could carry disease, although they did know flies were disease vectors (UNICEF, 2006). Around 50% of people were found to understand that toilets/proper sanitation are good for health. Most people thought the main purpose of a latrine is to improve the environment, convenience for elderly/sick people, or for privacy. Some preferred open defecation due to habit and the absence of bad smells, and some did not use their toilet if they had one due to the bad smells. In summary, lack of sanitation facilities and consistent use is therefore not only due to a lack of finances to construct and maintain the facility. It is also due to an
unwillingness, disinterest or inability to build toilets and/or change habits (ibid.). Building and using toilets may not be a priority for many households, which in turn may be related to a lack of knowledge and awareness, including a lack of understanding of all of the health- related benefits of using a toilet.
To addresses these types of issues, an approach developed in Bangladesh and introduced in Nepal called Community Led Total Sanitation focuses on building and strengthening the initiative of people to change their attitudes and behaviour with respect to sanitation. It prioritizes the use of systems that are affordable and appropriate for local context. This approach is discussed further in the following section.
2.5 Community Led Total Sanitation
The concept of Community Led Total Sanitation (CLTS) focuses on stopping open defecation (behaviour change), rather than just on building or promoting latrines (WaterAid, 2006).
These projects use a mobilization approach to “ignite” the villagers to desire change, rather than teaching them about the problems with their current practices and the merits of improved sanitation practices. The approach focuses on the importance of social and cultural factors in promoting sanitation behaviour change, instead of advocating purely economic or technological solutions.
The idea of including social factors in health studies and projects aiming to change behaviours is not new. Link and Phelan produced a paper in 1995 stating that although it is thoroughly acknowledged that disease and medical conditions are directly linked to individual behaviour and risks, social factors also influence an individual’s behaviour and risk, and are too often overlooked in disease/prevention studies. The same is true in a sanitation context – social and cultural factors impact heavily on an individual’s behaviours and attitudes regarding sanitation and hygiene, which in turn impact health. There are currently many investigations being conducted into the social determinants of health. Studies indicate that overall improvements and increased equality in socio-economic status within a community or nation contribute to overall improved public health (Marmot, 2004; CSDH, 2007; Gwatkin et al., 2004). As Link and Phelan (1995) assert, the indirect, social causes of disease have to be addressed, or the measures that are implemented to change behaviour and/or reduce risk may not have the intended effect, or opportunities to create change may be missed.
Core methods in the CLTS program to ignite change involve creating social pressure by shaming the residents for the act of open defecation and for finding the presence of faeces in their villages, calculating the potential amount of excreta found on the ground around their villages, and increasing knowledge and awareness, for example by facilitating group discussions focusing on disease and the cost of medications required to treat excreta- transmitted diseases. Proponents of CLTS are generally against subsidies for hardware, instead promoting low-cost, local and easily constructed solutions. WaterAid suggests that an 18-month timeframe is required to ignite a community and achieve total sanitation, or “open- defecation free” status.
Despite common obstacles in changing people’s sanitation practices, raising awareness and implementing sustainable and affordable systems, the Ethiopian government has had considerable success in promoting sanitation there, by means of social marketing (WHO &
UNICEF, 2006). They found that if sanitation facts became common knowledge, understanding of health and sanitation issues increased, schools were used as a tool for education, and the local leaders and extension officers were integrated into the program, the sanitation programs were successful. Subsidies were removed from sanitation hardware, and instead affordable local solutions were used. As with the CLTS approach, the approach used by the Ethiopian government suggests that increasing education about sanitation together with involving schools and local community leaders are effective tools to increase demand for and commitment to sanitation programs, even more so than economic incentives. The WHO estimates that if the same rate of success continues, the region could meet its MDG targets for sanitation six years early (WHO & UNICEF, 2006).
The Community Led Total Sanitation (CLTS) approach to sanitation project implementation has experienced several successes in Nepal in recent years, and the approach is being implemented by several organizations there (WaterAid, 2006, Karn, 2006). WaterAid Nepal, Plan Nepal, DFID Nepal, Oxfam Nepal, and others, working in partnership with local organizations such as Nepal Water for Health (NEWAH), have adopted the CLTS program, with several more projects being planned. At the time of the WaterAid report (2006), 14 villages in Nepal had been declared “open-defecation free”, and another 18 villages were under the program.
Plan Nepal presents one case study where despite all efforts they could not “ignite” a community to stop open defecation, and ended up leaving the community with the project goals unfulfilled (Karn, 2006). They emphasize the dependency of project results on the attitudes of the people and their willingness to change. The removal of subsidies stems from this: if people do not desire change, helping them to construct new latrines will not solve the problem. In both the CLTS approach and the social-marketing approach used by the Ethiopian government discussed above, it is recognized that the focus must be on creation of desire for change through education and awareness, and ideally self-initiated learning and realization.
The modes and extent of information and sanitation knowledge transferred between individuals and between communities are still poorly understood. It may seem logical to expect that the spread of information and motivation for building toilets between villagers via social networks and social pressure, which is the focus of the CLTS approach, would not be stopped by village boundaries, but that the information and motivation would be transferred to neighbouring communities as well. If this were taking place, sanitation would be spreading much more quickly and without intervention by the government or NGOs. No literature was found which addresses this topic directly. The fact that this effect has not been observed or documented may be an indication that inter-community interaction is not a primary factor influencing sanitation knowledge and behaviour, or that there is inadequate social pressure created between communities to inspire such attitude and behavioural changes.
2.6 Understanding The Demand for Sanitation
In addition to work done on CLTS, several other studies have tried to better understand the drivers and barriers for improved sanitation in various countries and cultural contexts. Work by Jenkins (1999 & 2004) and Cairncross (2004) focus on the issue of demand for sanitation (why people build latrines). They argue that demand is often poorly understood, cultivated, or met, to the demise of many projects. Furthermore, they suggest that a lack of understanding of the local demand for sanitation has resulted in slow improvements in global sanitation. In her PhD dissertation (1999), Jenkins examines sanitation as a private good, investigating theories of consumer choice and innovation diffusion, and their potential roles in sanitation promotion.
Based on her field work in Benin, she asserts that sanitation programs often fail to consider consumers’ evaluative criteria and underlying motives that create demand, that there is often a mismatch between design of sanitation programs and consumers. She concludes that if