Behavioural change for

sustainable actions and

investments in Sanitation

Why Sanitation?

Foundation of Public Health, the impact of other interventions are diminished without improvements in sanitation and hygiene.

Reduce poverty and boost economic growth

Systematically undermines progress in education

Reduce gender inequalities

Build people’s pride in their homes and community

Access to basic sanitation is a crucial human development goal and is also a means to far wider human development ends (HDR 2006)

Current Situation:

2.5 billion people worldwide lack access to improved sanitation.

2 billion live in rural areas 980 million are children under 18 years 280 million children under 5 years live in

households without access to improved sanitation

One in two people in the developing world lacks access

The world is not on track to meet the MDG sanitation target

54

67

62

77

40

60

80

100

1990 2006 2015

Projected coverage if current trend continues

Coverage needed to meet the MDG target

%

Improved sanitation coverage

2.5 billion people lack sanitation

Urban and Rural DisparitiesUrban Sanitation

Sanitation coverage, 2006

No or Insufficient data

Less than 50%

50 – 75%

76 - 90%

91 - 100%

Urban and Rural DisparitiesRural Sanitation

1.2 billion people practise open defecation,83 per cent of whom live in 13 countries

Rest of world, 205

India, 665

Indonesia, 66

Ethiopia, 52

Pakistan, 50

China, 37

Nigeria, 29

Brazil, 18

Bangladesh, 18

Sudan, 14

Nepal, 14

Niger, 11

Viet Nam, 10

Mozambique, 10

Rest of world, 205

In millions of people

The scale of the challenge• 2.6 billion people – four in ten people in

the world – do not have access to a toilet.

• Every day, diarrhoeal disease kills 5,000 children. Every week, it kills 42,000 people. Every one of these deaths is tragic – and preventable.

• Without concerted action, the lack of sanitation will continue to impact the lives of billions of people and impede progress on development.

Sanitation is vital for human health (1)Lack of sanitation is one of the biggest causes of illness and death in the developing world:

One gram of faeces can contain 10 million viruses, one million bacteria, one thousand parasite cysts and 100 worm eggs.

•More than half the hospital beds in Sub-Saharan Africa are currently occupied by patients with preventable diarrhoeal disease; improving sanitation and hygiene would free up money and resources to tackle other health issues.

Sanitation is vital for human health (2)Lack of sanitation is one of the biggest causes of illness and death in the developing world:

•Access to a toilet can reduce child diarrhoeal deaths by over 30 percent.

•Diarrhoea coupled with pneumonia kills more children than any other disease.

•Children infested by worms lose up to one-third of the nutrient value of their food.

“When there was little community transmission, household transmission acted primarily to amplify the waterborne process, which was the target of our intervention… resulting in a higher preventable fraction…

Specifically, when community sanitation is poor, water quality improvements may have minimal impact...

Unfortunately, strikingly few sanitation intervention studies are available to test the hypotheses generated in this model analysis.”

Eisenberg et al. (2007)

Socioeconomic status

Neighbourhood infrastructure, sanitation and living conditions Nutrition

Hygiene behaviourIntestinal

parasitic infections

Diarrhoea incidence

Socioeconomic status

Neighbourhood infrastructure, sanitation and living conditions Nutrition

Hygiene behaviourIntestinal

parasitic infections

Diarrhoea incidence

Source: Genser et al. (2008) Int J Epidemiol

Salvador da Bahia –

a sanitation success story

Total population Areas with high baseline risk1

Prevalence ratios (PR) after/before project PR (95% CI) PR (95% CI)

Unadjusted 0.79 (0.75-0.82) 0.58 (0.55-0.61)

Adjusted for baseline sewerage and confounders 0.78 (0.74-0.81) 0.57 (0.5400.61)

Adjusted as above, and for neighbourhood coverage with project sewers

1.02 (0.90-1.16) 1.02 (0.90-1.16)

1 12/24 study neighbourhoods > 8 diarrhoea days/child.year

Source: Barreto et al. (2007) Lancet 370(9599):1622-8

Impact of a sewerage project on diarrhoea in Salvador, Brazil (pop. 2.4 million) 1997 - 2004

Impact of Salvador sewerage project on intestinal parasites in pre-school children,

1997 - 2004

A. lumbricoides T. trichiura G. duodenalis

PRa (95% CI) PR (95% CI) PR (95% CI)

Unadjusted 0,49 (0,39-0,62) 0,28 (0,20-0,39) 0,38 (0,27-0,53)

Adjusted for confoundersb 0,50 (0,44-0,72) 0,34 (0,24-0,46) 0,40 (0,28-0,59)

Hygiene behaviourc 0,55 (0,42-0,73) 0,33 (0,23-0,48) 0,38 (0,26-0,58)

Regularity of water supplyc 0,59 (0,44-0,77) 0,37 (0,25-0,55) 0,42 (0,29-0,63) Local coverage with project seweragec 0,72 (0,34-1,43) 0,61 (0,49-0,78) 0,55 (0,22-1,37)

Adjusted for all intervention variables 1,14 (0,69-1,87) 1,13 (0,67-1,90) 0,94 (0,35-2,56) a PR = Prevalence ratio, after/before intervention b Confounders = child’s age, sex, mother’s education & marital status, paving of street c Adjusted for given variable & for confounders

DCPP estimates of effectiveness

Source: Disease Control Priorities in Developing Countries, Chapter 41.

Intervention Reduction in

diarrhoea (%) Water supply

- public source - additional, for house connection

17 63

Excreta disposal 36 Hygiene promotion 48

Source: Eisenberg et al. 2007. AJPH 97, 5; 846-52.

Sanitation generates economic benefits (1)

• Meeting the Millennium Development Goal for sanitation would cost about $10 billion every year, but yield benefits upwards of nearly $200 billion per year.

• Sanitation is among public health’s most cost-effective policy interventions.

• Around 12 percent of the health budget in countries of Sub-Saharan African is currently spent treating preventable diarrhoeal diseases.

Sanitation generates economic benefits (2)

• Investing in sanitation makes investments in education more effective; girls are more likely to go to school and stay in school when girls-friendly toilets are available.

• Investments in sanitation also protect water resources, make investments in water supply more effective, and increase tourism revenues.

Why Sanitation?

5.6 billion productive days gained through interventions including 443 million school days, 2.4 billion healthy infant days, 1.25 billion productive adult days.$229 billion would be gained through time saved$5.6 billion would be saved through deaths avoidedA combined value of $262 billion would be obtained

Every $1 invested would give an economic return of between $3 and $14

Achieving this target would require an estimated investment of $23 billion per year

Disparities between rich and poor…

Source: WHO/UNICEF Joint Monitoring Programme for Water and Sanitation

Defecation Practices

3% 9%18%

29%

55%53%59%

66%55%

33%30% 13%

6% 1% 1%

0%

20%

40%

60%

80%

100%

Poorest Lowermiddle

Middle Uppermiddle

Richest

Socioeconomic status

OpenDefecation

Pit Latrinesw/o seal or lid

ImprovedLatrines

Sanitation contributes to dignity & social development (1)

• Many of the 2.6 billion people without basic sanitation defecate in the open, exposing themselves to ridicule, shame, and, for women and girls, the risk of attack.

• Within thirty years, UN-Habitat estimatesthan one in three people in the world will live in a slum. Without adequate sanitation,they will live surrounded by human filth.

Sanitation contributes to dignity & social development (2)

• Girls are nearly twice as likely as boys to fail to complete primary education. Improving sanitation with girls-friendly toilets at schools can help them catch up.

Sanitation protects the environment

Investments in sanitation protect vital naturalresources, keep rivers and coastal seas clean, and reduce degradation of productive land and fisheries:

• Worldwide, every year more than 200 million tonnes of human waste and vast quantities of solid waste and wastewater remain untreated.

• In Southeast Asia 13 million tons of faeces are released to inland water sources each year, along with 122 million m3 of urine and 11 billion m3 of gray water.

Improving sanitation is achievable (1)

• Malaysia and Thailand achieved almost universal coverage through concerted programmes delivered over thirty years – well ahead of the Southeast Asian economic boom.

• The Southern region of Ethiopia has seen a quiet revolution led by health extensionistswho have supported behaviour change andmoved to eliminate open defecation.

Improving sanitation is achievable (2)

• Almost 10,000 villages in Bangladesh and countless others in more than 15 countries have become “open-defecation-free” through Total Sanitation approaches led by the community.

Challenges to increasing access to improved sanitation: Stigma – a problem which should be hidden from

view (like HIV/AIDS in the 1980’s)

Scale of the problem is daunting (164 million people need to be reached each year)

Absence of Government Leadership - Lack of national policies, strategies or institutional home

Urban/Rural and rich/poor disparities – costs and technologies

Behavioural and perception barriers – benefits of improved sanitation not widely understood

Community Based Sanitation Approaches

Open Defecation Free CommunitiesCommunity based processDemand DrivenTechnology choice secondarySocial change – pride and dignityCommunity managed

Working definition/terminology of community based sanitation for UNICEF

Processes whereby men and women demand, effect and sustain a hygienic and healthy environment for themselves (by creating barriers to prevent transmission of disease).

Minimum Elements

Driven by collective process (as opposed to targeting individual households).

Handwashing at critical times.

Community leadership including children and caregivers.

CATS – Community Approaches for Total Sanitation CATS encapsulate various approaches to community

based sanitation such as CLTS, TSA, TS, PHAST, PHE and others.

WES staff felt it was important, in working with governments and partners, to allow this flexibility in approach in developing the most appropriate route for a given setting.

CATS reflects the diversity between regions, countries and communities and acknowledges hygiene (handwashing more specifically) although allows for variable sequencing and integration of handwashing/ hygiene into sanitation programs.

The non-negotiable principles of CATS:

‘Communities’ and particularly community leadership and participation are emphasized, includes a role for schools, health centers, traditional leadership structures, women and girls.

Communities play a central role in planning with special consideration to the needs of vulnerable groups, women and girls and in respect of the community calendar.

Involves the training of community facilitators and regulation from the village.

Households will not have externally imposed standards for choice of sanitation infrastructure. Safe, affordable and user-friendly solutions are encouraged, particularly those from local artisans, and available and existing technologies. (Sanitation Ladder)

Subsidies (in the form of funds, hardware, etc) are not to be given straight to households. However, rewards and incentives are acceptable where they encourage collective action and total sanitation (i.e. Open Defecation Free communities - including the disposal of children’s feces)

Government role and cross fertilization of experience are important for scaling up.

Sanitation as an entry point for greater social change is implicit as a guiding principle.

CATS must include hygiene (the definition, scope and sequencing of hygiene component is contextual)

The non-negotiable principles of CATS: