Behavioural change for sustainable actions and investments in Sanitation

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Behavioural change for sustainable actions and
investments in Sanitation
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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 peoples 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)

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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

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2.5 billion people lack sanitation
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Urban and Rural Disparities

• Urban Sanitation

Sanitation coverage, 2006
Less than 50
50 75
76 - 90
91 - 100
No or Insufficient data
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Urban and Rural Disparities
Rural Sanitation
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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.

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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.

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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.

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• 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)

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Source Genser et al. (2008) Int J Epidemiol
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Salvador da Bahia a sanitation success story
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Impact of a sewerage project on diarrhoea in
Salvador, Brazil (pop. 2.4 million) 1997 - 2004
1 12/24 study neighbourhoods gt 8 diarrhoea
days/child.year Source Barreto et al. (2007)
Lancet 370(9599)1622-8
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Impact of Salvador sewerage project on intestinal
parasites in pre-school children, 1997 - 2004
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DCPP estimates of effectiveness
Source Disease Control Priorities in Developing
Countries, Chapter 41.
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Source Eisenberg et al. 2007. AJPH 97, 5 846-52.
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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 healths 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.

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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.

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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
  avoided
• A 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

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Disparities between rich and poor
Source WHO/UNICEF Joint Monitoring Programme for
Water and Sanitation
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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.

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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.

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Sanitation protects the environment
Investments in sanitation protect vital
natural resources, 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.

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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.

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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.

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Challenges to increasing access to improved
sanitation

• Stigma a problem which should be hidden from
  view (like HIV/AIDS in the 1980s)
• 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

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Community Based Sanitation Approaches

• Open Defecation Free Communities
• Community based process
• Demand Driven
• Technology choice secondary
• Social change pride and dignity
• Community managed

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• 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.

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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.

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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)

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The non-negotiable principles of CATS

• 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 childrens 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)