Last week I joined colleagues from Plan at the 2012 Water and Health Conference: Science, Policy and Innovation, hosted by the Water Institute at the University of North Carolina at Chapel Hill (UNC-CH). It is one of the largest gatherings of experts in this field in the United States.
Plan’s involvement in this event is not surprising. Plan cannot hope to produce tangible and lasting improvements in children’s health and education without tackling problems around water, sanitation and hygiene (activities known as WASH in the international development community).
- Diarrhea remains today the second leading cause of death among children under five globally. It kills more young children than AIDS, malaria and measles combined.
- Close to 300 million school days are missed worldwide as a result of diarrhea.
- Girls typically bear the burden of fetching water for their family. Simply providing reliable access to water enhances dramatically the probability that a girl with attend and complete school. If we care about girls staying and completing school, we cannot do it without addressing water, sanitation and hygiene issues.
A recent World Bank study across 70 countries found that improved water and sanitation infrastructure lowers the odds of children suffering from diarrhea by up to 17 percent, and reduces the mortality risk for children under the age of five by up to 20 percent. The effects are largest for modern sanitation technologies and least significant for basic water supply. In other words, it is not just improving access to water that matters. It is also about improving hygiene and sanitation. In many cases this involves altering a number of behaviors that are closely linked with disposal of feces. This is no small problem. Worldwide more than 2.6 billion people lack access to basic sanitation. In India more than 55% of the rural population still practices open defecation (OD).
Addressing behaviors related to OD is complicated, labor intensive and time-consuming work. The “problem” does not get fixed with construction of wells and latrines. A review of Plan’s WASH work completed in 2007 by the UK’s Loughborough University showed us that this approach did not always (or mostly) lead to sustained improvements in sanitation. We learned that providing a latrine and educating the community was simply not enough to stop OD.
Plan’s WASH work has moved from providing technologies and technical solutions to an increased focus on behavior change. At the same time, Plan’s work is empowering communities to talk about (and enforce their rights to) improved sanitation facilities. Plan’s Community-Led Total Sanitation (CLTS) programs embody this approach. The basic premise of CLTS is simple: get community members to realize that behaviors like OD have serious public health consequences. CLTS does this by triggering shame, fear and disgust among community members around OD and then motivating and equipping them to do something about it, by working with other members and local authorities. It recognizes that addressing these deep-seated behaviors requires more than the provision of water and latrines. We also need to worry about supply response as well.
There was quite a buzz at the conference around market-based sanitation solutions and sanitation marketing. And it makes sense. It is not just about triggering demand for sanitation. If more people want to stop OD, what are the options for disposing of feces? How do we get cost-effective feces disposal solutions to meet demand? Where are the supply chains to respond to demand? Experts in the past have often discussed the idea of moving “up a ladder” of technical options: from (shared) dry pits to more sophisticated facilities like pour-flush latrines. The belief was that (shared) dry pits would be cheaper and thus more attractive to use. But we are learning that an “expert’s” opinion about what constitutes acceptable, “improved” sanitation and what a community member’s view of the same may not always coincide. It turns out that “dry” and shared latrines might be better as a way of disposing feces safely than open defecation, but the user is not thrilled; such latrines are smelly, quite a hassle to build and a real pain to maintain. What people really want is more ‘modern’ systems, such as the pour-flush technology. We also learned that it is not always about money. In fact, the same people that we feared would not be able to afford a higher-end toilet were already demonstrating that they could finance bicycles and cell phones.
When there are cell phones and bicycles in the most remote villages but no toilets, market failures abound. Many parts of the value chain are missing. And, as John Sauer from Water for People noted in one session, we do not always have the right people working on the problem: “We need fewer sanitation engineers trying to figure out how to generate business solutions and more business people interested in working on sanitation solutions.”
So, why am I boring you with this history of feces and latrine specifications and value chains? To make the point that even things that seem pretty self-evident (open defecation is bad, and using a latrine is desirable) are very complicated and rarely solved by “technology” or behavior change alone. Sustainable solutions require that we think about both demand and supply responses, and that experts from a broad range of fields, who don’t usually talk to each other, find ways to partner and work together. We need to realize that success requires that we work across disciplines, not all of which are likely to be found in any one organization. We need to be much more creative about how we partner and leave our comfort zones.
Moreover, organizations like Plan owe it to the communities we are trying to improve and the children whose lives we are trying to save to up our game in terms of evidence gathering. We must be willing to invest in rigorous research and development and build partnerships. Plan’s CLTS agenda benefits tremendously from partnership with entities like UNC’s Water Institute. And we need to continue to be willing, no matter how painful, to air and examine both our successes and our failures with our partners and our donors. Only in this way are we able to continue to learn, innovate and deliver on our mission.