House of Commons - International Development

Select Committee on International Development Sixth Report

2 THE SANITATION CRISIS

The scale of the crisis and barriers to progress

15. Today, almost one in two people in the developing world lacks access to improved sanitation—a shocking indication of the scale of this under-recognised emergency.[20] "Improved sanitation"—according to the UN Development Programme's definition—requires access to "adequate excreta disposal facilities, such as a connection to a sewer or septic tank system, a pour-flush latrine, a simple pit latrine or a ventilated improved pit latrine. An excreta disposal system is considered adequate if it is private or shared (but not public) and if it can effectively prevent human, animal and insect contact with excreta."[21]

16. Across the world, sanitation provision lags far behind access to water. Sanitation is one of the most off-track MDGs, with the crisis focused on Sub-Saharan Africa and South Asia, both of which have 37% coverage. South Asia's rates of progress, which have doubled since 1990, give some cause for optimism, although much remains to be done—one in three unserved people lives in China. But Africa is the major source of concern: coverage has risen by only 5% since 1990 and this has been outstripped by population growth, so that the number of unserved people has actually increased by 111 million over the period.[22]

17. The UNDP's Human Development Report 2006 focused on water and sanitation. The report sets out six interlocking barriers which retard progress on sanitation: national policy, behaviour, perception, poverty, gender and supply (see Figure 1). We saw a number of these barriers operating in practice during our visit to Ethiopia, where no national sanitation policy exists and where latrine hardware is generally too costly to supply and maintain.[23] Evidence we have received highlighted the absence of sanitation in national planning instruments such as Poverty Reduction Strategy Papers (PRSPs) and the problem of women's voices being too weak to articulate demand for sanitation as factors contributing to these barriers.[24]

Figure 1 UNDP Human Development Report: the six barriers to progress on sanitation

The national policy barrier	Sanitation seldom features prominently on national political agendas - even within countries that have had success in expanding access to water such as South Africa and Morocco.
The behaviour barrier	Research shows that people attach a higher priority to water than sanitation. People often see sanitation more as a public rather than household issue e.g. the health benefits of building a latrine may be compromised by excrement in nearby streets.
The perception barrier	Health is not the primary motivation for people seeking improved sanitation: factors such as prestige and convenience often rank above disease prevention. This makes sanitation less likely to be viewed as a public good.
The poverty barrier	Even low-cost technology will be beyond the reach of the 1.4 billion unserved people who live on less than $2 a day. This is borne out in Vietnam, where rapid progress on rural sanitation has left the poorest households far behind.
The gender barrier	Evidence suggests that women place a higher value on sanitation than men - yet women tend to have the weakest voice within the household and outside, hence demand remains low.
The supply barrier	The oversupply of inappropriate technologies, or products that are difficult to maintain, is a problem.

Source: UNDP, Human Development Report 2006 - Beyond Scarcity: Power, poverty and the global water crisis, pp.118-120.

A distinct and neglected sector

18. The sanitation target within the MDGs was set belatedly, at the World Summit on Sustainable Development in Johannesburg in 2002, rather than at the Millennium Summit in 2000 with the majority of the other targets. DFID played a leading role in securing the target.[25] Whilst its inclusion in the MDGs was an enormous step forward, the target's late arrival gave it a disadvantage from the outset, with fewer years left till the target deadline of 2015 and the risk of being viewed as an 'add-on' rather than an integral part of MDG7.[26]

19. Sanitation tends to be viewed as an adjunct to water and is thus neglected as a sector.[27] From a historical perspective sanitation and water have been linked together by governments, and for the last few decades development practice has tried to ensure that water, sanitation and hygiene are integrated in the same projects. This has had some advantages: "piggy backing" sanitation on to the political demand for water supply has brought attention and funds to the sector.[28] DFID has conformed with this practice and treats sanitation and water as one integral sector, in line with its multi-disciplinary approach to development.[29] The links between sanitation and other social sectors, particularly water, health and education, are self-evident. We commend a multi-disciplinary approach to the sanitation sector.

20. The multi-disciplinary approach becomes problematic if one sector is marginalised, as is the case with sanitation. The reasons for the neglect of the sector are manifold. One problem is that sanitation is often shrouded in stigma and embarrassment. Sanitation itself is a euphemism for managing defecation.[30] Tearfund recommended that DFID could help address the taboos around sanitation by using lessons from the successes in tackling the stigma around HIV and AIDS.[31] A variety of interventions, including information awareness campaigns and community sensitisation, have been successful in changing attitudes and beliefs in relation to HIV and AIDS. DFID needs to be proactive in tackling the stigma around sanitation and should draw on lessons from the successes in tackling the stigma around HIV and AIDS.

21. Another factor in its marginalisation is that less is understood about how to make rapid progress on sanitation than on water.[32] 'Doing sanitation' is quite different from 'doing water', largely because sanitation is more about the 'softer' issues of raising demand and instituting behaviour change, rather than infrastructure provision.[33] Demand for water is well-articulated whereas for sanitation it is often hidden and needs to be voiced before systems are designed and implemented. Timescales differ between the sectors: a new water supply can be installed very quickly, whilst sanitation requires long-term behaviour change.[34] Women suffer the most from inadequate sanitation: journeys to public latrines or defecating in fields, especially at night-time, bring security risks, and women are likely to bear responsibility for caring for children and relatives suffering from disease caused by poor sanitation.[35] Yet women have the weakest voices in planning and decision-making and hence their need for improved sanitation fails to impact upon the political agenda.[36]

22. Assessing the scale of the need for sanitation in financial terms is difficult because the OECD and DFID currently aggregate the amount of aid which goes to sanitation and water.[37] Much of DFID's support for sanitation is through multilateral organisations, which makes it even harder to measure. However, the World Health Organisation (WHO) and UNICEF estimated in 2000 that sanitation attracts only one-eighth of the funding that water gets.[38] We recommend that DFID make its sanitation investments more transparent by disaggregating funding given to the sanitation and water sectors, and by encouraging the multilateral institutions to which it contributes funds to do the same.

23. There is evidence that DFID currently neglects the sanitation sector. Professor Sandy Cairncross from the London School of Hygiene and Tropical Medicine told us that DFID tends to think of sanitation as an adjunct to water: "If you look at [DFID's] Water Action Plan [...] the word 'sanitation' [...] always appears as the second half of 'water and sanitation'.[39] Laura Webster of Tearfund concurred with this view and noted that DFID's health strategy also neglects sanitation: "If you look at the latest target strategy on health, sanitation seems to be very much missing from that. The joined-up thinking seems to be missing."[40] DFID's neglect of the sector is borne out by the fact that no formal sanitation strategy exists—the current relevant policy document for sanitation is the Water Action Plan, the title of which speaks volumes, and which is weak on sanitation.[41] Without a distinct sanitation strategy, budgetary and policy objectives for sanitation are unclear. A multi-disciplinary approach to sanitation and water will only work if the two sectors are given equal attention. Sanitation is currently neglected within DFID. The complex, distinctive challenges inherent in reaching the sanitation MDG target require proactive measures on DFID's behalf to raise the profile of sanitation within its work on sanitation and water, including the creation of a separate sanitation strategy.

The demand side of sanitation

24. As Professor Sandy Cairncross told us, the crux of sanitation policy is working out what drives demand.[42] Often, health is not the primary reason that people want latrines—research has found that households often rank factors such as prestige and convenience higher than avoiding excreta-related disease (see Figure 1). Once the drivers of demand have been identified via market research, Professor Cairncross believes, a consumer-driven social marketing strategy needs to be carried out, so that the need for latrines is sold to the poor—"disseminated in the same way as double glazing or conservatories".[43] For reasons of sustainability, it is important that latrine designs respond to people's needs rather than to engineers' pre-conceptions.[44] In Ethiopia, this seemed to be working in practice: regional health officials in the Southern Nations region[45] told us they opt not to provide any sanitation hardware, due to both sustainability problems and cost, and we observed that households were using local materials such as rocks to build their latrines.

25. Social marketing campaigns have been successfully used for hygiene promotion. An example is the Public-Private Partnership for Handwashing in Ghana, through which government, donors, universities and soap companies are trying to prevent the 9 million episodes of diarrhoea which account for a quarter of child deaths in Ghana each year.[46] Prior to the Partnership's inception in 2002, handwashing with soap after using the toilet stood at just 4%.[47] Following the marketing campaign—which used methods ranging from car stickers to television advertisements—reported rates increased by 13% after using the toilet and by 41% before eating. The national evaluation found that 71% of target mothers could describe the television advertisement and 48% could sing the campaign song.[48]

26. Another highly successful example of socially-driven behaviour change can be found in the Community-Led Total Sanitation Scheme (CLTS). Pioneered by WaterAid and the Village Education Resource Centre in Bangladesh, CLTS uses community self-help to stimulate behaviour change and community action to end the practice of open defecation, which is widespread in rural South Asia, as well as other parts of Asia, Africa and Latin America. CLTS does not seek to provide latrine infrastructure but facilitates self and community analysis of defecation habits. Empirical evidence has shown that when individuals understand the health risks of open defecation, disgust and shame tend to provoke communities into a collective decision to reject the practice.[49] Community success is then broadcast on billboards outside the villages. Through CLTS, Bangladesh will—on current trends—meet the MDG target for sanitation. Coverage is reported to have increased from 33% in 2003 to 70% in 2006 and is set to reach 100% by 2010.[50]

27. In Ethiopia, we saw a CLTS-influenced approach to sanitation in the Southern Nations region, where local sanitation committees, supported by women health extension workers, were using advocacy and health education to promote latrine construction and usage. Virtually all dwellings in the village in Misha woreda (district) that we visited had their own latrine: across the region, latrine ownership has risen from 13% in 2003 to 78% in 2006.[51] We were told that health, especially amongst children, has improved considerably following the programme, with diarrhoea and skin and eye infections falling out of the top five reported diseases over the last four years.

28. A number of written submissions highlight CLTS's potential for replicability.[52] Like Ethiopia, a number of countries, including Indonesia and Cambodia, have initiated schemes influenced by CLTS.[53] The Water and Sanitation Programme, closely associated with the World Bank but also supported by DFID and other donors, is working with the Government of India to share lessons about CLTS from Bangladesh, and the scheme is currently being rolled out in the states of Maharashtra, Punjab and Northwest Frontier Province.[54]

29. DFID is funding research at the Institute of Development Studies (IDS) into how and where CLTS is working.[55] DFID expressed hesitation to us, however, about the replicability of CLTS: "There are certainly elements of CLTS work in Bangladesh and India that make it work particularly well in those continents. Transferring it elsewhere we will probably look at which of those elements makes sense."[56] DFID's support for research into the replicability of the Community-Led Total Sanitation (CLTS) scheme is important and should continue along with support to other promising approaches such as social marketing. The widespread success of CLTS in Bangladesh and emerging lessons from uptake elsewhere suggest that there are huge potential gains from the scheme.

30. WaterAid's submission suggests that DFID should consider moving beyond initial financing to mainstream the CLTS approach in its programme design and monitoring and evaluation systems.[57] Robert Chambers and John Thompson from the IDS suggested that "DFID probably has more experience of CLTS than any other agency except the World Bank, and so is exceptionally well placed to help other organisations like UNICEF learn." As they went on to point out, however, raising the profile of CLTS within its programmes would have staffing implications for DFID: "To do this well [...] will require more staff who understand and are committed to the need for sensitive restraint in providing the conditions for the spread of CLTS."[58] The development of such skills—which include advocacy techniques and community sensitisation, also useful for social marketing strategies—will require specialist training. The growing uptake of the Community-Led Total Sanitation scheme and social marketing approaches will require DFID staff working on sanitation to be adequately trained in the techniques needed for these approaches, so that they can advise governments and other development partners on how to design and invest in such programmes.

Rethinking sanitation expertise within DFID

31. This leads on to a wider issue of sanitation expertise within DFID. Sanitation expertise is currently provided by the same staff who advise on water—that is, a cadre of infrastructure advisers, 23 of whom work on sanitation and water across DFID's country programmes. In some country programmes, non-infrastructure advisers—including livelihoods advisers (in 11 cases) and environment advisers (in four cases)—lead the DFID contribution to the water sector, but this will be on a part-time basis: typically one day a week or less.[59] The other cadres of advisory staff (economics, governance, social development, health and statistics) can in theory provide input on sanitation but in practice it is overwhelmingly the responsibility of infrastructure, environment and livelihoods advisers to take forward work on sanitation and water.[60]

32. The obvious issue here is that the expertise of staff working on sanitation and water is overwhelmingly focused on water, rather than sanitation. Health advisers and social development advisers, who logically would seem most qualified to work on the behaviour change and health aspects of sanitation, provide very little input. Furthermore, sanitation expertise within DFID's Policy and Research Division's Water, Sanitation, Energy & Transport Team comes from water, environment and governance advisers—there are no health or social development advisers within the team. It is also telling that, until late 2006, the name of the team was the Water, Energy and Minerals Team—sanitation did not feature. This seems extraordinary given the priority that DFID claims to attach to sanitation and the obviously specialist nature of the skills required for the sector.

33. In their paper Rethinking Sanitation, Marion Jenkins and Steven Sugden of the London School of Hygiene and Tropical Medicine summarise a major problem inherent in deploying staff on integrated sanitation and water projects:

34. Professor Sandy Cairncross told us: "I was talking recently to the DFID Senior Health Adviser who agreed that sanitation was important but did not see it at all as a function of the health sector; but felt that within DFID it is for the water people to deal with."[62] Professor Cairncross expressed a preference for a separate cadre of sanitation advisers:

35. The Secretary of State and Greg Briffa, Head of DFID's Water, Sanitation, Energy & Transport Team, were clear that they didn't consider a separate cadre of sanitation advisers a sensible strategy.[64] DFID's multi-disciplinary approach and its headcount restrictions make the creation of a new staff cadre infeasible. But a reconfiguration of DFID expertise on sanitation is both practicable and necessary. Greg Briffa accepted that DFID needs to link its water, sanitation and health advisers more closely.[65]

36. But, as important as this is, we believe the problem runs much deeper than a need to improve inter-sectoral linkages. Different skillsets are required for the sanitation and water sectors: the former requires people-based skills and health and social development expertise, as opposed to the more technical solutions needed for water supply. DFID therefore needs fundamentally to rethink the situating of sanitation expertise within its infrastructure advisory cadre. The skillsets needed for sanitation require a multi-disciplinary approach including health and, to a lesser degree, social development advisers. Infrastructure advisers still have a significant role to play in DFID's sanitation strategy—clearly, collaboration between the advisory cadres will support a multi-disciplinary approach—but sanitation must become an integral part of health advisers' work, both within country programmes and in Policy Division.

37. Greg Briffa told us that a review of sanitation policy, including the creation of an action plan, will be carried out over the next six months, in collaboration with a team of experts including Professor Cairncross.[66] We welcome DFID's decision to carry out a review of its sanitation policy. Under the review, we recommend that DFID reconfigure its sanitation expertise. Sanitation must become an integral part of health advisers'—and, where possible, social development advisers'—work within country programmes. Within DFID's Policy and Research Division, the Water, Sanitation, Energy & Transport Team should contain health and social development advisory capacity.

The sanitation challenge in slums

38. Addressing staffing issues, as outlined above, would be one step forward to making progress on sanitation. However, there is another area in which DFID needs to act if it is to become a—much-needed—global champion for sanitation: sanitation provision in informal urban settlements.

39. Historically, the challenge in delivering sanitation and water has been rural, but in 2007 more people will be living in cities than rural areas for the first time in history, creating new and growing challenges in providing sanitation to poor urban dwellers. DFID's sanitation focus reflects the historical challenge and is very much focused on rural provision. The World Bank reverses this prioritisation—about 85% of its support to sanitation and water goes to urban projects—and DFID's support to the Bank ensures that at least some DFID funds contribute to urban provision.

40. But, as towns and cities continue to grow unstoppably, DFID needs to look ahead and ensure its prioritisation of rural over urban support adapts accordingly. Around 70% of urban dwellers in Africa and 60% in South Asia live in slums, and it is estimated that almost half a billion people who require sanitation and water services will be added to urban populations in Africa alone within the next 25 years.[67]

41. Sanitation provision in urban areas gives rise to a series of challenges. The responsibility for sanitation tends to be fragmented across a number of government agencies and departments, making lines of responsibility and accountability blurred.[68] Most urban dwellers live in informal settlements with insecure land tenure. David Satterthwaite from the International Institute for Environment and Development (IIED) used the example of Kibera in Nairobi—Africa's largest slum—to illustrate the difficulty of laying sewers and building latrines where land rights are not clear.[69] It is often not obvious if or by whom plots are owned, and it may be difficult to clear space to lay pipes and sewers due to the sheer concentration of people. Residents of informal settlements tend not to have effective access to political influence and their demands are often unheard. Sanitation provision in slums is constrained by institutional fragmentation, insecure land tenure and residents' lack of political influence. We recommend that DFID revisit its prioritisation of rural over urban support as the global urbanisation process continues. The Department needs to work with governments to raise the issue higher up the political agenda, seek solutions to provision in informal settlements that are appropriate to and designed in consultation with local communities and create an institutional home and effective co-ordinating mechanisms for urban sanitation provision.

42. The movement of human waste through sewerage systems is a costly and difficult process in informal urban settlements, partly because sewers are dependent on water supply.[70] Alternative sanitation provision includes pit latrines and composting toilets, but more research is needed into low-cost sanitation solutions and treatment of wastewater within informal settlements and other urban areas.[71] The World Health Organisation (WHO) highlighted that wastewater is often used for agriculture in both urban and rural areas, and so for public health reasons it must be properly treated.[72] DFID has supported the revised WHO Guidelines on Safe Use of Wastewater, Excreta and Greywater in Agriculture and Aquaculture and this is to be commended.[73]

43. One successful example of low-cost sewer provision is the Orangi Project.[74] Orangi is an informal settlement in Karachi, the largest city in Pakistan. In 1980 a group of Orangi's citizens and a local NGO formed the Orangi Pilot Project to address the dire sanitation situation, which meant that only one-sixth of the sewage generated by the city's population of 10 million was collected. Through dialogue and awareness-raising, residents of Orangi formed groups to build low-cost sewers to collect household waste. Eventually the municipal authority agreed to finance a trunk sewer to channel the collective waste away from the community. As a result, infant mortality rates have fallen from 130 deaths per 1000 live births in the early 1980s to fewer than 40 today.[75]

44. As David Satterthwaite pointed out in relation to the Orangi Project, the key to community provision is "demonstrating new ways of doing things."[76] It is crucial that lessons from successful initiatives in urban sanitation such as the Orangi project are widely promoted.[77] We recommend that DFID support the wide promotion of lesson-learning about successful low-cost urban sanitation schemes such as the Orangi Project in Pakistan.

DFID—a global champion for sanitation?

45. The doubling and re-doubling of DFID's water and sanitation programme in Africa by 2011 offers the Department what Professor Cairncross called "a historic opportunity to take a bold lead with new thinking and practices on sanitation".[78] There can be no illusions about the difficulty of making progress on sanitation: a dichotomy exists between achieving a culturally sensitive approach to behaviour change at the micro-level whilst moving with sufficient speed and scale to address the hugely off-track MDG target, which, on current trends, will not be met until 2076. Sanitation is a highly cost-effective route towards attaining all the MDGs: we heard that, whilst money for the sector is still a priority, sanitation is not necessarily about "MDG big budget thinking" but about breaking down taboos, raising demand and helping determine strategies for success so that governments accord the sector the priority it deserves.[79] However, this is not to say that funding is not essential to both the marketing approach—education campaigns, publicity materials and the necessary staff all come at a cost—and to urban infrastructure construction including sewers and water treatment plants. Sanitation needs international champions to reverse decades of neglect—and, with some re-prioritisation and staff reconfiguration, DFID could and should be one of these champions. We recommend that DFID act now to push sanitation far higher up the global political agenda. If progress towards the sanitation Millennium Development Goal target is not rapidly stepped up, the attainment of all the other MDGs will be compromised.

20 UNDP, Human Development Report 2006, p.111. Back

21 UNDP, Human Development Report 2006, p. 409 Back

22 Ev 228 [Dr Andrew Cotton] Back

23 Kevin Tayler and Jim Winpenny, WELL Resource Centre, Options for DFID support to the water and sanitation sector in Ethiopia: Pre-appraisal report, p.1. Back

24 Ev 273 [Jon Lane] and Q 112 [Professor Sandy Cairncross], Ev 229 [Dr Andrew Cotton] and Q 130 [Laura Webster], Ev 171 [WaterAid] Back

25 Ev 187 [WaterAid] Back

26 Q 190 [Dr David Tickner] Back

27 Ev 273 [Jon Lane] Back

28 Marion W. Jenkins and Steven Sugden, Rethinking Sanitation - Lessons and Innovation for Sustainability and Success in the New Millennium (2006), p.7. Back

29 Ev 109 [DFID] Back

30 Jenkins and Sugden (2006), p.6. Back

31 Ev 158 [Tearfund] Back