Examination of Witnesses (Questions 109
- 119)
TUESDAY 12 DECEMBER 2006
PROFESSOR SANDY
CAIRNCROSS, DR
DARREN SAYWELL
AND MS
LAURA WEBSTER
Q109 Chairman: May I wish you good
morning and apologise for keeping you three or four minutes, and
preface this by saying we are also very pressed for time and have
two sets of witnesses and, with various conflicts with diaries,
we have to try and finish the session by 12.30. I only say that
in advance because we do want to hear from you so if we could
bear that in mind and you could try to keep your answers crisp
and we will try to keep our questions short. Obviously it is important
for us to get the views of people like yourselves as to how we
can address what has been described by other witnesses as a "crisis"
in water and, even more so, in sanitation. Perhaps you could start
the proceedings by introducing yourselves.
Dr Saywell: I am Darren Saywell.
I am the Development Director at the International Water Association.
Professor Cairncross: I am Sandy
Cairncross, Professor of Environmental Health at the London School
of Hygiene and Tropical Medicine.
Ms Webster: Laura Webster. I am
Senior Policy Officer on water and sanitation at the UK NGO Tearfund.
Q110 Chairman: As I have just said
the "crisis" in sanitation has been described as that.
Clearly millions of children in particular are dying because of
a lack of proper sanitation. If you are looking at the role DFID
plays, can you identify whether it forms a coherent strategy,
because it is not entirely clear that they do, and what else could
be done to try and address this crisis. One of the most frustrating
things we hear is that even simple issues like washing hands and
basic public health education could make a huge difference and
yet, despite the money that has been put into it, it does not
seem to be happening. What do you think of DFID's strategy and
how do you think it might be improved?
Dr Saywell: The first question
you asked was whether it had a coherent strategy and I think,
looking through some of its recent papers, you can see that it
is focusing on some of the major touchstones—governance,
financing, inter-linkages and capacity building. However, I think
there was a major watershed, in my opinion, in 2002 just after
the World Summit on Sustainable Development when DFID restructured
itself, and a lot of the impetus and momentum that went into water
and sanitation was lost at that time. It has come back gradually
since then but I think that that has impacted on the policy coherence
of DFID, in my view.
Q111 Chairman: What could they do
now?
Dr Saywell: There are three things
that would spring to mind: have a coherent strategy around advocacy
for water and sanitation; how do you get issues of sanitation
at the top of the political agenda at a national level; how do
you respond to advocacy; what are the practical technical strategies,
advisory capacities, that DFID could be providing again at a national
level; and, thirdly, maybe in terms of re-looking at one of its
distinctive features which was its research and development capacity.
In the past DFID had very large knowledge and research programmes
which again I think have tended to wither. I think that was one
of the things which gave DFID its distinctiveness compared to
other bilateral agencies
Professor Cairncross: I would
like to support what Darren Saywell has said. I think part of
the problem is that DFID tends to think of sanitation as an adjunct
to water. If you look at the Water Action Plan that came out two
years ago, look for the word "sanitation", it always
appears as the second half of "water and sanitation".
Sanitation, particularly for the poor, needs to be addressed in
a rather different way from water supply. It needs to be disseminated
in the same way as double glazing or conservatories or other home
improvements. Even for the poor, we have to subsidise not the
construction of latrines, not see sanitation systems as engineering
structures, because the engineering task of building them is not
a major problem, the problem is selling them. You would not ask
the person who manufactured motor cars to sell motor cars; it
is a different kind of skill to sell a product and to persuade
people that they want it. If we want every latrine in the world
to be a wanted latrine, to paraphrase the birth control people,
then we need to improve our marketing, our market research—and
not much market research tends to get done when you have a project
that is mainly run by engineers and mainly seen as an adjunct
to a large water supply construction project. I think it needs
a different way of working. It needs more continuity in terms
of relationships with local institutions. People often talk about
sanitation as being something that involves sensitive cultural
issues but, in a way, the most difficult cultural change to achieve
is that of turning round municipal bureaucrats' perceptions of
their role as being one of persecuting the informal sector, the
small-scale builders who spend their time evading regulation,
tax and building codes, and turning their role into one that is
more supportive of the private sector—brokerage, promotion,
marketing and so on. To achieve that kind of cultural change needs
a long-term continuity of relationship; and DFID, working largely
through short-term consultants and with projects that do not last
more than four or five years pretty well at the maximum, is to
some extent constrained by its own systems from doing that.
Ms Webster: Building on the point
that Professor Cairncross made, I think sometimes seeing water
and sanitation too closely linked together can be problematic.
The water team at DFID has put some excellent things on sanitation
into some of their plans and strategies but, looking across the
whole of DFID, that's not coming through consistently. 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. I know that there is likely to be a new health
strategy coming from DFID; it was due this autumn but I have heard
it is has now been delayed until the spring. Seeing sanitation
coming up very strongly in that strategy will help show a bit
more joined-up thinking from DFID. And perhaps education as well.
Obviously having sanitation in schools and having sanitation programmes,
latrines and that kind of thing, are really important. To see
that coming through in education strategies too I think is key.
You asked what DFID are doing so far. Actually it is quite difficult
to know what DFID are doing on sanitation so far. The fact that
water and sanitation is seen as going hand in hand can be a useful
principle; but, looking through the Water Action Plan updates
and their submission to this Committee, the figures are quite
vague. It is difficult to tell what money has been spent in which
countries over what timescale. I know that the Environmental Audit
Select Committee recently asked for more information to be available
on DFID's website, and I think that could be really helpful; and
a bit more detailed information about what actually is happening
in country on sanitation; and not just what is going in but the
outputs being achieved from that. The final point I want to make,
and it is one that other witnesses have made, is that DFID maybe
have some strong policy work in London but how does that relay
at country level? Other people have mentioned that the number
of infrastructure advisers in countries has actually been going
down recently and infrastructure advisers tends to include water
and sanitation. I know there are constraints on dealing with that
issue, but perhaps by making sure health and education advisers
at a country level are really mainstreaming sanitation into everything
that DFID are doing at country level that is another improvement
that could be made.
Chairman: Just a summary. You all seem
to have said that it is time to stop talking about "water
and sanitation" and talk about "water" and "sanitation".
That is quite a simple separation that does not link them together.
I am sure they are two separate problems.
Q112 Hugh Bayley: Could I start with
Professor Cairncross. You seem to be saying to us that the need
for cultural sensitivity is greatly overplayed and, frankly, has
become an excuse for inaction, and unless there is a much greater
action by state authorities in developing countries to drive forward
a sanitation programme, Millennium Development Goals (MDGs) will
not be met. Is that what you are saying?
Professor Cairncross: Not quite.
I think the need for cultural sensitivity is embodied in the need
for market research—I put it that way. One needs to know,
why do people want sanitation? What are the drivers of demand?
Part of the problem of many sanitation programmes is the lack
of demand. It is assumed that health is the main reason why people
of low income want a latrine, because that is often the reason
why the donor agency is interested in sanitation; but in fact
other factors like prestige, convenience, protection from rape
on the way to the communal defecation area and security, those
factors are much more important drivers of demand. One needs to
study those drivers, and to carry out that study one needs time
and one needs a certain degree of cultural sensitivity of course.
What I was arguing was the big cultural change is not so much
the change from not using a latrine to having a latrine, but for
officials not chasing small builders for their tax bills, or for
building without land tenure, but to be more supportive of the
informal sector; because it is the informal sector that builds
low cost sanitation. Sanitation enjoyed by the poor has largely
been built by illegal, unregistered, non-tax paying, small-scale
masons. It is a major challenge to find out ways in which the
state at a local level can work with them instead of working against
them.
Q113 Hugh Bayley: If you look back
to our history in the 19th century, my understanding is that great
municipal schemes of sewerage and sanitation changed the public
health of this country enormously, in cities at any rate, and
that approach is very different from yours which appears to be
a consumer-driven approach which I can understand is maybe what
you need to do in rural areas where big infrastructure will not
provide solutions, but half of the developing world very soon
will be living in cities. Is there a different approach needed
in cities than in rural areas?
Professor Cairncross: There are
a number of important differences. As I was discussing with Laura
just before we came in, in the francophone countries of West Africa
you typically find coverage with sanitation of 90% in the major
urban areas but very low in the rural areas, because your tenure
of a plot of land depends on your having built a latrine on that
plot and these rules are enforced. There are some other countries,
some anglophone countries, for example Tanzania, where in urban
areas enforcement of by-laws has ensured there is a reasonably
good coverage but there is very deficient functioning of the sanitation
systems. In Tanzania, in Dar-es-Salaam, for example, you will
find pretty good coverage with sanitation but the latrines are
all overflowing and falling in; and what is needed is better maintenance,
better pit emptying mechanisms, which at the moment are only supplied
again by the informal sector, and ways of working with them to
improve the services which are on offer. In rural areas the demand
is often affected by these cultural factors. Questions like land
tenure, building codes and so on are less important. In urban
areas the constraints are not primarily cultural. Most people
want sanitation in urban areas for obvious reasons, but the constraints
need study and they vary from city to city, and from shanty town
to shanty town. They may relate to land tenure: landlords threatening
to evict people and raise the rent, even if the tenant finances
the latrine. Or there may be other constraints like a shortage
of building materials that will take tension to cover a pit and
make a floor.
Q114 Hugh Bayley: Who are the key
in-country development partners; who should do the marketing?
When it is a matter of providing by-laws, who should take the
lead; is it the local government, the health departments?
Professor Cairncross: In urban
areas certainly I would imagine it is local government; in rural
areas it is probably also local government. It can be different
government ministries. For example, 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. I was arguing to him that the job of regulation and
promotion (and let us not dirty one's fingers with construction
issues, but just the business of promotion and regulation of the
sanitation sector) very often can be discharged most efficiently
by the health sector.
Q115 Joan Ruddock: You have been
describing initially how it was necessary to try to sell the product
to the consumer or potential consumer. In much of what you have
said you seem to be describing quite a complex policy package.
How does that sit with donors who are moving away from programmatic
schemes to budget support? Within budget support is it possible
to deliver such complex packages?
Professor Cairncross: I think
it is difficult to do within the budgetary support framework,
but there is a way in which donors can use advocacy to promote
policy change, apart from their finance role or their funding
role; because this, if you like, cultural change I am talking
about, in terms of the management of sanitation programmes, does
not need a lot of money. In fact we argue there are very strong
programmatic reasons why one should not be subsidising sanitation
for the poor; one should be subsidising not the construction or
production but the promotion of the sanitation and that is not
very expensive. One option might be to have a separate fund in
a country office that could be used for advocacy, for small-scale
pilot experiments possibly led by NGOs, to leave them to set up
demonstration projects which can be shown to municipal officials
to help change their point of view. It would have to be an adjunct
to the budget support rather than a part of the budget support
mechanism.
Q116 Joan Ruddock: Could you give
us an idea of what are the relative effects of different aid instruments?
Is there a way in which—with programme support, sector wide
approaches and budget support—you can make a comparison
between those different types of delivery of aid by donors? Which,
in your view, is going to produce the best results overall?
Professor Cairncross: The experience
of the Poverty Reduction Strategy Papers so far has not been very
positive for the water sector. A number of countries' PRSPs have
had pictures of smiling children under taps on the front cover.
When one looks more closely at the budget one tends to find that
2% or less of the fund is devoted to the water sector. I suspect
with the sector-wide approach and the budgetary support approach
generally across ministries one is unlikely to be able through
that mechanism to influence countries' policy. In the past UNICEF
might be an example of an agency that has worked through governments
but at the same time devoted some of its funding to NGOs and other
local experiments and had a very powerful impact on much larger
national programmes. A good example would be UNICEF's water and
sanitation programme in India which, over 30 years, set the technical
and institutional model for India's rural water programme which
supplies now roughly one in 10 members of the human race, so it
is a lot. Yet if you look at what UNICEF was investing it was
less than 2 or 1% of what the Indian Government was investing
in rural water programmes. It does not take a huge amount. It
needs some presence in the field; some sign of activity and that
does not necessarily mean DFID directly—although there might
be a lot to be said for it; it could be entities funded by DFID
apart from, on a very small scale and aside from its budgetary
support role.
Q117 Joan Ruddock: I think that is
extremely interesting. One of the things which has worried us
is most of us can see how you might produce these complex packages
on a small scale and locally but how to scale up to meet the extent
of the challenge which is so colossal in terms of sanitation.
Obviously you are presenting a case that has been proven but over
30 years.
Professor Cairncross: The important
thing is designing the small-scale models in such a way they can
be replicated so the DFID staff or their advisers who are going
to be promoting these need to have always in mind the perspective
for scalability of the model.
Q118 Richard Burden: Given the emphasis
you have put on market research and seeing the improvement on
sanitation being a way of working out how to sell it, could I
perhaps ask you to comment on the issues around handwashing with
soap. All the evidence we have had so far indicates that could
have a big impact but the statistics for those numbers of people
who practise this is still very, very low. Where the programme
has been most successful, we have had statistics in Ghana where
the local Partnership for Handwashing with Soap, the success rate
has gone up by 40% in mothers and 60% in children. I just wondered
if I could get your take on that programme about the involvement
of the private sector in it, and also whether you think there
are any downsides to that partnership?
Professor Cairncross: It is important
to bear in mind that you cannot wash your hands if you do not
have access to water. Valerie Curtis and myself did a literature
review some years ago on handwashing with soap, and if you look
at three of the 17 settings we looked at, three research projects
where this is evaluated, where we had reason to believe there
was a shortage of available water in the context, the impact was
substantially less. If people do not have access to water then
the handwashing promotion is going to have a limit. That to some
extent addresses the downside question. There are limitations.
I guess the limitation of the Global Coalition on Handwashing
so far has been that the private sector has not invested a lot
of money in the promotion, with one exception which I will come
to. Generally speaking the model has been the Water and Sanitation
Programme and the World Bank have funds for water and sanitation
projects, and there is a hygiene promotion component and they
are wondering how to spend it. That money has then been used to
fund a private sector type generic promotion programme to promote
handwashing, as in Ghana for example. It has been public funding
and a lot of private expertise. I do not want to denigrate the
contribution of the private sector because they put a huge amount
of executive time into it, and executive time in a large private
company is perhaps even more valuable than funds as a resource.
The private sector expertise has greatly strengthened those initiatives.
An added advantage has been that the market research has been
put on the web so that the smaller companies, the local companies,
can look over their shoulder and see how a big multinational does
its market research; so it is a very useful capacity-building
exercise for the other local participants in the coalition. Your
question was: what is the potential? When a couple more national
programmes have been carried out we may be able to get some evidence
of the growth of the bar-soap market arising from these initiatives.
If we can prove that to the private sector then they will be much
more willing to devote their own resources to such generic or
even branded advertising.
Q119 Chairman: We are told waterless
soaps have been used in emergency situations quite effectively
but they are too expensive—these soaps that do not require
any water?
Professor Cairncross: Yes, they
are rather more expensive so they are probably not a solution
in the long-term but in emergency settings they can be used. It
is not that the handwashing promotion takes the place of water;
it should go with water supply programmes and there are lots of
other reasons for water supply programmes. The big jackpot which
I look to find in the next couple of years is if we can convince
the big soap companies that they can expand their market by this
kind of initiative then we will have convinced them and they will
be willing to put in more resources and then you really will have
self-sustaining hygiene promotion. That is the dream that we have
but we have not quite reached it.
|
