How to Get to Full Water and Sanitation Coverage

Tuesday, 3 September 2013 16:46 GMT

* Any views expressed in this article are those of the author and not of Thomson Reuters Foundation.

At an April press conference, the president of the World Bank, Jim Yong Kim, held up a handwritten number and announced, “2030. This is it. This is the global target to end poverty.”  That historic moment also served to underscore some of the dilemmas actors in the WASH sector grapple with. How do we establish audacious, yet realistic goals? How do we announce an ambitious goal, such as full water and sanitation coverage in a number of countries, and have confidence that we have a reasonable chance of achieving it? This week is World Water Week, and in partnership with the Thomson Reuters Foundation, we asked some of the world's water experts exactly these questions. View the full debate here.

Sanitation is one of the most lagging MDGs – over 35% of the world’s population does not have access to improved sanitation.  And most of the people who do not have access to improved sanitation are poor people living in poor countries as well as rich countries.  There are no easy fixes for “getting to full sanitation coverage”.  Success will require systematic and comprehensive policy and sector reform at the country, state and local government levels, evidenced based global knowledge about effective programmatic approaches and at scale service delivery models – and high level political champions at both the country and global levels.

Over 2.5 billion people currently lack  access to improved sanitation -  including  one billion people practicing open defecation.  Addressing the ‘unfinished business’ of the MDGs is a high priority in the post-2015 sustainable development framework.  There is growing country based and global stakeholder consensus that post-2015 sanitation related  goals and  targets should aim for the global elimination of open defecation by 2025 and the universal access to sanitation  by 2030.

In April 2013 the World Bank Development Committee endorsed the following  goals:  End extreme poverty and; promote shared prosperity and foster income growth of the bottom 40% of the population in every country.  Eliminating open defecation globally and achieving universal access to sanitation is key to achieving both of these goals.

As a result of ambitious and innovative programs  being carried out by  countries such as Indonesia, India, Tanzania, Ethiopia, Uganda and others, there is a growing body of evidence and global knowledge on how to accelerate access to sanitation and scale up.   The evidence suggests that what needs to be done to achieve universal access to sanitation is to create a strong government enabling environment capable of sustaining service delivery at scale; generate demand for improved sanitation and behavior change at scale, and scale up the supply of sanitation products and services that are affordable and responsive to aspirations of the poor.  Also needed is a strong and effective country based learning process that gathers real time evidence about what is working and what still needs to be improved.

To create a strong government enabling environment governments need  to strengthen the capacity of public sector institutions and local stakeholders across multiple dimensions, including:  development and adoption of a sanitation specific policy and strategy, clarifying  institutional arrangements;  developing effective program methodologies; developing and building the capacity of on an at scale implementation/service delivery model; assuring the availability of sanitation products and services that are responsive to household aspirations and are affordable at all income levels;  developing effective and feasible financing policies; committing to cost-effective implementation; and monitoring and evaluation.

To generate demand for sanitation and hygiene by households and communities, local government agencies and resource agencies need to implement behavior change activities (such as Community Led Total Sanitation – CLTS) and behavior change communication.

To increase the supply of sanitation products and services, efforts are needed to build the capacity of local builders, manufacturers, and suppliers of sanitation products and services. Sanitation marketing strategies have been applied to expand consumer awareness of product options and costs, strengthen business skills, and improve the design, availability, and affordability of sanitation products and services.

Finally, helping governments generate rigorous evidence and actively learn about what works and does not work in real time is instrumental in making adjustments to programming efforts and using the evidence to inform policies and practices.  The learning and knowledge generation activities range from rigorous impact evaluations using randomized control trials to performance benchmarking, to exposure visits to other countries.

Efforts by the Government of Indonesia over the past 7 years provide a good example of political leadership and government led reform leading to acceleration of rates of increasing access to improved sanitation.  In 2005 the Government of Indonesia embarked on a new approach to improving rural sanitation known as Community-Led Total Sanitation (or CLTS).  Instead of focusing on toilet construction, the CLTS approach recognized that sustainable demand for improved sanitation came only when households and communities were part of the process of identifying and addressing the problem.  Success with this approach at small scale led to its initial expansion to additional villages and eventually in 2007 to the creation of the Scaling Up Rural Sanitation Program in the province of East Jave. This program served as a learning laboratory for the government for working at scale.  This at scale pilot was led and implemented by Provincial and local governments  and combined three innovative approaches (i) CLTS to generate demand; (ii) sanitation marketing to reinforce demand generation and increase supply of sanitation goods and services; and (iii)  learning strategies to strengthen the country’s enabling environment so that improvements could grow and ultimately be sustained. By December 2011, 2,200 communities in 29 districts were officially declared and verified as Open Defecation Free (ODF), and over 1.4 million people gained access to improved sanitation as a result of exposure to the program.

As part of efforts to gather evidence on the health and welfare impacts of this approach, the program  utilized a rigorous impact evaluation to measure the effects of the intervention on individual and collective sanitation behaviors, as well as the program’s impact on the health and welfare of children under the age of five.  Treatment communities witnessed a 29% increase in toilet construction (albeit not among the poorest quintile of the households surveyed) and a 30% decrease in diarrhea prevalence reported by care-givers of children under the age of five . This evaluation also found that the program had impacts on other child health indicators ranging from reducing parasitic diseases to improvements in height and weight among households with no sanitation at baseline.  Findings from the evaluation led to program improvements – for example by working with the local private sector to produce a wider range of sanitation products that would be more affordable to the poorest households,  and working with microfinance institutions to make credit available.

This  program signified a strategic policy shift for sanitation on the part of the Government of Indonesia.  What began as an at-scale, provincial program has now become the backbone of Indonesia’s national rural sanitation program today.  Building on lessons learned in East Java,  32 out of 33 provinces in Indonesia are now beginning to assume full responsibility for financing and implementation of the new strategy, progressively internalizing the new approaches and applying these to their entire province.

As noted above, getting to full sanitation coverage will require high level political leadership.   Among others,  World Bank President, Jim Yong Kim, has called attention to the necessity of addressing sanitation in order to end poverty: “We have to fix sanitation if we want to end extreme poverty by 2030 and boost the incomes of the poorest 40 percent”

Eddy Perez is a Lead Sanitation Specialist with the Water and Sanitation Program (WSP) of the World Bank.