Scaling Up Rural Sanitation: Publications and Tools

WSP produces evidence-based publications and tools on an on-going basis to share approaches and lessons learned, with the aim to contribute to the sector and support adaptation and replication.

Knowledge products can be downloaded and disseminated using the links below.  Please contact us to share feedback, request hardcopy materials, or request permission for academic use. 

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Global Learning:
Enabling Environment for Working at Scale
| Behavior Change and Sanitation Marketing |

Performance Monitoring | Sanitation for the Urban Poor | Knowledge into Policy and Action |
Economic Evidence for Advocacy and Decision Making

Regional Focus:
Africa
 | East Asia and Pacific | Latin America and Caribbean | South Asia

Publication Type:
Academic Publications
| Technical Reports & Papers | Research Briefs |

Learning Notes | Presentations | Toolkits & Multimedia 



Global Learning: Enabling Environment for Working at Scale
 

What Influences Open Defecation and Latrine Ownership in Rural Households? Findings from a Global Review (WSP: O’Connell; 2014)
As part of its Scaling Up Rural Sanitation and Domestic Private Sector Participation programs, WSP has been commissioning formative research studies among households. Three specific sanitation behaviors are covered in the review: open defecation, acquisition of toilets, and improvement of latrines. This review collects the results from formative quantitative and qualitative research reports and presentations from eight countries: Cambodia, India (Rajasthan, Meghalaya, and Bihar), Indonesia (East Java), Kenya, Malawi, Peru, Tanzania, and Uganda. The most salient factors influencing rural sanitation behaviors that emerged from the review include access to and availability of functioning latrines, sanitation products, and services; latrine product attributes (for example, perceptions of cleanliness and durability); social norms around open defecation; perceptions of latrine affordability; self-efficacy to build latrines; and competing priorities for other household items. The review also identified a number of emotional, social, and physical drivers. These include shame and embarrassment associated with open defecation, as well as perceptions of improved social status, privacy, and convenience associated with latrine ownership and use.
 
 
Pathways to Success: Compendium of Best Practices in Rural Sanitation in India (WSP, Government of India; 2014)
This report addresses the need to broaden communication on rural sanitation. The 16 success stories documented in the Compendium can be lessons of great inspiration and serve as models for various Gram Panchayats, Districts, and States across India in overcoming hurdles and obstacles in various fields as diverse as community participation, sustainability, resource mobilization, solid and liquid waste management, program implementation, IEC practices, and institutional reforms.
 
 
Review of Community-Managed Decentralized Wastewater Treatment Systems in Indonesia
(WSP: Eales, Blackett, et al.; 2013)
In many developing countries, centralized sewerage and wastewater treatment systems cover only a portion of larger urban areas, and on-site sanitation is often inappropriate in densely populated settlements. Intermediate and complementary solutions are needed. Community-managed anaerobic decentralized wastewater treatment systems (DEWATS) offer the possibility of relatively swift sanitation improvements in high priority neighborhoods that communities can manage themselves, where local government does not yet provide a full sanitation service.
This review explores Indonesia’s experience in implementing community-managed DEWATS on a growing scale. In a context of extremely low sewer coverage, the Government of Indonesia sees community-managed DEWATS as its best available option for eradicating open defecation and improving sanitation in selected poor dense urban settlements until full municipal sewerage and wastewater treatment are feasible.
 

Linking Service Delivery Processes and Outcomes in Rural Sanitation: Findings from 56 Districts in India (WSP: Kumar, Singh, et al.; 2013)
WSP conducted a study to assess sanitation service delivery in 56 districts in India. The study found that when higher quality of service delivery processes are adopted at the district level, it is more likely that households will sustain behaviors linked to toilet usage and safe disposal of child feces. To assess quality of service delivery processes, the steps taken by district governments to achieve outcomes in rural sanitation were categorized into nine processes and grouped into three thematic components – Catalyzing, Implementing, and Sustaining. Among the three thematic components, sample districts' scores on the quality of processes were highest for Catalyzing, followed by Implementing and Sustaining. This implies that while districts performed well in terms of putting in place policies, institutions, and budgets related to program implementation, translating these enabling conditions into scaling up demand and supply to reach and sustain outcomes has been a challenge.

 Report

What Does It Take to Scale Up Rural Sanitation? (WSP; Perez, 2012)
This working paper shares lessons and best practices that were identified to generate demand for sanitation at the household and community level; increase the supply of affordable, aspirational sanitation products and services; and strengthen local and national governments to lead large-scale sanitation programs.  Key components are introduced and illustrated with examples from the field, including:  Community-Led Total Sanitation, Behavior Change Communication, and Sanitation Marketing.  The evidence presented in this Working Paper can help inform government and donor policies and practices, increase investment in sanitation, and ensure that these investments reach the poor.

Working Paper: English / French

WEDC/WSP Online Learning Course: Rural Sanitation at Scale: English | French

Policy and Sector Reform to Accelerate Access to Improved Rural Sanitation (WSP; 2012, Rosensweig, Perez, and Robinson)
Increasing access to improved sanitation requires systemic sector and policy reform.   Baseline and endline assessments of the enabling environment for rural sanitation programs in India, Indonesia, and Tanzania in 2007 and 2010, respectively, sought to learn more about the effect of these elements on access to improved sanitation.   These assessments examined the programmatic and institutional conditions needed to scale up and sustain large-scale rural sanitation programs.

The  assessments found that the most significant progress was made in four of the eight enabling environment component areas studied: program methodology, implementation capacity, availability of sanitation products and services, and monitoring and evaluation. The countries with the strongest enabling environment, such as Himachal Pradesh, India, which has achieved almost universal access, made the most progress in scaling up rural sanitation. The learning experience also indicated that not all components of the enabling environment are equally amenable to external intervention. External agencies have less influence, for example, in strengthening political will than in strengthening implementation capacity.  

Working Paper

Enabling Environment Endline Assessment: India (WSP: Robinson, 2012)
Research conducted in 2010 to assess the enabling environment for rural sanitation in two states—Himachal Pradesh and Madhya Pradesh—shows that rural sanitation coverage in HP increased around 50 percent since the 2007 baseline study, whereas coverage in MP grew barely 7 percent during the same period. Although the two states have similar government programs and received similar levels of program support, there was a huge difference in the scale of challenge in MP (MP is a much larger state and has higher proportions of poor and marginalized households). Nevertheless, the significantly better cost-effectiveness in HP reflects a much stronger enabling environment than that found in MP. Recommendations to further strengthen the enabling environment include developing more effective high-level advocacy, including the use of cost-effectiveness data to demonstrate how some strategies use resources more effectively than others; and working toward routine monitoring and benchmarking of sanitation outcomes, such as latrine use and sustainability.

Working Paper

Enabling Environment Endline Assessment: Tanzania (WSP: Robinson, 2011)
Tanzania’s enabling environment for rural sanitation shows highly promising developments, particularly at the national level, where greater consensus on direction and an increased separation between sanitation activities and water-supply development are evident.  As the government and development partners prepare a new national sanitation program, they are working to improve enabling environment at the district level and address the challenges that scaling up to all 132 districts brings including addressing needs and priorities of diverse conditions and maintaining implementation quality across such a large area.

Working Paper

Enabling Environment Endline Assessment: Indonesia (WSP: Robinson; 2011)
This follow-up to the 2007 baseline assessment in East Java, Indonesia, found clear evidence of accelerated sanitation progress in project communities, estimated at roughly 10 times the national average. Because sanitation remains a local government responsibility in East Java, a decentralized, demand-responsive approach to improvement has proven highly effective. Absent centralized programs, the assessment found that “district governments were convinced to use their own institutions and resources to implement the project, resulting in sustainable arrangements and finance, cost-effective use of local resources, as well as proactive efforts to learn from others, innovate, and develop locally appropriate approaches.

Working Paper

Identifying the Potential for Results-Based Financing for Sanitation (WSP and SHARE; Trémolet, 2011)
Results-Based Financing (RBF) offers an alternative to traditional sanitation financing by allocating public funds based on the achievement of specified results. This working paper offers practical ideas for advancing the use of results- and performance-based financing mechanisms in the delivery of sustainable sanitation services. The proposed “Grow Up with a Toilet” RBF program in Cambodia, for example, targets sanitation finance to improving sanitation among young children and promoting ongoing sanitation development. RBF incentives can also encourage service providers to provide services to the poor, such as in Morocco, where three providers of piped water and sewerage services received subsidies based on both their completion of the project and its ongoing support. Learn More

Working Paper

Getting Africa to Meet the Sanitation MDG: Lessons from Rwanda (WSP: Jain; 2011)
Household access to sanitation facilities has increased faster in rural Rwanda than in any other country in Sub-Saharan Africa. Almost four million people gained access to improved sanitation between 1990 and 2008. How has Rwanda been able to achieve its remarkable progress toward achieving the sanitation MDG? This Case Study highlights interrelated drivers including cultural factors, the post-genocide reconstruction process, progress in related sectors, and specific sector initiatives.
Case Study

Learning by Doing: Working at Scale in Ethiopia (Faris (WSP); Rosenbaum (FHI 360/WASHplus); 2011)
In 2006, WSP partnered with the Government of Ethiopia, the Amhara Regional Health Bureau, and USAID’s Hygiene Improvement Project (HIP) to launch the Learning by Doing Initiative in Amhara Regional State, focused on achieving total behavior change in sanitation and hygiene. The project started at scale, reaching an initial 93,000 households in four districts (estimated population of 418,000) and then expanded further to include an additional 90 districts. Overall, 5.8 million people were reached and 2.8 million more people stopped practicing open defecation and now use an open pit latrine. Key strategies discussed included building capacity at the community level and developing and testing tools and training manuals.

 Learning Note  |  Report  | Presentation   | Additional Resources

Making Sustainable Rural Sanitation a Reality: The Experience of Ecuador (WSP: 2011)
By the late 1990s, the Government of Ecuador and the World Bank had begun to formulate the Rural and Small Towns Water Supply and Sanitation Program (PRAGUAS). The development objective of the program was to increase the coverage and effective use of sustainable water and sanitation services in Ecuador, with a focus on poor populations in rural communities and small towns. As a middle-income country with a gross national income per capita of $4,290 (World Bank WDI 2010), households in Ecuador are increasingly better positioned to make home improvements, including household sanitary solutions. This publication is intended to share insights and lessons from the Compact Sanitary Unit implementation project in Ecuador as well as findings about the Rural and Small Towns Water Supply and Sanitation Program (PRAGUAS).

 Case Study: English / Spanish

Long Term Sustainability of Improved Sanitation in Rural Bangladesh (WSP: Hanchett, Krieger, Kahn, Kullmann, Ahmed; 2011)
A WSP study of 53 Union Parishads, declared 100% sanitized/open defecation free almost five years ago showed that 90% of households had sustained use of a latrine that adequately confines feces. Factors associated with this outcome include a shift in social norms away from open defecation to using a latrine; on-going sanitation programming that reinforces latrine use; and easy access to private sector sanitation providers. In addition, a comparative analysis of four programmatic approaches used revealed little variation in sustained outcomes.
 Technical Report | Research BriefEnglish / French | Presentation | Video

Political Economy of Sanitation (WSP; 2011)
This technical paper presents the results of a Global Economic and Sector Work (ESW) study on the political economy of sanitation in Brazil, India, Indonesia, and Senegal that was conducted by the Water and Sanitation Program (WSP) and the World Bank. The purpose of the study is to help WSP and sanitation practitioners in understanding the political economy of sanitation and therefore to support partner countries better in the design, implementation, and effectiveness of operations that aim to provide pro-poor sanitation investments and services to improve health and hygiene outcomes. Learn More
 Technical Report  | Research Brief

Gender in Water and Sanitation (WSP: Rop; 2010)
As the Water and Sanitation Program and its partners continue to explore and document emerging practice from the field, this working paper highlights, in brief form, approaches to redressing gender inequality in the water and sanitation sector. The review is intended for easy reference by sector ministries, donors, citizens, development banks, non-governmental organizations and water and sanitation service providers committed to mainstreaming gender in the sector. Two central features in the review are the illustration of good practices—which provide a quick pointer for replication, and are intended to guide tailoring the practice to local context—and end-of-chapter checklists, which provide practitioners with gender issues and responses to consider at various stages of decision making in the water and sanitation sector.

 Working Paper: English / French

Output-Based Aid for Sustainable Sanitation (WSP and GPOBA: Trémolet , Evans, Schaub-Jones; 2010)
This  study  reviewed experience to date with Output-Based Aid (OBA)  for sanitation and examined its potential to improve both  the delivery of public  financing to the sanitation sector and access to sustainable sanitation services. Key questions included: What explains such limited use of OBA-financing approaches for sanitation? How can OBA subsidies be delivered to providers of sanitation services? What other components (e.g., support services to small-scale independent providers, micro-finance, etc.) may be required to improve chances of success of OBA schemes for sanitation?
 Working Paper  |  Learning Note

Financing On-Site Sanitation (WSP: Kolsky, Tremolet, Perez; 2010)
Public investments of varying forms enable an absolute increase in the number of poor people gaining access to sanitation, varying from 20 percent to 70 percent, according to a WSP study of six cases in Bangladesh, Ecuador, India, Mozambique, Sénégal, and Vietnam. This report identifies the best-performing approaches, relevant factors, and issues to consider when designing a sanitation financing strategy. Learn More
 Research Brief  |  Technical Report (Full) |  Technical Report (Without Annexes) |  Technical Report (Spanish)

Enabling Environment Baseline Assessment: Three Country Synthesis (WSP: Rosensweig, 2008)
During the first year of the project, baseline enabling environment assessments were conducted in the project countries to better understand the programmatic and institutional conditions needed to scale up, sustain, and replicate the interventions used in the projects. This report synthesizes the findings from the four enabling environment assessment reports, including preliminary conclusions and lessons learned, and recommended interventions and practices that can be used to strengthen the enabling environment. The report also identifies knowledge gaps and, hence, priority areas for learning.
 Working Paper

Building the Capacity of Local Government to Scale Up Community-Led Total Sanitation and Sanitation Marketing in Rural Areas (WSP: Rosensweig; 2010)
One of the central premises of the Global Scaling Up Rural Sanitation project is that local governments can provide the vehicle to scale up rural sanitation. In all three project countries—India, Indonesia, and Tanzania—local governments are at the center of the implementation arrangements. This report looks at the experience to date in three project locations in developing the capacity of local government to carry out its role in rural sanitation. Learn More
Working Paper :  English  / French |  Learning Note

 

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Global Learning: Behavior Change and Sanitation Marketing

Making Sanitation Marketing Work: The Bangladesh Story (WSP; 2014)
Over the last decade, Bangladesh has emerged as a global reference point in experimenting with and implementing innovative approaches to rural sanitation. The Community-Led Total Sanitation (CLTS) approach was one such innovation that helped to move over 90 million people from open-defecation towards fixed-point defecation. WSP has designed and implement sanitation marketing in Bangladesh since 2008, enabling consumers to improve their sanitation status. This brochure explains the key components of the sanitation marketing program in Bangladesh, shares success stories, and describes outcomes so far.
 
 
Sanitation and Externalities: Evidence from Early Childhood Health in Rural India (WSP: Andres, Briceno, Chase, Echenique; 2014)
This paper estimates two sources of benefits related to sanitation infrastructure access on early childhood health: a direct benefit a household receives when moving from open to fixed-point defecation or from unimproved sanitation to improved sanitation, and an external benefit (externality) produced by the neighborhood’s access to sanitation infrastructure. The paper uses a sample of children under 48 months in rural areas of India from the Third Round of District Level Household Survey 2007–08 and finds evidence of positive and significant direct benefits and concave positive external effects for both improved sanitation and fixed-point defecation.
 
 
Investing in the Next Generation: Children Grow Taller, and Smarter, in Rural, Mountainous Villages of Vietnam Where Community Members Use Improved Sanitation (WSP: Quattri, Smets, Nguyen; 2014)
Widespread lack of improved sanitation in rural areas of Vietnam leads to stunting, i.e. children being too short for their age. It is not the water that makes children sick and malnourished, it is the feces: sanitation is the primary barrier to stop the ingestion of human feces. The use of unimproved latrines in rural villages in mountainous regions of Vietnam leads to five-year-old children being 3.7 cm shorter than healthy children living in villages where everybody practices improved sanitation. This difference in height is irreversible and matters a great deal for a child’s cognitive development and future productive potential. A child remains at risk of stunting if community members use unimproved sanitation facilities, even when the child’s family uses improved latrines themselves. Universal usage of improved sanitation is needed to adequately address stunting.
 
Investing in the Next Generation: Children Grow Taller, and Smarter, in Rural Villages of Lao PDR Where All Community Members Use Improved Sanitation (WSP: Quattri, Smets, Inthavong; 2014)
One of the underlying causes of child malnutrition—in addition to the mother’s and child’s dietary diversity and health care situation—is unsafe water, inadequate sanitation and poor hygiene practices that lead to increased exposure to human feces. While urban sanitation access in Lao PDR is 90%, 50% of rural households are still practicing open defecation and/or using unimproved sanitation as of 2012. Remote and poor rural areas are even worse off and only 13% of the poorest households are using improved sanitation. Inequalities along ethnic groups are persistent, with 74% of Lao-Tai families using improved sanitation and only 30% of Mon Khmer, 46% of Hmong-Mien and 30% of Chinese-Tibetan. During the last decade child malnutrition has improved very marginally and almost 49% of rural children were stunted in 2011 [27% of urban children]. Stunting has a permanent impact on the life of a child. It does not only affect the child’s height, but also her/his cognitive abilities. Stunted children are likely to become less productive adults, and be less able to contribute to their country’s growth and prosperity.
 
 
Improved Sanitation Can Make Children Taller and Smarter in Rural Tanzania (WSP: Quattri, Rand; 2014)
In Tanzania, 87.8% of households do not have access to improved sanitation, such as a latrine or a toilet that separates human feces from human contact. The situation is worse in rural areas, where 92.5% of households do not have improved sanitation. Among those without sanitation, 5.6 million individuals defecate in the open. Unfortunately, the situation is getting worse, not better. In 2012, more people in rural Tanzania were defecating in the open than in 2000. In those same areas, 45% of children under five were found to be stunted in 2010. Nutrition interventions alone can only reduce stunting by 36% and mortality by 25%. Other interventions are needed to make up the rest of the height difference. Recent research has shown that differences in open defecation can explain up to 54% of the variation in average child height in some developing countries and more than 60% if density of open defecation is considered. This analysis was conducted to determine if a lack of improved sanitation can similarly explain the large amount of stunting in Tanzania. This brief discusses an analysis conducted by WSP to examine the link between sanitation and stunting in Tanzania.
 
 
 
How Much International Variation in Child Height Can Sanitation Explain? (WSP: Spears, 2013)
Physical height is an important economic variable reflecting health and human capital. Puzzlingly, however, differences in average height across developing countries are not well explained by differences in wealth. In particular, children in India are shorter, on average, than children in Africa who are poorer, on average, a paradox called “the Asian enigma” which has received much attention from economists. This paper provides the first documentation of a quantitatively important gradient between child height and sanitation that can statistically explain a large fraction of international height differences.
 
 
 
Investing in the Next Generation: Growing Tall and Smart with Toilets (WSP; 2013)
As this brief shows, the level of open defecation in a community is associated with shorter children in Cambodia. Moreover, the level of open defecation in a community is more important for a child’s development than whether the child’s household itself openly defecates. By looking at the change in defecation levels and average child height between 2005 and 2010 within Cambodian provinces, the study is able to show that improvements in sanitation access played a substantial role in increasing average child height over the same five years.

Research Brief

 

Effects of Early-Life Exposure to Sanitation on Childhood Cognitive Skills: Evidence from India’s Total Sanitation Campaign (WSP: Spears, Lamba; 2013)
Early life health and net nutrition shape childhood and adult cognitive skills and human capital. In poor countries—and especially in South Asia—widespread open defecation without making use of a toilet or latrine is an important source of childhood disease. This paper studies the effects on childhood cognitive achievement of early life exposure to India’s Total Sanitation Campaign, a large government program that encouraged local governments to build and promote use of inexpensive pit latrines. 
 
  
Village Sanitation and Children’s Human Capital: Evidence from a Randomized Experiment by the Maharashtra Government (WSP: Hummer, Spears; 2013)
Open defecation is exceptionally widespread in India, a county with puzzlingly high rates of child stunting. This paper reports a randomized controlled trial of a village-level sanitation program, implemented in one district by the government of Maharashtra.
 
 
 
Coming Up Short Without Sanitation (WSP; 2013)
A study of a community sanitation program (Total Sanitation Campaign, or TSC) by the Indian Government showed that improved sanitation helped children grow taller and healthier. In Ahmednagar district of the State of Maharashtra, 30 villages were randomly assigned to a community-level sanitation motivation treatment group and 30 villages to a control group. Eighteen months later, surveyors measured how much the average height of children in the treatment and control groups had changed. Key findings include: 1) Children living in villages that received sanitation motivation treatment grew taller on average; 2) the program caused a modest increase in sanitation coverage. 3) The TSC program was not implemented everywhere and much work remains to be done. The findings of the study highlight the importance of improving sanitation as part of a multisectoral approach to addressing India’s malnutrition crisis. 
 
 

Sanitation Marketing Lessons from Cambodia: A Market-Based Approach to Delivering Sanitation (WSP: Pedi, Kov, Smets; 2012)
Based on a detailed sanitation demand and supply chain assessment in 2006, WSP designed and supported a Sanitation Marketing Pilot project in two provinces—Kandal and Svay Rieng. The project tests the applicability of a new market-based approach to strengthen the supply of affordable and aspirational toilets while introducing social marketing to generate toilet sales. This field note highlights how a market-based intervention can help increase sanitation coverage six times faster than the average increase in project areas. This makes sanitation marketing a promising approach for increasing sanitation at scale in rural Cambodia.

Field Note
 

The Trigger: A Film on Community-Led Total Sanitation—5 Day Workshop (WSP; India, 2012)
This video provides an overview of the WSP approach to CLTS training in a workshop setting that is inclusive and hands-on and also describes the steps involved in implementing the approach.

Video

Sanitation Markets at the Bottom of the Pyramid: A Win-Win Scenario for Government, the Private Sector, and Communities (WSP: 2011; Baskovich)
Research conducted in 2010 in Peru to identify techniques for reaching the population at the bottom of the pyramid shows that linking public infrastructure investments in water and sanitation with strategies for ensuring access to affordable products and services, healthy behaviors, and adequate maintenance of new sanitary infrastructure can improve public policies for sanitation. Domestic private participation at the bottom of the pyramid is viable and can be achieved through efforts such as the Creating Sanitation Markets initiative, which promotes sanitation for the very poor, with a focus on the domestic private sector’s active involvement in sanitation supply, and public awareness of sanitation as a business opportunity.
Learning Note

Factors Associated with Achieving and Sustaining Open Defecation Free Communities: Learning from East Java (WSP: Mukherjee; 2011)
Research conducted in 2010 in East Java to identify factors associated with achieving and sustaining behavior change by communities to become ODF shows that communities achieving ODF status within two months of triggering achieved markedly higher access gains. In addition, evidence from environmental observation, latrine ownership records, reported usage, and observation of facility maintenance show that 95 percent of the QUICKLY ODF communities had sustained their behavior change 4 to 28 months after ODF declaration.  Factors associated with QUICKLY ODF communities include high social capital, high-quality CLTS triggering, access to latrine supplies, easy payment terms, absence of external subsidy packages to a few households out of all, and regular monitoring. These QUICKLY ODF communities represent the most efficient model for scaling up sustainably.
Research Brief | Report

Introductory Guide to Sanitation Marketing (WSP: Devine and Kullmann; 2011)
WSP’s approach to scaling up rural sanitation combines three components — Community-led Total Sanitation (CLTS), behavior change communication, and sanitation marketing — in addition to efforts to strengthen the enabling environment. Of these, sanitation marketing is a relatively new field and WSP has amassed significant insights and resources through action learning efforts in various countries. With a goal to create a practical resource for program managers and commercial and social marketing specialists, lessons and resources were harvested to develop a companion online toolkit that includes narrated overviews, videos, and downloadable documents including research reports, sample questionnaires, and more.
 Introductory Guide: English/ FrenchSpanish    Online Toolkit

Experiences from Rural Benin: Sanitation Marketing at Scale (WSP: Scott, Jenkins, Kpinsoton; 2011)
This Field Note presents the Benin story and its development of a successful national sanitation marketing program adapted to the rural African context. The Benin story illustrates that sanitation marketing can work even in areas without a history of hardware subsidies — a valuable lesson for other African countries seeking to develop rural sanitation marketing programs that stimulate household demand at scale.
Field Note: English / French

 

Marketing Rural Sanitation Improvements in Tanzania (WSP: Cardosi; 2010)
In 2009 WSP began working with ten local governments to test the effectiveness of marketing as a method to prompt households in rural Tanzania to invest in improving their sanitation facilities. Lessons include: 1.) Fall in line with national reporting structures to make monitoring and evaluation easier; 2.) Design the program around the consumer’s immediate needs and wants to bridge the knowledge-behavior gap; 3.) Integrate supply and demand activities; and 4.) Strengthen the supply chain.

 IFC SmartLesson: English / French

Introducing SaniFOAM: A Framework to Analyze Sanitation Behaviors to Design Effective Sanitation Programs (WSP: Devine; 2009)
Why do individuals with latrines continue to defecate in the open? What factors enable individuals or households to move up the sanitation ladder? Before sanitation behaviors can be changed, they must first be understood. The SaniFOAM framework, developed to help answer some of these questions, categorizes sanitation behavioral determinants under Opportunity, Ability, and Motivation. With the letter F for Focus, these categories spell out F-O-A-M. Learn More

 Working Paper: English / French

Case Study on Sustainability of Rural Sanitation Marketing in Vietnam (WSP: Sijbesma, Truong, Devine; 2010)
To investigate the sustainability of sanitation marketing as an approach to creating and meeting rural sanitation demands in Vietnam, WSP collaborated with IRC International Water and Sanitation Centre and ADCOM to follow-up on a pilot project conducted by IDE from 2003 to 2006. Three years after the conclusion of an IDE-led sanitation marketing pilot project, the number of sanitary product providers and the demand for sanitary toilets continued to develop but progress over a longer term may be less sustainable. Learn More
 Technical Report (High Res) |  Technical Report (Low Res) |  Research Brief |  Presentation Video

Sanitation Marketing in Tanzania (WSP; 2010)
In 2009, WSP began working with ten local governments to test the effectiveness of marketing as a method to prompt households in rural Tanzania to invest in improving their sanitation facilities. Lessons include: 1) Fall in line with national reporting structures to make monitoring and evaluation easier; 2) Design the program around the consumer’s immediate needs and wants to bridge the knowledge-behavior gap; 3) Integrate supply and demand activities; and 4) Strengthen the supply chain.
 Smart Lesson | Video

Sanitation Marketing in Indonesia (WSP; 2010)
In a country where rural sanitation access rates remained stagnant at under 40% for recent decades, sanitation has suddenly become a profitable, fast growing business. This video features small-scale sanitation entrepreneurs serving households in Indonesia's East Java province, one of the most densely populated places on earth (38 million people).
 Presentation Video | Presentation Slides |  Academic Publication |  Field Note: English / French

Sanitation Marketing in Cambodia (WSP; 2010)
The Sanitation Marketing Project was launched in Cambodia in early October 2009, aiming to have over 10,000 toilets installed by households in rural villages over a period of 18 months through market force and demand creation activities. Unlike conventional approaches to sanitation improvement, which usually provide hardware subsidies to households and overlook the market as a driving force to sustainable sanitation, the current approach focuses on market-based solutions and the sustained behavior change of sanitation practice within communities. 
 Presentation Video

 

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Global Learning: Performance Monitoring

 
Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam (WSP: Ram, Briceño, and Chase; 2014)
Handwashing with soap has been shown to reduce diarrhea and respiratory disease, the two leading causes of childhood deaths in low- and middle-income settings. Global Scaling Up Handwashing was initiated in 2006 by WSP in Peru, Senegal, Tanzania, and Vietnam. The handwashing promotion interventions were developed using a framework known as Focus, Opportunity, Ability, and Motivation (FOAM). A handwashing promotion intervention can only result in improved health or other downstream benefits if it results in increased handwashing behavior. In the impact evaluation of Global Scaling Up Handwashing, handwashing is measured using self-reports, rapid observations, and structured observations, recognizing that each method provides useful insights into awareness about handwashing, the availability of materials necessary for handwashing, and the practice of washing hands at critical times. Specifically, with respect to the FOAM framework, this report addresses constructs within the focus, opportunity, and ability domains. The goal of this report is to describe handwashing behavior of households included in the project impact evaluation, as measured during the baseline surveys conducted in Peru, Senegal, and Vietnam. The baseline surveys of Global Scaling Up Handwashing indicate opportunities to improve handwashing behavior in all of the countries where interventions are being tested. In the future, correlations can be described between measures and relationship with disease risk and other hygiene behaviors in the home, including sanitation and household water treatment.
 
 
Validity of Rapid Measures of Handwashing Behavior: An Analysis of Data from Multiple Impact Evaluations in the Global Scaling Up Handwashing Project (WSP: Ram, Sahli, Arnold, et al.; 2014)
There is increasing interest in improving handwashing in low- and middle-income countries. The validity of rapid handwashing measures was evaluated by comparing them to handwashing behavior measured during five-hour structured observations. Handwashing was measured in the impact evaluation of the Global Scaling Up Handwashing project, carried out by WSP in Peru, Senegal, and Vietnam. The project tested the effects of at-scale implementation of hand washing promotion on various outcomes, including behavior and health, in those four countries, using cluster-randomized controlled trial designs. Structured observations were carried out among a subset of households participating in end line surveys in each country. Regression was used to model the relationship between the rapid hand washing measure and the probability that hands were washed during the observed event, accounting for the repeated nature of structured observation data. This multi-country analysis of the validity of rapid handwashing measures confirms the utility of observing handwashing materials at the places where people wash hands, at the times most necessary for washing them (after fecal contact and before food preparation). The findings described reinforce the global imperative of improving handwashing behavior for prevention of the leading causes of death in young children.
 
 
A randomized, controlled study of a rural sanitation behavior change program in Madhya Pradesh, India
Poor sanitation and open defecation are thought to be a major cause of diarrhea and intestinal parasite infections among young children. In 1999, India launched the Total Sanitation Campaign with the goal of achieving universal toilet coverage in rural India by 2012. This paper reports on a cluster-randomized, controlled trial that was conducted in 80 rural villages in Madhya Pradesh to measure the effect of the program on toilet access, sanitation behavior, and child health outcomes. The study analyzed a random sample of 3,039 households and 5,206 children under five years of age. Field staff collected baseline measures of sanitation conditions, behavior, and child health, and re-visited households 21 months later. The analysis finds that implementation of the program activities was slower than the original timeline (only 35 percent of villages were triggered more than six months before the follow-up survey). Nevertheless, the Total Sanitation Campaign successfully increased toilet coverage by 19 percent in intervention villages compared with control villages (41 percent v. 22 percent), while reported open defecation decreased by 10 percent among adults (74 percent v. 84 percent).
 
 
Impact Evaluation of a Large-Scale Rural Sanitation Project in Indonesia (WSP: Cameron, Shaw, Olivia; 2013)
This World Bank Policy Research Working Paper from WSP evaluates the impact of the Total Sanitation and Sanitation Marketing project in Indonesia, where about 11 percent of children have diarrhea in any two-week period and more than 33,000 children die each year from diarrhea. The evaluation utilizes a randomized controlled trial but is unusual in that the program was evaluated when implemented at scale across the province of rural East Java in a way that was designed to strengthen the enabling environment and so be sustainable. Among other findings, the authors found that diarrhea prevalence was 30 percent lower in treatment communities than in control communities at endline (3.3 versus 4.6 percent). The analysis cannot rule out that the differences in drinking water and handwashing behavior drove the decline in diarrhea. 

World Bank Policy Research | Working Paper | Research Brief | Field Note

 

Results, Impacts and Learning from Improving Sanitation at Scale in East Java, Indonesia (WSP: Pinto; 2013)
Indonesia has the second highest number of open defecators worldwide at 59 million, according to the 2013 update published by the WHO/UNICEF Joint Monitoring Program (JMP), and lags substantially behind its peers in the region in terms of access to sanitation. Efforts to expand sanitation coverage have barely affected the lives of poorest populations where rampant diarrheal disease continues to affect the health and well-being of the next generation of children. This field note presents the achievements, learning and reflections that resulted from implementing a large-scale sanitation program in East Java, Indonesia and provides recommendations for future initiatives aimed at increasing access to improved sanitation globally.
 

You Manage What You Measure: Using Mobile Phones to Strengthen Outcome Monitoring in Rural Sanitation (WSP: Kumar and Singh; 2012)
Monitoring rural sanitation outcomes, especially behavior change, has been a challenge for a variety of reasons. The lack of robust and timely information on outcomes leads to a situation where massive investments are made and interventions planned, without a credible and timely means to measure whether expected outcomes are on track. For example, the construction of infrastructure does not necessarily mean that people are using these sanitation facilities. This Field Note shows that affordable smartphones can collect quick, credible information in near real time and has potential for replication at scale for sector monitoring.

 Field Note

Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania (WSP: Briceno and Yusuf; 2012)
This technical report provides a snapshot of the conditions of the target population prior to the start of WSP’s sanitation and handwashing program in Tanzania, which was phased into 10 rural districts during the second half of 2009. The report presents summary descriptive statistics for key demographic, socioeconomic, hygiene, health, and child development variables based on a survey of approximately 1,500 households in five of the 10 districts (due to unexpected problems with data reliability collection was limited to five districts). The survey revealed limited baseline knowledge of the critical handwashing times among the target households prior to the program, indicating room to improve handwashing behavior. Likewise, the survey indicated limited access to improved water sources, a scarcity of pit latrines with slabs, and a non-negligible percentage of open defecation practice as reported by the studied households, suggesting the need for continued efforts toward improving the sanitation situation in the country.

Technical Paper

A Decade of the Total Sanitation Campaign (WSP; 2011)
Analyses primary and secondary data on the Government of India's Total Sanitation Campaign to understand the processes, outputs and outcomes at national and state levels and to benchmark the relative performance by states. This benchmarking, based on a combination of eight indicators, was undertaken for both states and districts across the country.
Report

Utilizing Community-Based Registers to Monitor Improved Access to Sanitation and Hygiene in Tanzania (WSP: Coombes; 2011)
Efforts to systematically collect data to monitor sanitation and hygiene conditions at the community-level face many challenges. To address some of these challenges in Tanzania, WSP collaborated with local governments and village-level CLTS committees to implement community-based and managed registers. This Learning Note reports on a validation exercise conducted through a random sampling of sub-villages and households to assess the use of the registers, including the accuracy and frequency of data collection.

Learning Note

Managing the Flow of Monitoring Information to Improve Rural Sanitation in East Java (WSP: Murkherjee; 2011)
WSP’s Global Scaling Up Rural Sanitation has linked community-based sanitation access monitoring  in real time with district and province level databases. A key innovation has been the development of a monitoring system that uses cell phones, SMS-text messaging, and a central database to transmit and store information reported from the field. Learn More
Working Paper:  English French

Monitoring Systems for Incentive Programs: Learning from Large-scale Rural Sanitation Initiatives in India (WSP: Kumar, Singh, Prakash; 2010)
In India, national and state level incentive programs are being used to reward rural communities verified open defecation free. Effective monitoring of these programs is essential - without it, accurate verification is not possible. WSP assessed two monitoring systems, one on the national level and the other at the state level, analyzing the process to identify best practices for scaling up and replication.  These systems, together with the participation of local governments, have promoted a significant increase in rural sanitation coverage. Learn More
 Guidance Note

Benchmarking Local Government Performance on Rural Sanitation (WSP: Kumar, Singh; 2010)
To strengthen outcome-focused management of the rural sanitation sector in India, the Water and Sanitation Program’s Global Scaling Up Sanitation Project, in partnership  with the Government of Himachal Pradesh, developed a five-step process to monitor and benchmark performance on a monthly basis across all 12 districts in the state. “Benchmarking” introduces the five-step process and key learnings drawn from experiences to date.

Learning Note:  EnglishFrench

 

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Global Learning: Sanitation for the Urban Poor

 
The Missing Link in Sanitation Service Delivery: A Review of Fecal Sludge Management in 12 Cities (WSP: Blackett, Hawkins, Heymans; 2014)
Globally, the great majority of urban dwellers, especially poor people, rely for their sanitation on non-sewered systems that generate a mix of solid and liquid wastes generally termed fecal sludge. In poor and rapidly expanding cities, fecal sludge management (FSM) represents a growing challenge, generating significant negative public health and environmental risks. Without proper management, fecal sludge is often allowed to accumulate in poorly designed pits, is discharged into storm drains and open water, or is dumped into waterways, wasteland, and unsanitary dumping sites. This study seeks to assess the extent of this issue, and the major constraints that need to be overcome to improve fecal sludge management.
 
Research Brief English/Spanish
 
 
Poor-Inclusive Urban Sanitation: An Overview (WSP: Blackett, Hawkins, Heymans; 2013)
Delivering poor-inclusive urban sanitation requires improved service delivery, rather than a focus on infrastructure. This is the core finding of a global review by WSP on challenges, trends, and approaches at the global, national and city levels to achieve viable poor-inclusive urban sanitation at scale. This summary paper highlights key observations and lessons from the original study report: “Delivering Sanitation to the Urban Poor: A Scoping Study” (2012; unpublished).
 


Global Learning: Knowledge into Policy and Action

Policy and Sector Reform to Accelerate Access to Improved Rural Sanitation (WSP: Rosensweig, Perez, and Robinson; 2012)
Increasing access to improved sanitation requires systemic sector and policy reform. Baseline and endline assessments of the enabling environment for rural sanitation programs in India, Indonesia, and Tanzania in 2007 and 2010, respectively, sought to learn more about the effect of these elements on access to improved sanitation. These assessments examined the programmatic and institutional conditions needed to scale up and sustain large-scale rural sanitation programs.

The  assessments found that the most significant progress was made in four of the eight enabling environment component areas studied: program methodology, implementation capacity, availability of sanitation products and services, and monitoring and evaluation. The countries with the strongest enabling environment, such as Himachal Pradesh, India, which has achieved almost universal access, made the most progress in scaling up rural sanitation. The learning experience also indicated that not all components of the enabling environment are equally amenable to external intervention. External agencies have less influence, for example, in strengthening political will than in strengthening implementation capacity.  

Working Paper
 

Partnering on the Road Towards Achieving Total Sanitation in East Africa (WSP: Coombes; 2011)
In East Africa, access to basic sanitation remains low, and intensive work is needed across the region to achieve sustained scaling up of sanitation. Determining how governments and non-governmental agencies can work together more effectively to achieve this goal is essential. This Learning Note highlights a learning exchange held for representatives from the Government of Tanzania and six non-governmental organizations. An initial outcome included consensus on a set learning questions to expand the knowledge base in areas such as equity and inclusion, sanitation marketing, and monitoring and evaluation.
 Learning Note

Emergent Learning about Learning (WSP: Frischmuth; 2011)
A challenge for projects implemented at scale and in multiple countries is to capture and disseminate learning in a way that is systematic, timely, and of benefit to country teams, clients, partners, and programmers. Another challenge is to continuously test key assumptions underlying the program design and activities. To mitigate these challenges, WSP developed a Team Charter, Learning Action Plans, and Learning Strategies to establish and support a culture of learning. Learning has also been integrated learning into the Results Framework.
 Learning Note

Findings from the Impact Evaluation Baseline Survey in Indonesia (WSP: Cameron, Shaw; 2010)
Baseline data collected from nearly 2,100 households reveals high rates of diarrhea and associated disorders such as childhood anemia. These health outcome measures will continue to be tracked during the project to assess the causal impacts of the project interventions. Learn More
 Technical Report |  Research Brief

Global Learning Strategy (WSP; 2008)
The purpose of this learning strategy, applicable to the entire Global Scaling Up Rural Sanitation Project team, is to develop a structured process of generating, sharing, capturing, and disseminating knowledge about what works in scaling up and sustaining sanitation programs. This learning process will help enable evidence-based decisions by policy-makers and implementation of large-scale programs.
 Working Paper

 

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