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. 

Regional Focus: Africa

Promoting Handwashing and Sanitation: An Impact Evaluation of Two Large-Scale Campaigns in Rural Tanzania
This research brief provides background on the problems of poor sanitation and hygiene in rural Tanzania, an overview of two large-scale campaigns that sought to address these problems, and the key results of a recent evaluation of the impact of these efforts.
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.


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


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

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

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

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

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

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


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: EnglishFrench

WSP Approaches to Scaling Up Rural Sanitation in Ethiopia and Tanzania (WSP: Muluneh; 2010)
This overview summarizes WSP's work with local and national governments and the local private sector to end open defecation and scale up rural sanitation in Ethiopia and Tanzania. The video describes how communities in rural Tanzania are reducing the spread of disease and creating local sanitation markets. Local masons are trained to make slabs, or Sanplats, which are more hygienic. These are purchased for US$5 by households and added to existing pit latrines.

Presentation Slides | Video

Stepping Onto the Sanitation Ladder: Stopping Open Defecation in Rural Ethiopia (WSP; 2010)
This video tells the story of Ethiopia's progress since the year 2000 in reducing the practice of open defecation in the East African nation.


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Regional Focus: East Asia and Pacific

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.
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.
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. 
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.
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

Findings from Hygiene and Sanitation Financing Study in Lao PDR (WSP: Colin; 2012)
In Laos, very little information is available on how much money is being spent on sanitation and hygiene, by which entities, for what purposes, or in what locations. There is also little information on who benefits from this expenditure. WSP conducted a study to provide an overview of the current status of sanitation and hygiene financing and to provide useful information and recommendations that can help strengthen planning and accelerate progress in sanitation and hygiene. This Research Brief summarizes the mains findings of that study in Lao PDR.

 Research Brief

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

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

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

Economic Impacts of Sanitation (WSP; ongoing)
A 2007 study by  WSP found that the economic costs of poor sanitation and hygiene amounted to over US$9.2 billion a year (2005 prices) in Cambodia, Indonesia, Lao PDR, the Philippines, and Vietnam. WSP has recently carried out an ESI study in India, with others in process or planned for Bangladesh, Pakistan, and countries in Africa, Latin America, and the Caribbean. Learn More

The second phase of ESI in Southeast Asia analyzes the cost-benefit of alternative sanitation interventions and will enable decisions on how to more efficiently spend funds allocated to sanitation. The study was conducted in Cambodia, Indonesia, Lao PDRthe Philippines, Vietnam, and Yunnan Province in China.

The study found that sanitation interventions have very favorable socio-economic returns to households and society, contributing improved health, clean environment, dignity and quality of life, among many other benefits. In addition, while the study showed sanitation options that protect the environment are more costly to provide (and environmental benefits are difficult to quantify in economic terms), the benefits are highly valued by households, tourists and businesses. When environmental benefits to downstream populations of proper wastewater management are valued, it can considerably increase the economic returns.
 Research Briefs (ESI Phase II): Cambodia | IndonesiaLao PDR | PhilippinesVietnam | Yunnan Province, China

Sanitation Marketing in Cambodia (Rosenboom, Jacks, Kov, Robert, Baker; 2011)
A pilot sanitation marketing program was launched in Cambodia to make affordable, desirable latrines available through market channels. Option design, contractor training, awareness raising, and marketing resulted in a branded, low-cost pour-flush latrine. Trained suppliers have sold more than 7,400 units 22 months after project inception. Planned next steps include expanding technology choices (still lower costs, and/or suitable for challenging physical circumstances), developing stronger linkages with micro-credit schemes and developing approaches for scaling up the approach. Published in Waterlines, Volume 30, Number 1.
 Academic PublicationVideo

Sustainability of Rural Sanitation Marketing in Vietnam: Findings from a new case study (Devine, Sijbesma; 2011)

A research study conducted by WSP found that coverage had continued to grow in pilot communes two years after the end of a rural sanitation marketing pilot project. Promoters had continued their activities, albeit at a lesser intensity level, and many suppliers had expanded their product range and customer base and reported increased revenues. Lack of tailored information on more affordable toilet construction and financing were the main barriers for those who had not yet built a sanitary toilet, despite having been reached by the pilot project. Published in Waterlines, Volume 30, Number 1.
 Academic Publication

Managing the Flow of Monitoring Information to Improve Rural Sanitation in East Java (WSP: Mukherjee; 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


Understanding Sanitation Options in Challenging Environments (WSP:  Djonoputro, Blackett, Rosenboom, Weitz; 2010)
Across Southeast Asia many of the poorest communities live on marginal land or over water. Owing to adverse geographic and climatic conditions in these areas, neither conventional nor most well known ‘alternative’ sanitation options are feasible at affordable prices for poor communities or poor governments. A recent study in the region has started to develop a typology of challenging environments for sanitation as a means to: assess the scale of the challenges; understand the specific issues involved in improving sanitation; identify, develop or improve sanitation technologies to cope with different environments; and to disseminate the results in the study countries, regionally and beyond.

 Academic Publication

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 Paper (High Res)Technical Paper (Low Res) | Research Brief |  Presentation Video

Findings from the Impact Evaluation Baseline Survey in Indonesia (WSP: Cameron, Shah; 2010)
In East Java, baseline data was collected from nearly 2,100 households in the Global Scaling Up Rural Sanitation project area. Among other findings, the survey 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 intervention. The baseline surveys lay the groundwork for the impact evaluation (IE) component of the Global Scaling Up projects, designed to establish the causal impacts of handwashing with soap behavior change and sanitation improvements on specific health and welfare measures, generating robust evidence on a cross-country basis. Learn More
 Technical Paper |  Research Brief

Overview: Scaling Up Rural Sanitation in East Java, Indonesia (WSP: Murkherjee; 2010)
In a country where rural sanitation access rates remained stagnant at under 40 percent for recent decades, WSP has partnered with local and national government and the local private sector to end open defecation and increase access to basic sanitation at large scale. Using sanitation marketing approaches, sanitation has suddenly become a profitable, fast growing business. A presentation, paper, and video share the project approach and lessons learned to date.
Learning at Scale (2009) 
 Field Note  |  Video  |  Presentation Slides

Sanitation Marketing as an Emergent Application of Social Marketing: Experiences from East Java (WSP: Devine; 2010)
The article showcases how the Global Scaling Up Rural Sanitation Project is seeking to overcome the challenges in East Java where innovative formative research, social franchising, product branding, and integrated communications using mass media are being introduced. Published in Cases in Public Health Communication and Marketing, Volume 4. 

Academic Publication

The CLTS Story in Indonesia: Empowering Communities, Transforming Institutions, Furthering Decentralization (2009)
This paper traces the history of CLTS in Indonesia, discussing its potential as a tool not only to improve sanitation but also to support the broader decentralization agenda in the country. Published as part of the Institute of Development Studies (IDS) research project Going to Scale? The Potential of Community-Led Total Sanitation. 


Communication Tools Menu for Implementing a Sanitation Marketing Plan (WSP; 2008)
WSP developed a communications toolkit to collect the strategies, materials, and campaign routes from the project’s work in East Java. Including radio spots, posters, and competitions, the broad menu of communication tools targets diverse audience groups.

Regional Focus: Latin America and Caribbean

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

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

Regional Focus: South Asia

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.
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.
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).
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. 
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.

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.


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

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.


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.

Long Term Sustainability of Improved Sanitation in Rural Bangladesh (WSP: Hanchett, Krieger, Kahn, Kullmann, Ahmed; 2011)
Analysis of 53 Union Parishads, that were declared 100% sanitized/Open Defecation Free almost five years ago, shows that 90% of households have 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 to reach 100% sanitation coverage and cessation of open defecation revealed little variation in sustained outcomes in these 53 Union Parishads.
 Technical Report | Research Brief:  EnglishFrench | Webinar

Scaling Up Rural Sanitation: Findings from the Impact Evaluation Baseline Survey in Madhya Pradesh, India (WSP: Salvatore, Patil; 2011)
Baseline data collected from approximately 2,000 households in two districts in Madhya Pradesh, India. indicate a substantial need for sustained improvements in rural sanitation in Madhya Pradesh: eighty percent of households openly defecated and few had access to improved sanitation.  High prevalence of related illnesses such as diarrhea (15%), acute lower respiratory infections (12%), and parasitosis (16%), were found among young children. The baseline surveys lay the groundwork for the impact evaluation (IE) component of the Global Scaling Up projects, designed to establish the causal impacts of handwashing with soap behavior change and sanitation improvements on specific health and welfare measures, generating robust evidence on a cross-country basis.
 Technical Paper

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

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

Overview: Scaling Up Rural Sanitation in India (WSP: Kumar; 2010)
This presentation offers a summary of WSP's work with local and national governments and the local private sector to end open defecation and scale up rural sanitation in the states of Himachal Pradesh and Madhya Pradesh, India. Presented June 2010.

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:  English / French

Community Led Total Sanitation in Bangladesh: Chronicles of a People’s Movement (2009)
This report traces the development and history of CLTS in Bangladesh, including the political economy and challenges to scaling up. Published as part of the Institute of Development Studies (IDS) research project Going to Scale? The Potential of Community-Led Total Sanitation. 

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