PREPARED FOR THE WORLD BANK BY W.S.ATKINS INTERNATIONAL LTD IN ASSOCIATION WITH ABT ASSOCIATES INC

Transcription

1 THE WORLD BANK State of the Art Hygiene and Sanitation Promotion Component Design of Large-Scale Rural Water Supply and Sanitation Programs PREPARED FOR THE WORLD BANK BY W.S.ATKINS INTERNATIONAL LTD IN ASSOCIATION WITH ABT ASSOCIATES INC. CARE INTERNATIONAL & THE LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE April 2005 This report was funded by the Bank-Netherlands Water Partnership, a facility that enhances World Bank operations to increase delivery of water supply and sanitation services to the poor (for more information see The views and opinions expressed in this report are those of the author(s) and do not necessarily reflect those of the World Bank, its Executive Directors, or the countries they represent. Any references provided in this document to a specific product, process, or service is not intended as, and does not constitute or imply an endorsement by the World Bank of that product, process, service, or its producer or provider.

2 EXECUTIVE SUMMARY This report is undertaken as part of the Word Bank State of the Art Hygiene and Sanitation Promotion Component Design of Large-Scale Rural Water Supply and Sanitation Programs, and is the main strategy document for the Ethiopia section of the project. This strategy report describes the results of an ethnographic survey carried out as part of this study and proposes a hygiene education and sanitation promotion strategy. Situation analysis Previous sanitation and hygiene projects carried out in Ethiopia have typically been unsuccessful. It is important that the reasons for this and the current situation in Ethiopia are understood before further sanitation and hygiene promotion work in planned. An initial ethnographic survey has therefore been carried out in sample woredas and villages to collect initial baseline information and to refine the methods proposed for the strategy. The ethnographic survey explores the view of rural dwellers participating in the RWSS, and develops an understanding of the current logic and reasoning behind communities thinking regarding water uses, hygiene and sanitation. There are a number of ongoing hygiene and sanitation programs funded by government departments and NGOs and these are reviewed and discussed in this report. The results of the ethnographic survey and the work from other projects are used to describe the current situation. Strategy formulation The strategy proposed focuses on changing behaviors including the management of water at the source and in the home, the use and maintenance of latrines, hand washing and personal hygiene. It facilitates the fourth objective of the Rural Water Supply, Sanitation and Hygiene Program: to maximize health benefits by integrating water, sanitation and hygiene education interventions, including the establishment of hygiene education and latrine construction capabilities at village level. An incremental approach to improving priority behaviors is used rather than the promotion of a large number of perfect hygiene behaviors, by assisting community members to identify and analyze problems and develop realistic solutions. The strategy reinforces existing behaviors (where beneficial) or helps people to develop specific, locally appropriate alternatives to existing behaviors. A multichannel approach is used with women taking a leading role but also involving men and children (both in and outside school), and starting with the Woreda Councilors and staff. The process implies that community members will monitor progress themselves, identifying problems and adjusting and improving solutions. The key elements of the strategy are: Engaging commitment and support for hygiene education and sanitation from leaders and influential people at the woreda, kebele and community levels Identifying the relationships between behavior, the environment and health Page i

3 Focusing on behaviors rather than messages or hardware targets, and on a few key behaviors rather than a large number of perfect behaviors Using a multi-channel approach to achieve community participation (decisionmaking) in all aspects problem solving, design, development of interventions, extension, monitoring, etc. Emphasizing the role of voluntary community promoters making regular household visits to ensure community-wide participation and action to improve the environment and health for all community members Basing interventions on the local context (existing beliefs, norms and practices) Marketing the convenience and privacy as well as the health benefits of latrines Developing and implementing a behavior-based monitoring and improvement system for refining the intervention. Implementation The proposed strategy for the project is broken down into activities at regional, woreda and community levels. Regional level Although funding for the program will be focused through the Regional Bureau of Water, it is proposed that at regional level the program should be managed by a cross-sectoral team, including members of the bureaux of health and education and others with an interest to ensure ownership and support for the scheme across all the functions involved. It is proposed that Regional Bureaux of Water and Health work with local radio stations to incorporate water, hygiene and sanitation themes in local language soap operas. Woreda level To promote the value of hygiene education and sanitation, representatives of woreda councils and staff will be encouraged to visit a woreda where a successful program of HSP has been implemented, and to experience firsthand through observation and enquiry, the benefits accruing to the population. At each woreda a baseline survey will be carried out prior to the start of hygiene and sanitation promotion to determine the existing situation and to increase understanding of the various factors that foster or limit the adoption of improved hygiene and sanitation behavior. The surveys will be carried out in three kebeles involving a representative sample of households in each. A suggested questionnaire is included as an appendix to this report. Woreda staff will identify local service providers who can supply items such as latrine slabs. Community level At a community level a multi-channel approach will be used working with various groups within the community. Female volunteers will be appointed and trained as community promoters to facilitate peer group meetings and make household visits. A participatory planning process will be led by the WASHCO in each community using PHAST tools. Regional consultants and woreda teams will monitor the planning process to ensure that participatory approaches are successfully used. Page ii

4 Work at community level will be split into two steps: planning and construction. In the planning step, which will take 3-6 months to complete, the community identifies and analyses the problems associated with unsafe and inadequate water supply, and poor hygiene and sanitation behaviors, and develops solutions. These solutions are incorporated within a facilities management plan, which is approved by the whole community and submitted to the woreda for approval and funding. Hygiene education and sanitation promotion will be led by the WASHCO and promoters. Community promoters will facilitate group meetings, make household visits and support water, hygiene and sanitation activities at schools and health posts. A set of community-specific behavioral objectives and the steps and timing for achieving them will be developed by the community. Household visits are an important part of the program ensuring that members of the community who would not normally attend meetings are involved. The promoter will assist the household to develop and implement a plan of action to address the poor hygiene behaviors prioritized by the community. Visits should continue through the program and follow up period to help to maintain changes in hygiene behavior. School and health post water and sanitation facilities need to be included in the community plans and hygiene and sanitation education in schools may include group discussions, role-play, cleaning of the school compound, personal hygiene inspections and formation of sanitation clubs. The second step of the strategy and community level involves construction of water supply facilities and latrines. In this step additional training of the WASHCO and community promoters will be carried out, further group meetings on hygiene and sanitation will be held and household visits will continue. Progress on achieving behavioral objectives will be reviewed. As access to water and sanitation facilities improves, the potential for improvements in hygiene behavior increases and this is a critical period for hygiene education and sanitation promotion. For many communities in Ethiopia, the latrine is a poorly defined product with limited availability, an unknown price range, and no obvious benefits. Previous surveys have found that the ability and willingness to pay for latrines is limited. These issues will need to be addressed. Selection of appropriate latrine design should take account of local conditions, expectations, costs and availability of materials. Potential designs are discussed in the proposed strategy. The strategy will be to invest in creating a demand for latrines through promotion of the health benefits, convenience and privacy of latrines primarily to women but also to men, and then marketing a series of latrine options that people want and are willing to pay for. Schools and health posts will be used as sites for demonstrating different latrine designs. During the construction phase the Woreda RWSS Team will organize five-day sanitation campaigns in the communities, with local service providers giving technical advice on latrine construction and delivering materials. Subsidized Sanplats will be offered during the first stages of the project, the intention being to set up a system that offers an initial incentive but has potential to be sustained beyond the subsidy period. Page iii

5 Monitoring and evaluation The report sets out a list of possible behavioral objectives (in Appendix 8) which could be used as indicators for monitoring and evaluation. These objectives include: 1. Safe water (source protection, water storage and handling) 2. Hand washing (use of soap/ash, washing before contact with food, after contact with feces) 3. Latrine use and feces disposal (defecation in hygienic latrines) 4. Environmental cleanliness (water point, latrine and compound cleanliness and maintenance) 5. Personal hygiene (face washing, bathing and clothes changing) 6. Food hygiene (storage and cooking) 7. Diarrhea management (treatment and feeding) In practice community-specific objectives and priorities, and the steps and timing for achieving them need to be worked out by each community through the participatory process facilitated by the WASHCO and the community promoters. Page iv

6 CONTENTS 1. INTRODUCTION SITUATION ANALYSIS Baseline Survey Current Government and NGO Programs 9 3. STRATEGY DEVELOPMENT AND PROJECT IMPLEMENTATION Overview, Key Elements and Sequence of Activities Activities at the Regional Level Initial Activities at Woreda Level Activities at Community-Level HSP strategy cost of implementation Roles and Responsibilities of Stakeholders 31 LIST OF APPENDICES...32 Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 Ethnographic Survey UNICEF Sanitation Program Stepped Approach at Woreda and Community Levels Estimated Timing of Activities - First Project Cycle Consultations with Regional Health Bureaux on Draft Strategy Initial Household Survey Community Data Collection, Problem Analysis, and Planning Behavioral Objectives Page v

7 Acronyms and Abbreviations FMP HSP LSP NGO PHAST PMT PRA RWSEP RWSH RWSS RWSSHP UNICEF VHC VIP WASHCO WB WHO WSG Facilities Management Plan Hygiene and sanitation promotion Local service provider Non Governmental Organization Participatory Hygiene and Sanitation Transformation Program Management Team Participatory rural appraisal Rural Water Supply and Environmental Program Rural Water, Sanitation and Hygiene Rural Water Supply and Sanitation Rural Water Supply, Sanitation and Hygiene Program United Nations Children Fund Village health communicator Ventilated improved pit Water, sanitation and hygiene committee World Bank World Health Organization Woreda support group Page vi

8 1. INTRODUCTION This report is undertaken as part of the Word Bank State of the Art Hygiene and Sanitation Promotion Component Design of Large-Scale Rural Water Supply and Sanitation Programs, and is the main strategy document for the Ethiopia section of the project. The objective of the State of the Art Hygiene and Sanitation Promotion project is to foster effective implementation of the sanitation and hygiene components of large-scale rural water supply and sanitation investment projects. The project is to look at how to improve the design and implementation of hygiene and sanitation promotion (HSP) in large-scale rural water supply and sanitation (RWSS) projects, based on examination of the situation and experience in Uzbekistan, Ethiopia and Sri Lanka. The ultimate output of the project is a guidance manual for use by World Bank (WB) staff and implementing agencies, which will provide information on best practice for design of HSP elements for WB -assisted RWSS projects. The project team is led by WSAtkins International in association with Abt Associates Inc., CARE International and the London School of Hygiene and Tropical Medicine. The current situation in Ethiopia regarding hygiene and sanitation in the rural areas of the country and the work of various agencies concerned with poor hygiene and sanitation were discussed in the Inception Report issued in December This strategy report describes the results of an ethnographic survey carried out as part of this study and presents a hygiene education and sanitation promotion strategy. The report is structured as follows: The situation analysis uses the results of the ethnographic survey, together with the results of two other studies, to analyze the baseline situation and examines the various existing government and NGO programs, with comments on the approaches adopted and their relative merits; The strategy development and project implementation proposes a detailed hygiene education and sanitation promotion strategy and discusses the roles and responsibilities of stakeholders implementing this strategy within the World Bankassisted Rural Water, Sanitation and Hygiene Program. Page 1

9 2. SITUATION ANALYSIS 2.1 Baseline Survey Key parameters and indicators of hygiene and sanitation have been identified from the findings of the ethnographic survey 1 carried out as part of this study (see Appendix 1), and the findings of two other studies carried out by WaterAid 2 and the FINNIDA-assisted Rural Water Supply and Environmental Program (RWSEP) 3 respectively. By understanding the knowledge, attitude, and practices of a community as they relate to these indicators, hygiene and sanitation interventions may be focused to meet the particular needs of a specific community. The indicators can serve as a baseline when entering the community and later, when the interventions are complete, as a means of identifying changes in knowledge, attitudes and practices. This section presents and discusses potential key parameters and indicators Water source and use One of the biggest challenges for rural Ethiopians is the scarcity of water. They raise the issue as an indicator in nearly all conversations about livelihoods and poverty Knowledge of safer versus less safe water sources Community members are able to differentiate between safer and less safe sources. Sources that are identified as safer included protected springs and protected hand dug wells. Sources that are identified as less safe include unprotected wells, unprotected springs, and rivers Water for drinking In general, there is a preference to use the cleanest water available for drinking. The ethnographic study shows that when available, there is a strong preference to use water from a protected spring for drinking. When a protected spring is not available, an unprotected spring is used most often as a source of drinking water. However, water source preference is sometimes dependent on the proximity of the source as well as the perceived cleanliness. Some survey respondents mentioned that safe water sources were further away from the compound and less convenient. WaterAid cites an example of young boys quenching their thirst at school by drinking from the nearby river that they know is polluted and unsafe because it is closer and more convenient than the safer water near their home. 1 CARE Ethiopia, Ethnographic Survey in Dera Woreda, Amhara Region and Tolla Woreda, Oromia Region carried out February 24 March 1, 2004 and March 16 22, 2004 respectively see Appendix 1. 2 WaterAid Ethiopia, Sanitation Preference, Draft for comment, November Amhara Bureau of Health and Rural Water Supply and Environmental Program, Assessment of Household and School Water Supply, Sanitation and Hygiene Status in Selected Woredas of East Gojjam and South Gondar Zones, Amhara Region, October Page 2

10 Water used for food preparation and cooking Similar preferences are shown for water used in preparing and cooking food. In general and when available, water from cleaner sources, such as protected springs, is used to prepare and cook food. In the areas sampled, there is very little difference between the sources used for gathering drinking water and gathering water for cooking and preparing food Water used for cleaning, washing, and personal hygiene Less clean sources are acceptable for cleaning, washing, and personal hygiene. In this case, the nearest source is preferred including river water. However, personal hygiene practices are quite limited and in many cases, this appears to be the result of prioritizing the available water for drinking, food preparation and cooking Water used for watering livestock Livestock are watered at the nearest water source where adequate quantity is available. River water is frequently used for this purpose Water use during the dry season During the dry season, water becomes scarcer, and the distance to a functioning water source may increase. Although preferences still exist for cleaner sources, the time to the water source often becomes the dominant factor in determining which water source is used for all purposes in the dry season Who fetches water? Much of Ethiopian society demonstrates a strongly dichotomized division of labor. Traditionally, men were responsible for warfare and hunting. Their duties have since been amended to include most cultivation, harvesting, and threshing. Women are responsible for milking and sometimes herding the cattle, cleaning the house, repairing walls and floors, cooking, and fetching water. Thus, in the vast majority of cases, it is the women of the household who are responsible for collecting water. In some cases, men who collect water are highly stigmatized. However, it is generally accepted that a man fetches water for the household when his wife is sick and unable to fetch the water herself. It was suggested in some of the focus groups conducted for the ethnographic study that the stigma of men collecting water is decreasing in some communities, although women still collect the vast majority of the water even in these communities. Additionally, the stigma is decreasing in some of the communities supported by WaterAid projects that have intentionally worked to involve men in watercollection. Children of both sexes also help to collect water. Children help to fetch water mostly in cases where the distance to the water source is very great or if a mother is unable to fetch water. In these cases, children often miss school. Page 3

11 Containers used to fetch and store drinking water Vessels are seen to vary by region. In the villages surveyed in Oromia, jerry cans are used by nearly everybody. In the Amhara villages very few people use jerry cans. Instead, they used a locally available clay pot, known as a maseru, to collect and store water. These results are similar to those reported by the RWSEP. The size of the containers used range from about 20 liters to as much as 70 liters. Jerry cans typically have handles and narrow mouths, thereby reducing the risk of inserting hands into the collected water. Maserus have wider mouths, and hands and cups can be inserted. RWSEP reported that nearly 98 percent of households with traditional clay pots transferred water from storage by dipping and 60 percent put the cup used for dipping on the floor. Experience with similar pots in Kenya suggests that evaporation from the external surface has a cooling effect and they are likely to be preferred to jerry cans for this reason. Further research is needed on how to make maserus safer. Most water containers of all types were seen to have lids protecting the water inside. The cleanliness of the water vessel was at times a sensitive issue. In these cases, the head of household suggested that the way the vessel was kept was a family matter and not the business of the interviewer Time spent fetching water The time spent fetching water is a function of the distance to the water source, the time spent waiting in line and filling containers, and the number of times per day water is fetched. Among those surveyed in the ethnographic study, the majority walks between 15 and 30 minutes each time they collect water. The distance increases during the dry season. The majority of those interviewed in the ethnographic survey, fetch water two or three times per day although several fetch water four or more times. This represents one to three hours per day collecting water or 10 to 20 percent of their total workday. WaterAid reports that prior to their intervention in communities, the average time to fetch water during the dry season was over 6 hours, which encompasses nearly half of the available daylight hours. This information should be considered when designing an intervention for several reasons. First, it should be a priority to decrease the amount of time spent collecting water so that that time can be used in other ways. Second, many of the successful water and sanitation committees in WaterAid projects have women as key members. It is difficult to expect women to participate fully in the activities of the committee if they are also required to spend 20 percent of their day collecting water Water treatment Nearly all of those surveyed in the ethnographic survey suggested that they do nothing to treat their water. The RWSEP reported that in some parts of Amhara, over 90 percent of households use simple sedimentation, i.e. allowing sediment to settle out before using, but concluded that this practice does not in itself demonstrate knowledge on how to reduce the presence of pathogens. Page 4

12 Water tariffs Households do not pay for water in any of the areas surveyed in the ethnographic study; provision of water and latrines is regarded as the responsibility of the government. However, in other areas of the country, WaterAid reports that it is normal to pay 10 cents for 75 liters of water. While most people are able to pay this tariff, it is often insufficient to adequately maintain the water supply. WaterAid has spent considerable time and effort determining a fair price for water that will allow the system to be properly maintained and is within the reach of people served by the system. WaterAid has experienced conflicts between the community around a water source and other communities that receive water from the source. Communities with a source often argue that the water belongs to the community in which the source is located, and people in that community should not have to pay for water, even though there are costs associated with developing and maintaining the water supply. Source communities also argue that the water should not be distributed to those outside their community, or that those outside their community should be charged significantly more for the water Hygiene Hand washing behavior Hand washing behavior is generally dictated by the amount of water available. It was generally found that out of 20 to 40 liters of water per household, only 5% is allocated to washing hands and performing other acts of personal hygiene. Soap is rarely present in households. In a few cases, ash is used instead of soap. The ethnographic study found that the majority of adults wash their hands before meals. Fewer, but more than half of the adults surveyed, wash their hands after the meal, and the majority of adults wash their hands in the morning. Children showed similar hand washing practices, with the majority washing their hands before a meal. About one third of children surveyed wash their hands after the meal and about the same number wash their hands in the morning. WaterAid reports that hand washing after defecation is not practiced. However, if defecation is followed immediately by eating, hands are washed before eating. It was noted that observant Muslims wash their hands after defecation as a religious act of ablution. It was also reported that women often wash, even with just water, before handling food, and people who live closer to an urban area are more likely to use soap than those who live in more remote areas. The RWSEP reports that 75 percent of those interviewed in a survey of two woredas in Amhara claimed to wash their hands after defecating. Further, 99 percent reported washing their hands before a meal, 82 percent each morning, and nearly 64 percent after a meal. About 51 percent reported washing their hands before dipping stored drinking water. In two other Amhara woredas, hand-washing behaviors were reported to be less frequent. The RWSEP report acknowledges that some of these percentages appear unrealistically high. Those carrying out the survey were unable to observe handwashing behavior, and it is possible that those interviewed were eager to please the Page 5

13 enumerators and so gave false answers. However, these data should not be entirely discounted. The RWSEP suggests that although those interviewed may not wash their hands to the extent reported, they appear to understand the importance of hand washing Hand washing facilities in schools RWSEP found that children often receive messages in school about proper hand washing techniques but there is no hand washing facility in many schools where children can practice. Also, many teachers are not good role models Washing clothes The ethnographic study reported that the majority of people wash their clothes in the river Bathing Bathing practice is highly dependent on the quantity of water available. The ethnographic survey found that most respondents bathe between once a week and once a month. However, about 15 percent of those surveyed in Amhara reported bathing only once every six months. These results are echoed in the RWSEP report. Frequency of bathing varies by woreda with some woredas reporting much more frequent bathing than others. It is not clear why these differences occur. It is possible that there are different cultural norms between the woredas in the Amhara region. It is also possible that water is more readily available in some woredas than others. The differences in the frequency of bathing should be further examined, and the differences between woreda practices better understood. In addition, different preferences were observed for the location of bathing. The ethnographic work suggested that people in Oromia prefer to bath in their house, with the majority of those surveyed doing so. There was considerable difference reported between the intervention kebele (that had received hygiene education) and the control kebele (no previous hygiene education) in the Amhara region. While there was strong preference for bathing in the river, with 83 percent of surveyed members of the control kebele reporting bathing by the riverside, only 43 percent of the intervention group reported bathing in the river. Fifty-three percent of those surveyed from the intervention group reported bathing in the house, whereas only 4 percent from the control group reported bathing in the house. Strong taboos are associated with being seen naked in public. It is possible that because water may have been more available in the intervention group, they were eager to move their bathing practices inside and out of view of their neighbors Reported diseases In the ethnographic survey, diarrheal diseases and diseases associated with lack of washing, e.g. eye infections, were reported as the most frequent diseases among young children. In some cases, malaria was also reported as the most frequent disease, and was perceived to be associated with new water projects developed by the government. Page 6

14 When the last Demographic and Health Survey 4 was carried out in 2000, 37 percent of infants in the age group 6-23 months had diarrhea in the preceding two weeks. Dehydration from diarrhea is a major cause of death in infancy and childhood. Death is often not the result of diarrhea alone but the synergistic effect of diarrhea, severe anemia from worm infestations (another result of poor hygiene and sanitation), nutritional deficiencies and opportunistic infections. The combination of conditions and infections is not only dangerous for children under five but also for people living with AIDS. This makes diarrhea prevention and management a high priority Cause recognition In several cases, people identified the water source as a cause of disease in their children. In other cases, there was understanding of germ theory and the fecal-oral route. This is important because it suggests that if safer options are presented, there are community members who will readily understand the potential for reducing illness in children Sanitation Household latrines Among the different surveys, there is wide variation in the coverage of household latrines. Coverage varies from 70 percent in a community that had received hygiene education to just 4 percent in a community surveyed by the RWSEP. All household latrines surveyed were traditional pit latrines, some with plain timber and mud slabs and others with 60cm x 60cm concrete squatting slabs Barriers to having a latrine In many cases, it was reported that the supplies to construct a latrine are unavailable or too expensive to purchase, and therefore unattainable. Additionally, WaterAid found that, except for the case of the traditional pit latrine, the skills needed to construct a latrine are beyond those of community members Sanitation preference In most cases, WaterAid found traditional pit latrines with 60cm x 60cm concrete squatting slabs (sanplats) to be the preferred latrine. Community members fear traditional timber and mud slabs because they are subject to rot and termite attack and can give way. Because sanplats are constructed with concrete, community members do not worry about the platform breaking. Additionally, the small hole is considered to be safer for children, and the cement slab is easier to keep clean and can be moved to a new pit when the old pit is full. WaterAid found that plastered walls are not as popular as walls that provide more ventilation. Latrines are especially appreciated during the wet season when they are considerably more comfortable than open defecation. 4 Ethiopia Demographic and Health Survey 2000, Central Statistical Authority, Addis Ababa Page 7

15 Open defecation There is a tradition of open defecation in Ethiopia, and it is the norm in households that have no latrine. WaterAid found that, even in households with a latrine, household members still sometimes practice open defecation. In these cases, the latrine was being saved for the wet season when it would be more comfortable than open defecation. There is a perception even amongst the educated middle classes in Ethiopia that openair defecation in rural areas is a relatively harmless practice as long as it is practiced away from the household. There are no fixed places set aside for defecation and men in rural areas use bushes, wooded areas and fields during the dry season and around the fence of their plot during the rainy season. There is shame for both men and women if they are spotted defecating but men have more opportunities to seek out privacy further from the household. A woman does not have time and opportunity to defecate far from the household. She uses the backyard around the fences at dawn and dusk. Older children also use the fence line but young children defecate indiscriminately, anywhere in the compound, and there is no serious tradition of training them where to defecate and how to clean themselves Odor Among the reasons given for preferring open defecation is the belief that the odor associated with defecation that comes from a latrine causes respiratory diseases such as asthma, cough, or flu. Because many latrines are poorly ventilated and have a bad odor in the superstructure, people cover their mouth and nose while using them, making latrine use both difficult and uncomfortable Advantages of latrines WaterAid notes several perceived advantages of latrines: Disease reduction users noted that reduction of diarrhea and trachoma is associated with latrine use. This perception is important, as it is a message that can be used in the promotion of latrines. Comfort, time, and privacy latrines were reported on several occasions to be more comfortable, especially during the rainy season. Additionally, when talking about household latrines, people enjoy being able to take the time necessary to defecate without worrying about people waiting to use the latrine when they have finished. Most people enjoy the privacy provided by latrines. This is especially true for women for whom household latrines make it possible to defecate as needed, rather than waiting until sundown. Teenage girls also find the privacy desirable. It makes menstruation easier to manage and hide from young men. When latrines are reserved for girls at school, young women are more likely to attend school as they can defecate without the fear of their male counterparts spying on them. Page 8

16 Who uses the latrine? When latrines are available, men use them but they also continue to practice open defecation. Women are more likely to consistently use a household latrine as it allows them to defecate as needed, and children over the age of five or six also tend to use the latrine. Younger children use a potty, which is then emptied into the latrine. In some cases, people view the feces of children under age two as harmless because the child does not eat solid foods. In other cases, it was acknowledged that the feces of infants are equally likely to spread disease as those of older children and adults. In these cases, more care is taken in disposing of infant feces Decision to construct the latrine The husband and head of the household normally makes the decision to construct a latrine, and is responsible for the construction. WaterAid reports that when competition between different parts of the community is used to promote latrine construction, people construct a latrine to avoid a feeling of failure. According to the ethnographic survey, latrines in some woredas have been built at the direction of informal leaders Cleanliness of the latrine Women are responsible for cleaning household latrines. Latrines with concrete slabs are generally cleaner than latrines made from other materials, mostly because the concrete slab is easier to clean. Private, household latrines are more likely to be clean than public latrines because there is frequently a lack of clarity as to who is responsible for cleaning the public latrine or, if the responsibility is clear, there may be little incentive. Latrines at schools are often in bad condition. Although children are taught in school how to use the latrine, it may be an uncomfortable and unpleasant experience because of lack of ventilation and cleanliness. In response to this situation, children may revert to open defecation or, if they are girls, drop out of school so that they do not have to use the school latrine. 2.2 Current Government and NGO Programs Health extension workers As part of the Health Sector Development Plan II, the Ministry of Education is training approximately 30,000 women over the next five years as health extension workers on behalf of the Ministry of Health. Women selected for the training must have completed 10th grade. On completion of their one-year course, the health extension workers will be permanent government employees trained in preventive and promotive health measures, who will extend health services to communities, carry out home visits that make the health extension package program accessible to communities and households 5 and work with voluntary community health workers, where they are present. The Health Extension Package referred to is actually 16 packages, seven of which cover hygiene and environmental sanitation. These are excreta disposal, solid and liquid waste disposal, water quality control, food hygiene and safety measures, 5 Federal Ministry of Health, Health Extension Package Implementation Guideline, Addis Ababa, February 2004 Page 9

17 proper housing, arthropods and rodent control, and personal hygiene. The packages provide details of the subject areas in textbook form but do not indicate the methodologies that the extension worker will use to increase awareness and change behavior in the communities. The first batch of trainees (including, for example, about 700 from Amhara Region, 750 from Oromia and 400 from Tigray) will graduate in June 2004 and return to their woredas where two will be assigned to each kebele and deployed at health posts. This is a substantial commitment by the Government of Ethiopia to extending preventive health measures to communities and households, and particularly women. (The Prime Minister is reportedly following up on the progress of the program.) It is not known how effective this cadre will be if they use didactic methods, and whether they will be service oriented with accountability to the communities. They are likely to be attracted to work with local service providers in the World Bank -assisted RWSSHP. UNICEF has expressed concern about this possibility because at least one region is not utilizing the sanitation budget provided by UNICEF due to lack of staff and accountability at the woreda level. UNICEF has a budget of $500,000 for this program in FY Hygiene and sanitation training materials At the request of the Ministry of Health, Jima University has been developing training materials for hygiene and sanitation, which are intended to be a standard set of materials for use throughout the country. The materials comprise leaflets (one on hand washing and one on safe water), two flipcharts on environmental sanitation, six posters on flies and rodents, three games (actually participatory tools three-pile sorting, sanitation ladder, and unserialized posters), 57 pictures, radio spots, dramas, songs, two stickers and one logo. The printed materials, particularly the posters, are reported to be elaborate with many messages included in each. This contrasts with materials that are used for participatory processes, which tend to be relatively simple and drawn by local artists featuring topography, buildings and clothing that people are familiar with. The materials have been pre-tested by the Ministry of Health and UNICEF in Oromia, Amhara, Southern Nations, and Tigray. The results were reported at a workshop for Ministry of Health and Regional Bureau of Health staff (IEC and Environmental Health) and NGOs in mid-may The workshop discussed training materials and the PHAST methodology UNICEF UNICEF allocates 29 percent of its water supply and sanitation budget to the health sector (Ministry of Health and Regional Health Bureaux) for environmental sanitation activities, 69 percent of the budget is allocated for water and the remaining 2 percent for Guinea worm eradication. The funds are used for both emergency response and longterm developmental programming with a focus on drought-prone areas. The budget is distributed to all regions. UNICEF channels most of the funds to the regional health bureaux, which train the woreda health staff who work with communities. A five-year operational plan with an ultimate goal of increasing national sanitation Page 10

18 coverage from 17 percent to 30 percent was agreed in 2002 and each year each region is expected to develop its own action plan. 10 percent of the health budget is allocated to the Ministry of Health, mainly for monitoring and providing technical assistance to the regions. The budget allocated from UNICEF and its matching fund from the government is used to finalize hygiene education materials, to train health workers, to produce sanplats (60cm x 60cm concrete slabs) for household use, and to construct school latrines. Project woredas in the largest regions are tabulated in Appendix 2. In , for example, the plan in Tigray is to train 26 environmental health workers, 100 community health workers (volunteers?), and 40 focal persons; form 46 school sanitation clubs; produce 465 sanplats for households use; construct two health institution latrines; and create awareness by distribution of 3,000 leaflets. UNICEF reports achieving 92 percent coverage with traditional latrines in Mota Woreda, Amhara Region. Sanitarians and nurses worked together to form sanitation committees at community level, which mobilized the community for construction of latrines through house-to-house visits. Hygiene education has been provided to community and religious leaders and to the sanitation committee. Latrines were constructed in schools, market places and the homes of community leaders as models for the community. The lack of a latrine prevented a woman from defecating during the day. Women put pressure on their husbands to build latrines, and husbands were also insulted by other men who had latrines. Many residents of Mota did not wait for sanplats to be made available but went ahead and built traditional latrines. Later, sanplats were provided free of charge in accordance with UNICEF policy although the Regional Health Bureau does not want to continue the subsidy, which it does not have the resources to provide. The woreda contracted a local contractor to produce sanplats. An initial mould was provided free of charge to the contractor, who then made his own moulds. The cost of the sanplat was ETB per slab, which was paid by the woreda. There was no standard design for school latrines except that separate blocks were provided for boys and girls. Schools were provided with slabs, concrete blocks for the walls, and corrugated galvanized steel roof sheets. An eight compartment toilet cost about ETB 70,000 including ETB 20,000 contributed as in kind labor and local materials. Communal latrines where each compartment is shared by five families were provided free to the users but they have to pay for maintenance. Under the WHO Healthy Cities Program, public toilets have been also been constructed with assistance from the Regional Bureau of Health in Amhara. There are standard designs for these latrines, and the cost sharing arrangements are 30 percent by the woreda in labor and cash, and 70 percent by WHO. Commercial operation is planned but currently not implemented Ethiopian Red Cross Society The Red Cross is one of the few agencies that use the PHAST methodology for hygiene education and sanitation promotion in Ethiopia. Training in PHAST has been given Page 11

19 directly to over 250 Red Cross community health volunteers selected from communities in three regions 6. The training of trainers lasts ten days, is given in the local language, and adapted to the local situation. Trainees can be literate or illiterate because the tools are picture based. Twelve tools have been adapted to the Ethiopian context. The materials to produce a set of tools cost about $50, which is largely the cost of the plastic sheets for lamination. Each volunteer is given a kit of materials and a sanplat, and required to train three groups of 30 people over 12 weeks. The volunteer meets with each group each week and trains them using a different tool each week. Red Cross zonal staff members are expected to provide back up and support but they lack motivation. The Red Cross has developed selection criteria to ensure that trained volunteers are likely to stay with their communities. The volunteers tend to be men and only a few women have been trained so far but the Red Cross is considering a greater focus on female volunteers because they have greater access in the community. The cadre of trained volunteers is reportedly proving useful not only to the communities but also to other agencies working in the same communities FINNIDA-assisted Rural Water Supply and Environmental Program (RWSEP) The RWSEP has worked in a total of 18 woredas 7 in Amhara Region since For each water point constructed, four or five contact women are trained 8. The woreda health desk personnel provide three days training in personal hygiene, household management, latrine construction, use of latrines, hand washing, and waste disposal. Contact women are also given one day of refresher training each year. Each contact woman is responsible for training the women in 15 households in tap-to-mouth hygiene, general hygiene and sanitation, and house management. After the initial training, the contact woman visits each household once per month and checks the cleanliness and condition of facilities, and provides additional training to the women on a quarterly basis. All contact women are registered with the woreda health desk. The contact women receive a free sanplat slab and a hand-washing container as an incentive. In the future, health extension agents will supervise and guide contact women but overall supervisory responsibility will remain with the sanitation focal person in the woreda. The WATSANCO members and water point caretakers are also trained in hygiene and environmental sanitation, and provide back up and support to the contact women, particularly in encouraging people to construct latrines. Development agents, employed by the woreda in each kebele, are trained in hygiene education and sanitation promotion. They act as Kebele Program Coordinators for implementation of the RWSEP and as secretaries for the Kebele Development Committee meetings. 6 Includes 60 volunteers from Hadiya in SNNP; 66 from East Harerghe, 30 from Illibabur, 30 from Jimma, 42 from Zeway in Oromia; and 34 from Wello in Amhara. 7 Four woredas in South Gondar, eight in East Gojam, four in West Gojam, and two in Awi. 8 A total of 5,910 contact women serving 1,216 communities have been trained. Page 12

20 Woreda staff involved with the program do not go to the field in some cases because the woreda has not provided the matching funds and per diem is not paid. In schools, two periods per week have been set aside for training using manuals prepared by the project. School sanitation clubs have also been set up where trained club members encourage students to adopt improved hygiene practices. Demonstration latrines are constructed at two selected households for each water point and also at the houses of school sanitation promoters. VIP latrines have been introduced at institutions including schools where separate blocks of latrines with handwashing facilities are constructed for boys and girls. The cost of a four compartment latrine is ETB 50,000. At a school visited near Bahir Dar, a water point and VIP latrines have been constructed with superstructure built from concrete blocks. The latrines contrasted sharply with the rest of the school that was constructed from traditional materials except for the corrugated galvanized steel roofing sheets. Waste water from the hand pump was channeled to a small plot where vegetables were grown by students and sold to raise money for the maintenance of the water and sanitation facilities. Household latrines are demonstrated to children in school; they are shown the materials and how to construct a latrine. Ecosan toilets with urine diversion and above ground vaults facing the sun and providing easy access for removal of decomposed feces, have been constructed at the houses of selected opinion leaders in each woreda. This was done in cooperation with a NGO called SUDEA. Demonstration villages with high levels of sanitation coverage have been established by intensive promotion and some free sanplats. Two demonstration villages have failed to achieve significant coverage but the others have had a positive effect on surrounding villages. Ten production centers have been established for sanplats and other slabs. RWSEP has trained private entrepreneurs and provided each one with a locally made steel sanplat mould free of charge. The woredas buy or provide selling space to the entrepreneurs. Slabs are sold at ETB 15 but cost ETB to produce. Production is subsidized by the program but ETB 15 is reportedly too expensive for farmers and sales are slow, although middle income families earning more than ETH 150 per month are purchasing. Individuals wanting slabs can purchase from their local development agent or, failing that, travel to the woreda capital and buy from the producer. (Typical contributions by a community of 50 households for the construction of a water point are ETB 700 in cash and ETB 1,300 in kind. The annual water fee is ETB 6 per household.) Women often walk long distances to a river or other water source to wash clothes. Clothes washing basins are constructed with water points and washing of clothes has increased with a resulting improvement in personal hygiene. On the request of the community, a cattle trough is also constructed outside the fenced water point area. This keeps livestock and their waste away from the water point. Materials developed by the project include posters using the style of the traditional church paintings, sanitation and hygiene training manuals for schools, visual aids, and sanitation brochures. Drama at the community, school and woreda levels, and traditional poems are also used to convey messages. Page 13