BASELINE SURVEY REPORT

Transcription

1 SUSTAINABLE SANITATION AND HYGIENE FOR ALL RESULTS PROGRAMME SNV GHANA COUNTRY OFFICE GHANA 2014 ACCRA, GHANA 0

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3 TABLE OF CONTENTS LIST OF ABBREVIATIONS AND ACRONYMS... 5 OPERATIONAL DEFINITIONS... 6 EXECUTIVE SUMMARY INTRODUCTION COUNTRY CONTEXT SSH4A RESULTS PROGRAMME IN GHANA OBJECTIVES OF THE BASELINE REPORT STRUCTURE METHODOLOGY OF THE BASELINE INDICATORS MEASURED IN THE BASELINE USE OF QIS SCALES (QUALITATIVE INFORMATION SYSTEM) DATA COLLECTION TOOLS USED IN THE BASELINE Household questionnaire Focus group discussions and guided self-assessment SAMPLING TRAINING AND SUPERVISION OF ENUMERATORS METHODOLOGY OF DATA PROCESSING AND ANALYSIS WORK PLAN OF THE BASELINE RESULTS AND FINDINGS ON OUTCOME INDICATORS CHARACTERISTICS OF RESPONDENTS Percentage of male and female respondents Respondents that were head of household HOUSEHOLD CHARACTERISTICS Percentage of female headed households Average household size Percentage of households with children under 2 years Percentage of households with children under 5 years Percentage of households with women or girls in reproductive age Percentage of households with people older than 50 years Percentage of households with people with disability Wealth quintiles by districts Wealth Quintile by female headed households OUTCOME INDICATOR 1: ACCESS TO SANITARY FACILITIES Overall access to sanitary facilities Access to sanitary facilities in the districts Access to sanitation against gender of the head of household Types of toilets found in the programme area Access to sanitary facilities against wealth quintile Discussion on the findings access to a sanitary toilet OUTCOME INDICATOR 2: HYGIENIC USE AND MAINTENANCE OF SANITATION FACILITIES Overall hygienic use and maintenance of sanitation facilities Hygienic use and maintenance of sanitation facilities per district Hygienic use and maintenance of sanitation facilities against gender of the head of household Hygienic use and maintenance of sanitation facilities against wealth quintile Discussion on the findings for hygienic use and maintenance of sanitation facilities OUTCOME INDICATOR 3: ACCESS TO HAND WASHING WITH SOAP (HWWS) Knowledge of critical moments of HWWS Presence of a hand washing station with soap for after defecation Presence of a hand washing station with soap before cooking and food preparation Discussion on the findings for Access to hand washing with soap (HWWS) RESULTS AND FINDINGS ON SUSTAINABILITY INDICATORS SUSTAINABILITY INDICATOR 1: CAPACITY OF LOCAL GOVERNMENTS OR LINE AGENCIES TO STEER SANITATION DEMAND CREATION AT SCALE IN THEIR AREA Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in KEEA Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in Jasikan Capacity of Local Government to Steer Sanitation Demand Creation at Scale in the Nanumba South Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in Nandom Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in Lawra Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in Saboba Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in East Gonja

4 4.1.8 Discussion on the findings for sustainability indicator SUSTAINABILITY INDICATOR 6: IMPROVED SECTOR ALIGNMENT AT LOCAL LEVEL Improved Sector Alignment at Local Level in KEEA Improved Sector Alignment at Local Level in Jasikan Improved Sector Alignment at Local Level Nanumba South Improved Sector Alignment at Local Level in Nandom Improved Sector Alignment at Local Level in Lawra Improved Sector Alignment at Local Level in Saboba Improved Sector Alignment at Local Level in East Gonja Discussion on the Findings for Sustainability Indicator SUSTAINABILITY INDICATOR 10: PROGRESS IN FSM - EMPTYING AND COLLECTION Overall Findings on Safety of Pit Emptying and Collection Other data on environmental safety CONCLUSION AND RECOMMENDATIONS Conclusions of individual districts East Gonja District Jasikan district KEEA District Lawra District Nandom district Nanumba South District Saboba District OVERALL CONCLUSIONS AND RECOMMENDATIONS Overall Conclusions: Overall Recommendations:...56 REFERENCES APPENDIX 1. HOUSEHOLD QUESTIONNAIRE APPENDIX 2. FOCUS GROUP DISCUSSION FORMS SUSTAINABILITY INDICATOR 1 CAPACITY OF LOCAL GOVERNMENTS OR LINE AGENCIES TO STEER SANITATION DEMAND CREATION AT SCALE IN THEIR AREA...74 SUSTAINABILITY INDICATOR 6: IMPROVED SECTOR ALIGNMENT AT LOCAL LEVEL...76 APPENDIX 3 SUMMARY OF OUTCOME AND SUSTAINABILITY INDICATORS

5 LIST OF TABLES AND FIGURES LIST OF TABLES TABLE 1: COMPARISON OF SANITATION DEFINITIONS... 6 TABLE 2: PROJECT REGIONS AND DISTRICTS AND RELATED SANITATION AND SOCIO-ECONOMIC CHARACTERISTICS...10 TABLE 3: TYPICAL QUALITATIVE INFORMATION SYSTEM SCALE...12 TABLE 4: SUMMARY TABULATION OF SAMPLE DESIGN BY COMMUNITIES...14 TABLE 5: KEY ACTIVITIES AND THEIR SCHEDULING...16 TABLE 6: SUMMARY OF FINDINGS ON SUSTAINABILITY INDICATOR TABLE 7: FINDINGS FOR SUSTAINABILITY INDICATOR LIST OF FIGURES FIGURE 1: SSH4A PROJECT REGIONS AND DISTRICTS... 9 FIGURE 2: PROPORTION OF MALE AND FEMALE RESPONDENTS PER DISTRICT...17 FIGURE 3: PROPORTION OF RESPONDENTS WHO ARE HOUSEHOLD HEADS BY DISTRICT...17 FIGURE 4: PROPORTION OF FEMALE HEADED HOUSEHOLDS BY DISTRICT...18 FIGURE 5: MEAN HOUSEHOLD SIZES PER DISTRICT...18 FIGURE 6: PROPORTION OF HOUSEHOLDS WITH CHILDREN U2 BY DISTRICT...19 FIGURE 7: PROPORTION OF HOUSEHOLDS WITH CHILDREN U5 BY DISTRICT...19 FIGURE 8: PROPORTION OF HH WITH WOMEN OR GIRLS IN REPRODUCTIVE AGE BY DISTRICT...20 FIGURE 9: PROPORTION OF HOUSEHOLDS WITH PEOPLE ABOVE 50 YEARS...20 FIGURE 10: PROPORTION OF HOUSEHOLDS WITH PEOPLE WITH DISABILITY...21 FIGURE 11: WEALTH QUINTILE BY DISTRICTS...21 FIGURE 12: WEALTH QUINTILE BY GENDER OF HOUSEHOLD HEAD...22 FIGURE 13: OVERALL ACCESS TO SANITARY FACILITIES...23 FIGURE 14: COMPARING ACCESS TO SANITATION ACROSS DISTRICTS...24 FIGURE 15: ACCESS TO SANITATION AGAINST GENDER OF HH HEAD...24 FIGURE 16: COMPARISON OF KINDS OF TOILET FACILITIES USED BY HOUSEHOLDS IN DISTRICTS...25 FIGURE 17: COMPARISON OF KINDS OF TOILETS USED BY HH ACROSS DISTRICTS...25 FIGURE 18: OVERALL HYGIENE AND SANITATION MANAGEMENT BY RESPONDENT...27 FIGURE 19: COMPARISON OF HOUSEHOLDS PRACTICING GOOD HYGIENE AND SANITATION MANAGEMENT ACROSS DISTRICT...28 FIGURE 20: HYGIENIC USE AND MAINTENANCE OF SANITATION FACILITIES AGAINST GENDER OF THE HEAD OF HH...29 FIGURE 21: REASONS FOR USE AND MAINTENANCE OF SANITATION FACILITIES AGAINST GENDER OF THE HEAD OF HH...29 FIGURE 22: HYGIENIC USE AND MAINTENANCE OF SANITATION FACILITIES AGAINST WEALTH QUINTILE...30 FIGURE 23: KNOWLEDGE OF HAND WASHING MOMENTS...31 FIGURE 24: KNOWLEDGE OF HAND WASHING MOMENTS BY GENDER OF HOUSEHOLD HEAD...31 FIGURE 25: KNOWLEDGE OF HAND-WASHING MOMENTS FOR HOUSEHOLDS WITH AND WITHOUT CHILDREN UNDER 2 AND UNDER FIGURE 26: KNOWLEDGE OF HAND WASHING MOMENTS BY WEALTH QUINTILE...32 FIGURE 27: HOUSEHOLDS DOING HAND WASHING AFTER DEFECATING...33 FIGURE 28: COMPARISON OF HOUSEHOLDS DOING HAND WASHING AFTER DEFECATING WITHIN DISTRICTS...33 FIGURE 29: HOUSEHOLDS DOING HAND WASHING BEFORE FOOD PREPARATION...34 FIGURE 30: COMPARISON OF HOUSEHOLDS WITH HAND-WASHING FACILITY CLOSE TO PLACE OF COOKING/FOOD PREPARATION ACROSS DISTRICTS...34 FIGURE 31: CAPACITY OF LOCAL GOVERNMENT TO STEER SANITATION DEMAND CREATION AT SCALE IN THE KEEA...35 FIGURE 32: CAPACITY OF LOCAL GOVERNMENT AND LINE AGENCIES TO STEER SANITATION DEMAND CREATION AT SCALE IN JASIKAN...36 FIGURE 33: CAPACITY OF LOCAL GOVERNMENT TO STEER SANITATION DEMAND CREATION AT SCALE IN NANUMBA SOUTH...37 FIGURE 34: CAPACITY OF LOCAL GOVERNMENT TO STEER SANITATION DEMAND CREATION AT SCALE IN THE NANDOM...38 FIGURE 35: CAPACITY OF LOCAL GOVERNMENT TO STEER SANITATION DEMAND CREATION AT SCALE IN LAWRA...39 FIGURE 36: CAPACITY OF LOCAL GOVERNMENT TO STEER SANITATION DEMAND CREATION AT SCALE IN SABOBA...40 FIGURE 37: CAPACITY OF LOCAL GOVERNMENT TO STEER SANITATION DEMAND CREATION AT SCALE IN EAST GONJA...41 FIGURE 38: FINDINGS ON IMPROVED SECTOR ALIGNMENT AT LOCAL LEVEL IN THE KEEA DISTRICT...43 FIGURE 39: FINDINGS ON IMPROVED SECTOR ALIGNMENT AT LOCAL LEVEL IN THE JASIKAN DISTRICT...44 FIGURE 40: FINDINGS ON IMPROVED SECTOR ALIGNMENT AT LOCAL LEVEL IN THE NANUMBA DISTRICT...45 FIGURE 41: FINDINGS ON IMPROVED SECTOR ALIGNMENT AT LOCAL LEVEL IN THE NANDOM DISTRICT...45 FIGURE 42: FINDINGS ON IMPROVED SECTOR ALIGNMENT AT LOCAL LEVEL IN THE LAWRA DISTRICT...46 FIGURE 43: FINDINGS ON IMPROVED SECTOR ALIGNMENT AT LOCAL LEVEL IN THE SABOBA DISTRICT...47 FIGURE 44: FINDINGS ON IMPROVED SECTOR ALIGNMENT AT LOCAL LEVEL IN THE LAWRA DISTRICT...47 FIGURE 45: STORAGE OF EXCRETA...49 FIGURE 46: STORAGE OF EXCRETA ACROSS DISTRICTS...50 FIGURE 47: GROUNDWATER SEEPAGE...50 FIGURE 48: METHOD OF PIT-EMPTYING...51 FIGURE 49: DISPOSAL OF EXCRETA...51 FIGURE 50: DISTANCE OF LATRINE TO NEAREST WATER SOURCE...52 FIGURE 51: LOCATION OF LATRINE WITH REGARD TO NEAREST WATER SOURCE

6 LIST OF ABBREVIATIONS AND ACRONYMS BCC CLTS CSOs DEHO DESSAP DGIS DHS DICCS EHA EHO ESP FDG GoG HH KEEA KVIPs MDGs MICS MMDA NGOs NORST ODF QIS RICCs RSMS SLTS SSH4A UNICEF VIPs Behavioural Change Communication Community Led Total Sanitation Civil Society Organizations District Environmental Health Officer District Environmental Sanitation Strategy and Action Plan Directorate General for International Cooperation Demographic Health Survey District Inter-Agency Coordinating Committee on Sanitation Environmental Health Assistant Environmental Health Officer Environmental Sanitation Policy Focus group discussion Government of Ghana Household Komenda Edina Eguafo Abrem Kumasi Ventilated Improved Pits Millennium Development Goals Multiple Indicator Cluster Survey Metropolitan, Municipal and District Assembly Non-Governmental Organisations The Northern Region Small Towns Water and Sanitation Project Open Defecation Free Qualitative Information System Regional Inter Agency Coordinating Committee on Sanitation Rural Sanitation Model and Strategy School-Led Total Sanitation Sustainable Sanitation and Hygiene for All United Nations Children's Fund Ventilated Pit Latrines 5

7 OPERATIONAL DEFINITIONS Household Head of household Shared latrine: Unimproved latrine Improved latrine Improved + fly management Environmentally safe latrine Functional latrine Hand-washing facility for use after defecation: Hand-washing facility for use during cooking/preparing food A person or group of persons living in the same dwelling and providing themselves jointly with food prepared from the same pot. A male or female member of the household recognised as such by the other household members. It is generally the person with economic and social responsibility of the household. Latrine shared by two or more households living closely together. Not to be confused with public latrines which are open to anyone Latrines which (following JMP definition) do not ensure hygienic separation of human excreta from human contact (e.g. pit latrines without slab, hanging latrines, bucket latrines) Latrine which (following JMP definition), ensures hygienic separation of human excreta from human contact (e.g. VIP latrines, pit latrines with slab, composting toilets, flush/our flush latrines). Latrine which (following JMP definition), ensures hygienic separation of human excreta from human contact, and has a functioning water seal or lid covering the squat hole. Latrine which (following JMP definition), ensures hygienic separation of human excreta from human contact, has a functioning water seal or lid covering the squat hole, and is located at least 10 meters from a groundwater or surface water source. Latrine with either a functioning water seal or a lid that is in use and that completely covers the squatting hole so that rodents and or flies cannot get into the pit or tank. A device at a designated place that is used for the washing of hands. Should not be more than 10 metres from place for defecation. A device at a designated place that is used for the washing of hands. Should not be more than 10 metres from place of cooking/food preparation. Table 1: Comparison of sanitation definitions Indicator levels JMP definitions DFID definitions Ghana definition used in the study (for this RBF programme) OD OD OD OD Shared Shared Shared Shared Unimproved Unimproved Improved Unimproved Improved Improved sanitation Improved Improved+ fly management Environmentally safe 6

8 EXECUTIVE SUMMARY This report summarizes the baseline status for access to sanitation, hygienic use and maintenances of sanitation facilities and access to hand washing facilities (with soap) for seven districts in Ghana. It also explains current level of key sector performances that will ensure sustainability of similar interventions across seven districts. It sets the bench mark for measuring change with reference to a new program targeted to improve these basic services and sector performances. The report presents the findings of house to house data collected about basic sanitation disaggregated in to those who don t have facilities and the type of sanitation facilities for those who already have it. It also spells out the different features and current status of the facilities in use. Knowledge and practice of hand washing was also subject of this baseline study. In addition to the basic services the capacity of the sector to steer demand at scale and to align actor s effort was assessed. A sustainable sanitation and hygiene for all (SSH4A) project is planned to be implemented across seven districts of Ghana and has four different components with a purpose of improving public health and quality of life. To this end the project will be contributing to sanitation and hygiene service of the country where the peoples are continuing to suffer from its ill effects. Cholera outbreak is currently active in Ghana where it claims the lives of thousands. It will also add to the global commitment in terms of supporting the country s effort to reach MDG for sanitation and hygiene that is currently far behind. To ensure quality and reliability of the data, the Akvo flow application, integrating use of smartphones, was adopted. Data was geo-referenced and as much as possible supported with pictures of facilities and their owners. The enumerators, mainly district environmental health officers, collected the baseline data between June 24 and July In all a total of 2112 households were surveyed in the seven districts. The demographic distribution of the population in the seven districts show that men headed households are more than women headed and the average household size is about weighted for the seven districts. This figure is twice the national average. Majority (92.7%) of the households in the sampled districts have women and girls in their reproductive ages. The coverage for household toilet facilities was found to be extremely low in all the districts where the study was conducted. 89% of the total respondents interviewed did not have access to any toilet facility for defecating. Only 3.4% had improved toilet facilities, including those which are environmentally safe and with fly management. 3.5% of the sanitation facilities is unimproved and a further 3.7% is shared. The JMP 2012 report revealed 44% of households to have access to shared sanitation in rural areas, however this large difference can be attributed to a difference in definition whereby the JMP counts public latrines as shared latrines but this study considered public latrine as a practice of open defecation. Most households are aware of the importance of hand-washing after defecation and before eating. However, only about 1% of households has a hand-washing facility close to their place of defecation or cooking/food preparation. Therefore it cannot be known if their knowledge about hand-washing is actually put into practise. It was found that in general if a household had a latrine that was in use, it is functioning well. Storage of excreta is done properly in most of the cases (95.5%). Emptying of the latrine is mostly done in an unsafe manner. In 83.9% of the households that had their pit emptied, someone had to go into the pit without wearing full protection. Furthermore in more than 50% of the households, the excreta was thereafter disposed of unsafely. It was also found that about 29.1% of the latrines were built to close to a water source (less than 10m). Along with improving the basic service levels the program has defined objectives that will ensure sustainability and ownership of the achievements maintained during the project period. From similar interventions in other countries a couple of sector actor s capacities are identified to ensure the sustainability and continuity of the envisaged project achievements. Among these are; capacity of sector to steer sanitation and hygiene demand creation at scale in the district; and capacity of district to ensure sector alignment With reference to these sustainability indicators all the seven districts are below the bench mark required to ensure sustainability of development progress in sanitation and hygiene. 7

9 1 INTRODUCTION 1.1 Country Context Located on the west coast of Africa, Ghana shares boundaries with Côte d Ivoire which lies to the west, Togo to the east, and Burkina Faso to the north as well as the Gulf of Guinea (Atlantic Ocean) to the south. The country has an estimated population of million (females 51.2%; males -48.8%) as at 2010 (Ghana Statistical Service, 2012) and is one of the most populous countries in West Africa, second to Nigeria. Ghana is one of the most successful maturing democracies in Africa having seen successful transition of governments from one administration to the other since its fourth republic began in A little over half (50.9%) of Ghana s population is rural based with 49.1% residing in urban settings. The country is divided into ten administrative regions which are subdivided into 216 distinctive Metropolitan, Municipal and District Assemblies (MMDAs). Beyond the MMDAs level, there are 58 town councils, 108 zonal councils and 626 area councils. A large proportion of sub-saharan African populations face challenges with access to improved sanitation facilities. In Ghana sanitation coverage is low. According to the 2014 JMP report, Ghana s total sanitation coverage is estimated at 14%, with 20% of the urban and 8% of rural population having access to improved sanitation (JMP standard). The same report also indicates that estimated drinking water coverage is 19% with 34% of urban and 3% of rural population having access to improved drinking water in 2012 (WHO/UNICEF, 2014). The Government of Ghana has made several attempts at improving the sanitation situation in the country, especially the rural communities, with very little success. As part of Government s effort at addressing rural sanitation gaps, the Environmental Sanitation Policy (ESP), revised in 2010, has adopted the Community Led Total Sanitation (CLTS) approach. The CLTS approach was fully adopted after a successful pilot between 2008 and Evaluation of the CLTS approach concluded that, CLTS could rapidly change attitudes towards sanitation practices and ignite efforts by communities to improve sanitation in their communities, including increasing demand for latrines. UNICEF supported the Government of Ghana (GoG) in 2012 to develop the Rural Sanitation Model and Strategy (RSMS), which outlines strategies for scaling up rural sanitation in the Country. The RSMS requires that there should be supply-side interventions for improved sanitation uptake, to complement Community Led Total Sanitation (CLTS) as a demand-side intervention. The RSMS places the District Assemblies as the pivot for implementation with the active support and participation of local private sector actors. The RSMS is anchored on five pillars. These are Building an Enabling Environment, Strengthening Capacity, Demand Creation, Facilitate Supply and Monitoring and Evaluation. The Millennium Development Goal (MDG) for water and sanitation in Ghana is to halve by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. It is expected that 54% would be using improved sanitation by 2015 whiles 78% will have access to improved drinking water. Ghana continues to be on track to meeting the MDG target for improved drinking water, but the same cannot be said about sanitation. Household latrine ownership has only increased from 7% in 1990, the MDG base year to 14% in Attainment of 54% and 78% by 2015 requires the adoption of major, multiple and parallel interventions if the target is to be achieved. The slow progress being made towards addressing sanitation problems in Ghana require the implementation of alternative interventions which strengthen the CLTS approach. There are a number of interventions currently on-going to improve the sanitation situation including GoG-UNICEF WASH Programme ( ) and the CIDA funded Enhanced Water and Sanitation Services in Schools and Communities Project. Mid 2014, implementation started of SNV s Rural Sustainable Sanitation and Hygiene for All (SSH4A) Results Programme. The SSH4A approach combines work on sanitation demand creation mostly through Community Lead Total Sanitation (CLTS) sanitation supply chains, hygiene behavioural change communication (BCC) and governance and this aligns well with Ghana s sanitation policy. To aid in assessing progress made towards achieving the aims of this project, this report presents findings of a baseline situation of seven districts where the intervention will be implemented to facilitate monitoring and evaluation. 1.2 SSH4A Results Programme in Ghana Sustainable Sanitation & Hygiene for All (SSH4A) is a comprehensive local government-led approach to addressing sanitation problems that, looks beyond the community, and works towards a district-wide coverage. SSH4A focuses on strengthening capacity in four (4) areas key to sustainable and improved sanitation - sanitation demand creation, sanitation supply chain and finance, behavioural change 8

10 communication and WASH governance. According to the SSH4A performance monitoring guideline 2014, the SSH4A programme aims to strengthen the capacities and performance of local governments, NGOs, the local private sector and other stakeholders to improve access to, and quality of, rural sanitation and hygiene in a sustainable manner and at scale. The overarching goal of the programme is to improve health and quality of life of men and women through access to improved health and hygiene practices. The SSH4A Results Programme is being financed by the UK Department of International Development (DFID). It is a multi-country programme being carried out in 9 countries in Africa and Asia. In Ghana, the project is being implemented in seven districts covering four regions as presented in Figure 1. The breakdown of the project regions and districts and the population, demographic, economic activities, water and sanitation situation as well as social infrastructure within each district is presented in Table 1. Figure 1: SSH4A Project Regions and Districts Districts located in the northern part of Ghana have relatively poor conditions compared to those in the south in terms of water and sanitation infrastructure. Nevertheless, all these districts face similar issues of inadequate water supply, inadequate disposal of refuse, indiscriminate defecation as well as inadequate or few sanitation facilities. The common sanitation facilities used in these areas are septic tank latrines, Ventilated Pit Latrines (VIPs), Kumasi Ventilated Improved Pits (KVIPs) and in some cases, water closets. Water sources include surface water, boreholes, hand-dug wells and standpipes. The overall water supply is not adequate especially in the north where water bodies dry up in the dry season, affecting the groundwater level. 9

11 Table 2: Project Regions and Districts and Related Sanitation and Socio-Economic Characteristics Region District District Economic Activities 2 Water and Sanitation 7 Population 1 Central Region Northern Region Upper Region West Komenda- Edina-Eguafo Abrem (KEEA) 144,705 The economy of the district relies on agriculture, fishing, manufacturing, commerce, petty trading and support services 62% of the population have access to treated water Specific hygiene and sanitation problems include widespread and indiscriminate defecation East Gonja 135,450 Predominant economic activity is Agriculture About 5,856 hand-dug wells 49 public toilet facilities, 85 Private latrines and 72 institutional latrines for schools and health care centres. Nanumba 93,464 85% of the district population are into Water supply coverage in the district is South agriculture, 1% into fishery, 3% 68% manufacture, and 11% into other small and informal enterprises. 76.4% of the working Open defecation based on this survey is 96% population is employed Saboba 65,706 Economy is purely rural and dominated by agriculture. Others are commerce and agrobased Sources of drinking water is mainly rain, spring, river and stream small-scale industries 91.1% of households have no toilet facilities Lawra 100,929 Majority of people are into subsistence 404 boreholes fitted with hand pumps. farmers with a few along the banks of the Black Volta engaged in fishing. Most women engage in pito brewing, petty trading and shea butter extraction. Nandom 56,090 80% of the District economy is agriculture. One mechanized small town water Commerce /Service and industry account for systems about 18.2% and 0.8% respectively. 452 boreholes 83% of the population engaged in Sanitation coverage is 21% subsistence agriculture. Volta Region Jasikan 59,181 Major economic activity is trade 70% of the population in agriculture. 55.7% of the population not having access to potable water 1 Ghana Statistical Service (GSS): 2010 Population and Housing Census 2 Source: 10

12 1.3 Objectives of the Baseline The objective of the baseline is to establish a benchmark for the implementation of the SSH4A Results Programme and contribute to a better understanding of the sanitation and hygiene situation in the area. The specific objectives are: 1. To create an initial baseline of sanitation and hygiene behaviour to facilitate the measure of progress overtime. 2. Provide the basis for measuring changes in districts. 3. Provide a reliable database to facilitate comparison of baseline and progress information on sanitation and hygiene among countries. 4. Provide aggregate data that facilitates learning and steering of the programme. 1.4 Report Structure This report is divided into five (5) main sections which include introduction, methodology, results and findings on outcome, results and findings on sustainability indicators, conclusions and recommendations. The introductory section gives a background of the sanitation status of Ghana, a brief of the SSH4A programme and the objectives of the baseline study. The next section of the report describes the methods used to address the objectives of the survey. The methodology discusses the list of indicators, data collection tools, sample size determination, selection and training of enumerators and data collection and analysis. In section 3, the results and findings on outcome indicators are presented. The results and findings section focuses on the demographic characteristics of respondents and households; outcome indicators mentioned in the previous section. In the fourth section a discussion of sustainable indicators is presented. The final section summarizes conclusions from the study and distils recommendations for monitoring and evaluation of the SSH4A program. 11

13 2 METHODOLOGY OF THE BASELINE 2.1 Indicators Measured in the Baseline This baseline survey is intended to measure outcomes and sustainability indicators set in the DFID funded SSH4A Results Programme. These indicators will be measured five times through subsequent baseline and household surveys during the project period. The indicators are ladders and score cards, and in the surveys progress against these is measured. In total there are 4 outcomes indicators and 10 sustainability indicators. In this report, only 3 outcome indicators and 3 sustainability indicators are addressed. The other indicators will be measured at the start of relevant activities. The indicators in this report are: Outcome indicators Progress in access to sanitary facility (outcome indicator 1) Progress in access to a sanitation facility that is hygienically used and maintained (outcome indicator 2) Progress in practicing hand washing with soap at critical times (outcome indicator 3) Sustainability Indicators Capacity of local governments or line agencies to steer sanitation demand creation at scale in their area (sustainability indicator 1) Improved sector alignment at local level (sustainability indicator 6) Progress on faecal sludge management - emptying and collection (sustainability indicator 10) The outcome indicators and one sustainability indicator (#10) were measured using a structured questionnaire that was administered at household level. The other two sustainability indicators were measured using focused group discussion and guided self-assessment. These indicators will be measured again through the same process in the 2nd and 4th quarter of 2015, and thereafter in the 4th quarter of 2016 and Use of QIS Scales (Qualitative Information System) The performance monitoring framework uses the so called ladders, very similar to the ones used in the JMP programme. The method is called Qualitative Information System (QIS) and was developed by IRC and WSP at the end of the 1990s as a means to quantify qualitative data used in process indicators and outcome indicators. Qualitative information is quantified with the help of progressive scales called ladders. Each step on the ladder has a short description, called mini-scenario, which are factual statements that describe the situation for a particular score. Each scale ranges from the absence of the particular indicator at the lowest level (score 0) to the optimal mini-scenario at the highest level (score 4). Levels 1, 2 and 3 describe the scenarios in-between levels 0 and 4 for each specific indicator. Where there is a benchmark it is usually indicated at level 2. A typical scale looks like this: Table 3: Typical Qualitative Information System Scale DESCRIPTION None of the characteristics are present (Condition or practice is not present) 0 One characteristic is present 1 BENCHMARK: Two characteristics are present 2 Three characteristics are present 3 IDEAL: All four (key) characteristics are present 4 LEVEL 2.3 Data Collection Tools Used in the Baseline Household questionnaire In fulfilling the objectives of the baseline survey, both quantitative and qualitative data collection techniques were employed. Quantitative measures were obtained using structured household 12

14 questionnaire. The questions were structured into the following eight modules: Household information (HH), household members (HM), household characteristics /wealth index (W), sanitation (SAN), use of Sanitation (USAN), hand washing (HW), country-specific questions (C), and observations. For assessment of household characteristics/ wealth index, the DHS wealth index was used because: 1. It is an asset based wealth ranking (based on what people have: motor cycle, permanent house, and phone) 2. This is also used by the JMP and has credibility. 3. It is done by UNICEF in every country, therefore specific lists of assets exist for every country (as part of Multiple Indicator Cluster Survey = MICS) The questionnaire was uploaded into a mobile phone data collection application called AkvoFLOW. The enumerators used smartphones with this application to perform the household survey. The data collected was sent directly to an online dashboard which increases the efficiency of the data collection. The fact that GPS points and pictures had to be taken also increased the reliability of the data Focus group discussions and guided self-assessment Participatory methods such as focus group discussion were used for the measurement of the sustainability indicators. A team, comprising of managers of the district sanitation and hygiene programmes, took part in the measurement of these indicators. In addition to these government officers; private sector and CSOs were part of the discussion. The objective of the measurement was explained to participants and consensus was reached on the tools of measurement. Objective and transparent discussions were held on each criterion in the measurement tools and a consensus was reached regarding how scoring was to be carried out. As most of the discussions were conducted at the district headquarters it was easy to support any relevant evidence to the group whenever it was required. It was moderated to reflect the comprehensive picture of the district in performing the required work with quality. Facilitation of the process was kept as neutral as possible to make objective decisions. In each of the Focus Group Discussions (FGD) conducted, the facilitators provided a brief overview of SNV, the three (3) sectors the organization focuses on and the programmes implemented in these sectors and the approaches used. Thereafter, the facilitator narrowed down to the SSH4A Results Programme and the ultimate aim of the sustainability indicators survey. The facilitators then started the discussions by asking the relevant questions on sustainability indicators one and six. Every effort was undertaken to ensure that all participants contributed to the discussions. Probing was done and examples sought from the participants to help provide more clarity on the issues that emerged during the FGDs. Scoring was done based on the situation as revealed during the discussions. 2.4 Sampling In order to determine the sample size, it was important to agree on what change one would like to be able to measure between the different surveys to be held during the lifespan of this project. This was agreed between SNV and DFID that the program should at least make a 5% change in Ghana. The variance of the population proportion was assumed to be 0.5 and a design effect of 1.7 was chosen to make an adjustment for the clustering effect. The actual sample size was then calculated based on the following sampling formulae which is widely used for determining absolute percentage change. Where: deff Z n 1 P Z1 P1 1 P1 P2 P2 P P 2 1 2P n is the sample size P1 is the hypothesised value of Sanitation prevalence (100-%practising OD) at year X (This is set at 50% for Ghana. Setting at 50% yields the maximum sample size since the percentage of the population practising some form of sanitation is not clearly known at the country level). 13

15 P2 is the expected value of the indicator at year X+1 (This is set at either 5% for a maximum sample of 2095). P= (P1+P2)/2 Za is the standard normal deviate value for an a type I error (set at 1.96) Z1-b is the standard normal deviate value for a c type II error Deff is the design effect in case of multi-stage cluster sample design (set at 1.7% in this survey) The above formulae yielded a sample of A multi-stage sampling design was chosen for this study. The primary sampling unit (PSU) was the four regions namely: central, northern, upper west and the Volta region. These were not sampled. Within these regions there are districts and communities within districts which were sampled. Firstly, the sampling size per district was determined based on the number of communities in each district. It was decided to survey about 24% of the communities in each district so that the same proportion of the communities in each district would be surveyed. The communities were chosen in a way so that ethnic and geographic variation is represented as well as possible. In each community, 8 households were chosen randomly using the random walk method. The enumerator would randomly choose a walking direction and starting household (using the spinning-bottle method) after which he/she would survey households in the community at a fixed interval calculated by dividing the estimated total number of households in the community by 8. Table 2 presents a summary tabulation of the sample design by the communities. Table 4: Summary Tabulation of Sample Design by Communities Region District District Total No. of Sampled No. of Sampled Population 3 Communities Communities Households Households Central Region Northern Region Upper West Region Volta Region Komenda- Edina- Eguafo Abrem (KEEA) 144, , East Gonja 135, , Nanumba 93, , South Saboba 65, , Lawra 100, , Nandom 56, , Jasikan 59, , Total 2112 Notes: The total sample slightly exceeds 2095 because of rounding off 2.5 Training and Supervision of Enumerators In line with the goal of developing adequate capacity at MMDA level for reliable and quality baseline data collection, SNV Ghana sent an official request to the MMDAs, clearly setting out criteria for the selection. In collaboration with the target MMDAs, enumerators were finally selected based on knowledge in ICT (ability to use smart phone), good understanding of and familiarity of the district, availability from time of training to the entire data collection period, and ability to speak the dominant local language in the intended project district area. Consequently, a 3-day training workshop was organised by AKVO (in collaboration with SNV Ghana and PMU) for the enumerators and supervisors in the use of AkvoFLOW software for data collection. The workshop took place in Tamale from the 17th to 19th June, The enumerators were mainly environmental health officers selected from the MMDAs and the supervisors were all SNV staff. In all there were 21 enumerators and five supervisors. It was a hands on training on the use of smart phones in data collection. The trainees were taken through a step by step process in the use of the mobile phone to collect data. The questionnaire was then uploaded unto the smart phone for the use of the enumerators. This was followed by field testing (pilot test) of the tools in a village called Fuu in the Northern region near Tamale. Feedback from the piloting helped to further improve the questionnaire. Reasonable time was spent to make clear the contents of the master questionnaire with the aim to deepen the understanding of enumerators. Country specific issues were raised and ideas were shared on how to collect the data by participants. The questionnaire was translated into six Ghanaian languages namely, Ewe, Twi, Fante, Dagari, Likpakpa and Dagbani and uploaded unto the mobile phone. Finally when all the trainees were confident 3 Ghana Statistical Service (GSS): 2010 Population and Housing Census 14

16 to operate individually and their smart phones were loaded with the required applications, dates were fixed for the field data collection. The trainers from Akvo took SNV advisors through the operation of different components of the dashboard. The data collection started on the 24th of June 2014 and ended on 18th July Supervisors were assigned to each district and the data collection was supervised on the start and finished days. The data collection was centrally supervised from the dashboard. The data was submitted each day and it was assessed on the dashboard. Problems identified were communicated to the enumerators and the issues were addressed. 2.6 Methodology of Data Processing and Analysis Data processing and analysis was done centrally by the Project Management Unit (PMU) under the leadership of Monitoring and Evaluation Advisor for SSH4A project. The data processing and analysis entailed the following steps: downloading Ghana data from the AKVOFLOW application and performing exploratory analysis to check for accuracy, completeness, relevance and consistency of the critical data elements; converting the downloaded data from excel to the standard Stata format file using the StatTransfer program; creating a Stata do file command for Ghana with a view to computing indicators and other critical data elements as specified in the mutually agreed reporting template between SNV and the DFID MVE provider; performing data cleaning using a set of Stata manipulation commands to ensure that data are aligned to the data analysis plan and the agreed reporting template; creating a log file for Ghana and performing actual data analysis using descriptive statistics. Descriptive analysis entailed computing frequency distributions; means and cross tabulations with chi square statistics. Graphs were also used to visually present summary results. District level analysis was also done to provide further details that could otherwise be masked with regional level analysis. The analysed results were shared with the Ghana project team for report writing. The PMU continued engaging the country level team for further technical support in analysis and interpretation of the results. The deliverables of the baseline analysis were as follows: a log file of the results of the analysis; a syntax or do file for Ghana and a cleaned copy of the baseline dataset for Ghana. 2.7 Work Plan of the Baseline As part of the baseline survey, a number of activities took place from inception through to generation of the final report. The key activities and their scheduling are noted in Table 3. The work begin by preparation of terms of reference for a consultant and ends up when the final report is submitted to the PMU in the first week of October. It was organized and lead centrally by a planning and monitoring unit from Nairobi where country specifics were taken care by the team on the ground. As it has used latest technology for collection of data the necessary equipment s such as smart phones were procured with the required specification to capture and process the data. Due to involvement of various layers of expertise in the work coordination was one of the issues taken care. For ensuring quality of the work a team of expertise participated from country and multi country program support unit. Clearly defining the roles and timely tracking the progress all relevant inputs were secured to make sure that the result is as objective as possible. At country level preparations for the baselines are done in logistics, selection and invitation of enumerators. Considering the required capacity to operate with smart phones, their future relevance in the program and creation of ownership by local authorities it was decided to make environmental health officers in the districts to be data enumerators. They were communicated timely to attend the Akvo training organized in Tamale for three days time. From the seven district offices the population, households and community numbers and sizes were collected and used as a basis for planning the data collection. 15

17 Table 5: Key Activities and their Scheduling S. Activities May June 2014 July 2014 August 2014 September 2014 N W 1 W 2 W 3 W 4 W 1 W 2 W3 W 4 W1 W2 W3 W 4 W1 W2 W3 W 4 1 Prepare Terms of Reference (ToR) for the baseline survey 2 Procure the Local Capacity Builder(LCB)/consultant 3 Purchase smart mobile phones and solar chargers for mobile phone battery backup during baseline survey data collection in the remote villages 4 Select and recruit enumerators and supervisors as per the criteria set 5 Provide training (including field exercise) for enumerators, supervisors, coordinators, CPL and M&E staffs on mobile phone application in data collection including Akvo Flow dashboard and administration 6 Arrange logistics and transportation for the actual data collection in the six DFID SSH4A Results Programme/ 7 Determine the sample size for each district and community 8 Assign and mobilize all the enumerators, supervisors and coordinators to the field 9 Collect the actual baseline survey data under supervision in the field using smart mobile phones, submit collected household data to the Akvo Flow server as Wi-Fi is accessible. 10 Editing of the raw data downloaded from Akvo Flow software 11 Analyse, interpret and write the first draft baseline survey report 12 Review the draft baseline survey report 13 Submit the baseline survey report to PMU 16

18 3 RESULTS AND FINDINGS ON OUTCOME INDICATORS Section 3 presents the results and findings as indicated by the respondents on the outcome indicators. 3.1 Characteristics of Respondents Percentage of male and female respondents A total of 2,112 respondents participated in the survey. Majority (1,304) of the respondents were males representing (61.7%) and the remaining 808 (38.3%) were females. All the districts had more male respondents than females, except for the KEEA district in the Central region. In the KEEA district, female respondents outnumbered the males, i.e. 60.2% and 39.2% respectively as shown in Figure 2. Figure 2: Proportion of Male and Female Respondents Per District Respondents that were head of household In all, 42.3% of the respondents were household heads. In the specific districts, most of the respondents were not household heads except Lawra where majority of the respondents (76.9 %) were household heads (figure 3). Among the seven districts, Jasikan had the least respondents (27.5%) being household heads. The other districts, KEEA, East Gonja, Saboba, Nandom and Nanumba South had 46.1%, 41.3%, 40.2%, 39.2% and 27.9% respondents respectively as household heads. Figure 3: Proportion of Respondents Who are Household Heads by District 17

19 3.2 Household Characteristics Percentage of female headed households The head of household is generally the person who has economic and social responsibility for the household. Female headed households formed 13% (274) of the total sample as compared to 87% (1,828) male headed households. The trend of majority of households being headed by males is reflected in all the districts as shown in Figure 4. The female headed households were high in KEEA (central region) and Jasikan (Volta Region), i.e., 37.1% and 35.0% respectively. This compares well with data from the Ghana Living standards survey, 2005 (GLSS V) where the percentage of female headed households in rural areas of the Central and Volta regions is 30% and 22% respectively. The districts in the Northern Region: Saboba, Nanumba South and East Gonja had the least percentage of female household heads, 2.6%, 3.6% and 5.2% respectively. This is comparable to the regional average of 5%. In the Upper-West region, Lawra and Nandom districts had female household heads of 26.9% and 8.0% respectively the figure from Lawra is far higher while the Nandom figure is slightly higher than the regional average of 6% (Ghana Statistical Service, 2008). The reason for this is probably the fact that rural-urban migration over the past 10 years has increased the number of female-headed households in these rural areas. Figure 4: Proportion of Female Headed Households by District Average household size The size of a household determines to a large extent the demand for goods and services in the household. The larger the household, the more strain is exerted on available resources. The average household size in Ghana, as noted by the 2010 population census results, is 4.4 persons. Average household size in rural areas is 5.0 persons compared to urban areas of 4.1 persons. The mean household size of in the sampled districts was about twice the national average. High household size of 14.25, and are recorded in Nanumba South, East Gonja and Saboba, all situated in the Northern Region where polygamy is an accepted norm. The peace and understanding existing among the man, his wives and their children results in the entire family eating food prepared from the same pot thus constituting a household. Also this survey only covered 7 districts compared to the 170 districts covered in the 2010 population census. This could be the reason for the high variation in household size from this survey and the National average household size. Nanumba South district had the highest mean household size of and Nandom had the least household size of about 6.97 as shown in Figure 5. Figure 5: Mean Household Sizes per District 18

20 3.2.3 Percentage of households with children under 2 years In all the sampled districts, there were households with children under two years of age. For the entire sample, 50.5% of households reported having children under 2 years. As presented in Figure 6, households with the highest number of children under two years were found in the districts in the Northern region - East Gonja (66.4%), Nanumba South (61.8%) and Saboba (51.9%). Lawra district had the least households (31.9%) with children under two years of age. The reason for this variation is the fact that households in the Northern Region are larger and therefore have a higher chance of containing children under the age of 2. Figure 6: Proportion of Households with Children U2 by District Percentage of households with children under 5 years Most households interviewed had children under 5 years (74.6%). Households with children under 5 years were found mostly in Nanumba South (89.2%) and East Gonja (88.5%) as indicated in Figure 7. The communities with the least households with children under five years were found in Lawra (50.0%), Jasikan (54.4%) and Nandom (60.8%). Jasikan and Saboba had 63.8% and 80.6% respectively of households with children under 5 years. The reason for this is, as mentioned earlier, the household size in the Northern Region. Figure 7: Proportion of Households with Children U5 by District Percentage of households with women or girls in reproductive age Women and girls in their reproductive ages were found in households across all the districts as shown in Figure 8. Overall, majority (92.7%) of the households in the sampled districts have women and girls in their reproductive ages. There were more households with women and girls in their reproductive ages in East Gonja (96.9%), Nanumba South (95.6%) and Saboba (94.1%) than the other districts. Lawra had the least households (85.0%) with women in their reproductive ages. 19

21 Figure 8: Proportion of HH with Women or Girls in Reproductive Age by District Percentage of households with people older than 50 years Majority (67.8%) of the sampled households have people above 50 years. Households with persons who are aged 50 years and above were found in all the districts. Nanumba South had the highest number (83.3%) of households with people over 50 years of age. Jasikan and Lawra both followed with 78.8%. Nandom had the least number (61.4%) of households with people above 50 years. This was followed by Saboba (61.8%), East Gonja (64%) and KEEA (67.1%) as shown in Figure 9. Figure 9: Proportion of Households with People Above 50 Years Percentage of households with people with disability Persons with disability were defined as those who were unable to or were restricted in the performance of specific tasks/activities due to loss of function of some part of the body as a result of impairment or malformation. In this regard, respondents were asked if the household member have a difficulty in seeing, walking or climbing and self-care. Households in all the districts had people with a disability. Across all the sampled districts, 10.7% of respondents have people with a disability. In terms of district distribution, those with the most households having people with disability are Jasikan (22.5%), Nanumba South (18.7%) and East Gonja (16.6%). Nandom District had the least households with disability (1.19%) followed by Lawra (2.5%), Saboba (6.5%) and KEEA (7.5%) as indicated in Figure 10. The reason for this variation is, as mentioned earlier, the larger household size in the Northern Region. The larger the household, the higher the chance of it having people with disabilities. 20

22 Figure 10: Proportion of Households with People with Disability Wealth quintiles by districts In devising the wealth quintile of the survey districts, we selected household durables including housing type (wall and roof type), household electronics possession such as TV, Radio, Watch and Mobile phone; household furniture and possession of domestic animals, including cow, donkey, sheep/goat, and chicken. Figure 11 displays wealth quintiles in the survey districts. Within each district the households are disaggregated according to the wealth quintiles Q1 to Q5 where Q1 is the poorest and Q5 is the richest. As presented in Figure 11, sampled households in the East Gonja districts has the highest proportion of households in the richest wealth quintile of 30.7% while those in the Lawra district has the least proportion (9.4%) of households in the richest wealth quintile. The reverse of the same trend is found in these two districts with East Gonja having the least proportion (7.0%) of households in the poorest quintile and Lawra having the highest proportion (38.9%) of households in the poorest wealth quintile. Figure 11: Wealth Quintile by Districts East Gonja: In East Gonja 30.7% of households are in the highest wealth quintile whilst 7.0% of households are in the least wealth quintile. There was a steady decrease in the proportion of households from Q5 to Q1. Jasikan: Up to 10.9% of the households in the Jasikan district are in the richest wealth quintile whilst 15.2% are in the poorest wealth quintile. Q3 had the highest proportion of households (26.1%) followed by Q2 and Q4 both 23.9%. KEEA: In KEEA 11.3% of households fell within the richest wealth quintile. The poorest wealth quintile had 23.8% of households. The highest proportion of households (27.5%) was in Q3 followed by 22.5% in Q4 and 15% in Q2. 21

23 Lawra: In Lawra only 9.35% which is the least proportion of households were found in the richest wealth quintile. Meanwhile 38.9% of the households were in the poorest wealth quintile. There was steady decrease in the proportion of households from the poorest wealth quintile to the richest wealth quintile. Nandom: In Nandom 37.9% of households fell within the poorest wealth quintile whilst 7.4% of the households were in the richest wealth quintile. The proportion of households decreased from the poorest wealth quintile to the richest wealth quintile as in the case of Lawra. Nanumba South: In Nanumba South 20.8% of households are in the richest wealth quintile as compared to 16.7% of the proportion of households in the poorest wealth quintile. The highest proportion of households were in Q3 (24.4%) followed by Q2 and Q4 with household proportions of 20.2% and 17.9% respectively. Saboba: In Saboba the highest proportion of households 24.8% fell within the poorest wealth quintile as compared to 17.1% of households that fell within the richest wealth quintile. About 28.2% of the households were found in the Q2 followed by Q3 and Q4 with proportion of households being 18.4% and 16.9% respectively Wealth Quintile by female headed households Figure 12 shows the distribution of wealth quintiles among female and male headed households. It can be seen that female headed households have a smaller Q5 quintile than male headed households and that the Q1 quintile is larger for female headed households than for male households. This means that male headed households are generally wealthier than those households headed by females. Figure 12: Wealth Quintile by gender of household head 3.3 Outcome Indicator 1: Access to Sanitary Facilities According to the Millennium Development Goal 7, Target 7C calls on countries to Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The official MDG indicator is: the proportion of the population that uses an improved sanitation facility 4, urban and rural. For the purpose of this programme however, DFID considers all sanitation facilities used by a single household (so excluding shared toilets). As can be seen in the section on definitions, the SSH4A captures these different definitions in a ladder: level Definition 0 Open defecation 1 Unimproved sanitation (JMP) Shared Shared facilities 2 Improved sanitation (JMP) 3 Improved sanitation (JMP) + fly management 4 Improved sanitation (JMP) + fly management+ environmentally safe 4 An improved sanitation facility is defined as one that hygienically separates human excreta from human contact. 22

24 3.3.1 Overall access to sanitary facilities The coverage for household toilet facilities was low in all the districts where the study was conducted. Approximately 89.4% of the total respondents interviewed did not have a household latrine. 3.7% of the households used a shared latrine, and about 3.5% of the households had an unimproved latrine. Only 3.4% of the respondents had improved toilet facilities of which a tiny fraction had proper fly management and was environmentally safe Figure 13: Overall Access to Sanitary Facilities Access to sanitary facilities in the districts Comparing the access to sanitation for the different districts yielded interesting results. It was found that Jasikan had the largest percentage of both shared (22.5%) and unimproved latrines (28.9%). This is probably due to previous interventions in the district, most notably the DANIDA project which promoted access to improved sanitation in the past and has been quite successful. Most improved latrines can be found in Lawra (7.5%) and Nandom (6.8%). A large percentage of shared latrines (more than 4%) can be found in the districts of Saboba, Nandom and Lawra. 23

25 Figure 14: Comparing access to sanitation across districts Access to sanitation against gender of the head of household Comparing access to sanitary facilities between gender of head of households: male heads recorded the highest percentage of households without toilet facilities (89.7%); shared toilet facilities (3.8%) and JMP improved toilet (including those facilities with fly management and which are environmentally safe) (3.2%) as compared to their female counterparts. Female household heads recorded the largest number of unimproved toilet facilities (5.1%). However, differences between male and female headed households are not significant. Figure 15: Access to sanitation against gender of HH head Types of toilets found in the programme area The predominant types of latrine found in the project districts are the ventilated improved pit (VIP) toilet, the traditional pit toilet, the pit toilet with slab, the pit toilet without slab and the flush toilet. The 24

26 main type of improved latrine can be seen to be the ventilated improved latrine (as compared to the pit latrine with slab). This is interesting because it is also the more expensive option of the two. Traditional pit latrines can be seen to be the most dominant across the seven districts. Flush toilets are hardly found. Figure 16: Comparison of Kinds of Toilet Facilities Used by Households in Districts Comparing the type of toilets by district shows us that there are large differences. The ventilated pit latrine is very popular in Saboba (78%) and Nanumba South (58%). In Lawra only a very small proportion of toilets are ventilated improved pit latrines (6%), while in East Gonja, no ventilated improved pit latrines were encountered at all. The flush toilet is found more in KEEA. Pit toilets without slabs are found throughout all districts except for Lawra and Jasikan. In Jasikan it is especially the traditional pit latrine which is very popular (78%), and in Lawra there are a lot of pit latrines with slabs (68%). Figure 17: Comparison of Kinds of Toilets Used by HH across Districts Access to sanitary facilities against wealth quintile It is interesting to note that slightly more of the households with latrine access are in the higher wealth quintiles, however the correlation is not strong. Where 12% to 9% of wealth quintiles 3-5 have access to sanitation, in wealth quintiles 1-2, only 8-9% have access to sanitation. Improved sanitation facilities are found equally across all wealth quintiles. 25

27 3.3.6 Discussion on the findings access to a sanitary toilet The study suggests that most households in the various study districts do not have access to sanitary toilets in their Households. About half of the households with household latrines are using unimproved options (3.5%), the other half uses improved options (3.4%). This is short by about 11 percent and 50 percent of the national access to improved sanitation and the MDG target of 54 percent with barely 1 year left to the MDG target year (2015). The results seems to suggest that majority of the Households with toilets do not use their facilities with other neighbours (only 3.7%). It has been reported in other studies that some landlords do not even share their toilet facilities with their tenants. JMP reports indicate that in rural Ghana in 2012, 8% have improved facilities, 44% have shared facilities, 15% have access to other unimproved facilities and 33% defecate in the open. The reason for the large difference in access to shared latrines between this study and that of the JMP is a difference in definition. For the JMP, public latrines are counted as shared latrines while in this study it is not. The JMP reports access to improved sanitation to be 4.8% higher than was found in this study. The reason for this could be the fact that the 7 districts sampled in this study have relatively less improved sanitation facilities than others in Ghana. The study revealed that Households in the northern districts of Ghana predominantly use dry on-site facilities as opposed to the Coastal areas who had a variety of toilet facilities ranging from pit latrines, to flush toilets. The study seems to suggest that the prevailing conditions in a particular area determine the type of toilet facility to be used. For instance, in areas like the north where there is vast land and dry conditions; it was seen that dry facilities were predominantly being used while areas with reliable water source promoted the use of flush toilets. In addition, locations within rural settings were more inclined to the use of dry on-site facilities particularly unimproved toilet facilities. A strong trend could not be found between access to sanitation and wealth of the household. Neither was there any strong relationship between access to sanitation and gender of head of household. Looking across the districts, it was interesting that both districts in the Upper-West region (Nandom and Lawra) had slightly higher numbers of households with access to both improved and unimproved latrines. Jasikan had by far the largest proportion of the population with access to sanitation mainly shared and unimproved latrines. The reason for this is probably previous interventions in the district such as the DANIDA project. The worst part of the findings is that most Households still do not have access to their own toilet 26

28 facilities improved or unimproved. This could be associated to a lack of knowledge on how to construct latrines, the high price of the available latrine options, or more probable simply a lack of demand. 3.4 Outcome indicator 2: Hygienic Use and Maintenance of Sanitation Facilities Householders are responsible for the operation and maintenance of their home toilet facilities. Generally, the users themselves do the actual cleaning except for those who have pan/bucket latrines who employ the services of a conservancy labourer to collect the faeces for disposal. People normally clean their facilities by sweeping, scrubbing with water or soapy water and at times by disinfection Overall hygienic use and maintenance of sanitation facilities In most cases, the households did not have their own latrine so did not have much to do in terms of maintaining toilet facilities. Approximately 11% of the respondents did have household toilets. About 4% of these did not use the toilet as a toilet; another 1 % of the latrines were not functioning as intended. That leaves only 5.5% of the households to be having a latrine functioning and using them as intended (having functional water seal/lid). Figure 18: Overall Hygiene and Sanitation Management by Respondent Hygienic use and maintenance of sanitation facilities per district Toilets which are in use as toilets and are functioning as intended (with functioning water seal/lid) were recorded in all the districts but with the highest in Jasikan, Nandom, Lawra, KEEA 47%, 13%, 11%, and 4% respectively. East Gonja had the least with 1% and in Nanumba South and Saboba, 2% of households had latrines that were functioning as intended. When comparing this graph with the graph of access to sanitation per district, it can be seen that in all districts there are households with latrines which are not in use as latrines. In Lawra and Nandom this is higher (8%) and in Nanumba South this is lowest (2%). In the other districts it is between 5% and 6%. There were hardly any latrines which were in use as latrines but not functioning as intended (3% in Jasikan and Lawra, 2% in KEEA and 1% in East Gonja). Therefore in conclusion, when people have a toilet, it is generally functioning well. 27

29 Figure 19: Comparison of Households Practicing Good Hygiene and Sanitation Management Across District The proper usage and maintenance of a toilet facility is a key component of making the facility functional and accepted by the user. It is evident that the selected areas require adequate education on the use of different toilet options as they all work differently. Knowledge of these technological options will render many HH toilets functional, desired and increase their life span. In Jasikan, Nandom and Nanumba South districts, Households with flush toilets attributed the lack of proper maintenance to the unavailability of materials for cleaning. A greater proportion of users mentioned design difficulty, lack of cleaning materials and lack of knowledge on how to clean and maintain their toilets Hygienic use and maintenance of sanitation facilities against gender of the head of household It can be seen from Figure 20 that a larger proportion of female headed households have latrines which are in use as latrines and are also functioning as intended (proper lid/water seal). Comparing this graph with that of access to sanitation it can be calculated that 3% of female headed households have latrines which are not in use as latrines, while for male headed households this percentage is 4%. The variation is therefore very small. 28

30 Figure 20: Hygienic Use and Maintenance of Sanitation Facilities against Gender of the Head of HH In addition, the reasons attributed to the usage and poor maintenance of the HH toilets between the male and female heads were similar though a large proportion of the facilities owned by females had the availability of cleaning materials as the main cause. In terms of human contribution, toilet owned by females had a high percentage of other users taking their turn to clean the facility as compared to those owned by the males. Figure 21: Reasons for Use and Maintenance of Sanitation Facilities against Gender of the Head of HH It is evident that the cleaning of latrine in all communities is a responsibility of the female adults, coupled with the fact that females are more inclined to cleanliness than their male counterparts. The males are hardly involved in the cleaning of latrines. This observation is limited to household latrines only. However, the availability of cleaning materials which require some purchasing power was generally seen in both situations of ownership Hygienic use and maintenance of sanitation facilities against wealth quintile Comparing the wealth of the household with the hygienic use and maintenance of the sanitation facility shows us that a slightly higher percentage of the households in the higher wealth quintiles have latrines which are in use as latrines (12.85%, 10.5% and 13.22% for wealth quintiles 3, 4, and 5 respectively) than those households in the lower wealth quintiles (10.47% and 9.83% for wealth quintiles 1 and 2 respectively), these differences however are only small. In all the wealth quintiles about 10% of the households have a latrine which is in use as a latrine and also properly functioning (intact water seal/closed/lid). 29

31 Figure 22: Hygienic Use and Maintenance of Sanitation Facilities Against Wealth quintile Discussion on the findings for hygienic use and maintenance of sanitation facilities In terms of maintenance of the different toilet technological options, those using flush toilets had little problems with usage and maintenance issues. The only reason associated to maintenance of flush facilities was the availability of cleaning materials in the study areas. However, majority of the problems associated with cleaning and maintenance was linked to the dry onsite facilities. A high percentage of the reason was attributed to the design of the dry facilities making cleaning difficult. Others did not know how to clean them and an equal proportion had other users failure to take their turns to clean them. It is evident that dry facilities had the most cleaning problems. There is a special need for user education around disposal of anal cleansing material and the likes. Regarding the use and functionality of latrines, 4% of the latrines encountered were not used as toilets. The ones which were used as toilets were generally functioning well. 3.3 Outcome Indicator 3: Access to Hand Washing With Soap (HWWS) Hand washing with soap and water is a critical action in the prevention of a number of diseases including all forms of diarrhoeal diseases. Knowledge of the critical times for hand washing is vital for disease control Knowledge of critical moments of HWWS Figure 23 shows the knowledge of critical hand washing moments by the surveyed households. It can be seen that almost all households know that it is important to wash hands before eating (95% and after defecation (85%). Before breast feeding/feeding a child, before cooking/preparing food, and as ablution are named by some households (18%, 37% and 14% respectively). After cleaning toilet/potty is hardly mentioned, and after cleaning child that has defecated/changing nappy hasn t been mentioned at all. 30

32 Figure 23: Knowledge of hand washing moments Figure 24, shows us that in general male headed households have more knowledge about critical hand washing moments than female headed households. All answers have been given my male headed households 2-3% more. Figure 24: Knowledge of hand washing moments by gender of household head Comparing households with and without children under the ages of 2 and 5 show us some interesting results. Households with children under the age of 2 mentioned most critical hand washing moments, followed by households with children under the age of 5. Households without children under the ages of 2 or 5 mentioned the least amount of critical hand washing moments (but differences are small). 31

33 Figure 25: Knowledge of hand-washing moments for households with and without children under 2 and under 5 Figure 26 shows the knowledge of critical hand washing moments by wealth quintile. A clear pattern cannot be seen. The richest wealth quintile mentioned most that hand washing should be done before eating, but the middle wealth quintile for example mentioned most that hand washing should be done before cooking or preparing food. Figure 26: Knowledge of hand washing moments by wealth quintile Presence of a hand washing station with soap for after defecation The overall performance of the districts regarding the presence of hand-washing facilities for use after defecation was woefully inadequate. Less than 1% of Households with toilet facilities has a place or facility for hand washing after defecating. Approximately 99% of Households do not have access to hand washing places or facilities for hand washing after defecating. Presented in Figure 27, slightly more than half of those with hand washing facilities (0.3%) have hand-washing facilities whereby the water cannot be contaminated 32

34 Figure 27: Households Doing Hand Washing After Defecating Comparing the results across the districts indicated that hand-washing facilities for use after defecation are lacking to an equal extent in all districts. Only in KEEA and East Gonja were there some households with had hand washing facilities close to their latrine. In East Gonja this was the case for 1.3% of the households (most of them preventing contamination of water) and in KEEA this was the case for 0.3% of the households (all of them not preventing the water from contamination, and all of them without soap). Saboba, Nanumba South, Nandom, Lawra and Jasikan recorded 100% for no place or facility for hand washing. Figure 28: Comparison of Households Doing Hand Washing After Defecating within Districts Presence of a hand washing station with soap before cooking and food preparation Similarly, the number of households with a hand-washing facility close to the place of cooking/food preparation was also appalling. Overall, less than 1% of the households surveyed had a hand-washing facility close to the place for cooking/food-preparation. Only 0.2% of the Households had a hand washing facility with soap and only 0.1% had a hand-washing facility unsusceptible to contamination 33

35 Figure 29: Households Doing Hand Washing Before Food Preparation Comparing the presence of hand-washing facilities close to the place for cooking/food preparation across districts shows that they are lacking equally in all districts. Nanumba South, Jasikan, East Gonja and Saboba had 99.2%, 97.5%, 99.0% and 99.8% of Households without hand-washing facility close to the place of cooking/food preparation. In both Nandom and Lawra, 100% of Households did not have a hand-washing facility close to their place of cooking/food preparation. Jasikan is doing slightly better bu the differences between the districts are tiny. Figure 30: Comparison of Households with hand-washing facility close to place of cooking/food preparation across Districts Discussion on the findings for Access to hand washing with soap (HWWS) Almost all respondents were aware of the need to wash hands before eating (95%), 85% of households mentioned the importance of hand-washing after defecation. The other critical moments for handwashing (before cooking/food preparation, before feeding child and after cleaning toilet) were mentioned a lot less (37%, 18% and 6% respectively). This trend was found across all districts and all types of households. In spite of knowledge, no evidence of sustained practice of hand washing after defecation and before cooking is found. Almost none of the households had a hand-washing facility, not close to the latrine and not close to the place of cooking/food preparation either. It is therefore questionable whether this knowledge about hand-washing practise is also put into action. 34

36 4 RESULTS AND FINDINGS ON SUSTAINABILITY INDICATORS The sustainability of the SSH4A program will be achieved mainly through an enabling environment with appropriate government policies in place. These policies include strengthened local government capacity and improved local sector alignment to steer demand creation at scale in the programme area among other aspects. The baseline survey assessed the capacity of local government, local sector alignment and faecal sludge management progress of the seven districts. In-depth interviews were held with relevant sector heads and households. The findings are presented below: 4.1 Sustainability Indicator 1: Capacity of Local Governments or Line Agencies to Steer Sanitation Demand Creation at Scale in their Area Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in KEEA The capacity of local government and line agencies to steer sanitation demand creation at scale in the KEEA district using all ten parameters are presented in Figure 31. Figure 31: Capacity of Local Government to Steer Sanitation Demand Creation at Scale in the KEEA In KEEA, every Environmental Health Officer (EHO) and Environmental Health Assistant (EHA) are supposed to trigger two (2) communities per year as indicted in the annual implementation plan of the District Environmental Health Officer (DEHO). The plan is however, not well documented. This is because almost all the budget for the environmental health department goes to solid waste management with none allocated to demand creation. Human resources are however, available to support activities that will be aimed at driving sanitation demand in the district. Out of a maximum scale of 4, only one sub-sustainability indicator-1 relating to the promotion of standards and regular assessment of performance of organisations engaged in demand creation had a score of 3. Three (3) other sanitation demand creation indicators scored 2. These are: availability of monitoring systems that measure progress on demand creation targets and results at village level; systems to ensure follow-up at most appropriate times; and systems to ensure that monitoring includes data that assesses inclusion of all groups within the villages, including people with a disability. The indicators that had scores of 2 include: Planning for implementing demand creation activities covering the entire district; and ensuring availability of human and financial resources to implement demand creation activities in line with its plans (in-house or other). The remaining 4 indicators of sanitation demand creation had scores of zero (0) indicating no activity covering these indicators. The scores for the KEEA district were based on the following: The district triggered a few communities in 2011 and 2012 with support from SNV. However, the last 1,5 years, nothing has been done. A national framework for monitoring of demand creation targets is available but demand 35

37 creation activities has not been carried out in the district. There has been no follow-up due to resource constraints. Initial preparation and submission of progress report to the Municipal Chief Executive (MCE) and regional environmental health office. This was however, not further discussed and no reporting has been done since then. Initial monitoring of access and use of latrines has been carried out including people with disability. The monitoring data has never been used to adjust or improve implementation. There was no special approach for districts lagging behind and which are hard to reach, and in the last two (2) years there has been no activity to mobilize local government and other local leadership around sanitation Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in Jasikan The capacity of local government and line agencies to steer sanitation demand creation at scale in the Jasikan district using all ten parameters are presented in Figure 32. Figure 32: Capacity of Local Government and Line Agencies to Steer Sanitation Demand Creation at Scale in Jasikan In the Jasikan district, only three (3) sub-sustainability indicator-1 had scores of 1 and above. Two subsustainability indicator-1 relating to: planning for implementing demand creation activities covering the entire district (even if in phases); and mobilising local government and other local leadership around sanitation were scored 2. The scores were on the basis that there was a plan in place for the implementation of CLTS but the plans contained in the documents were not specific to CLTS and demand creation. Another sub-sustainability indicator-1 of ensuring availability of human and financial resources to implement demand creation activities in line with its plans (in-house or other) was scored 1. This was on the basis that human resources are available but the district lacks the financial resources to implement sanitation demand creation activities. The rest of the other indicators on the capacity of local government or line agencies to steer sanitation demand creation at scale in their area were scored zero due to the fact that CLTS is in the conceptual phase in the district. 36

38 The scores for the Jasikan district were based on the following: Availability of a plan for the implementation of CLTS which was contained in their DESSAP document. Availability of a proposal for funding CLTS CLTS is in the conceptual stage Availability of human resources for CLTS and demand creation Lack of financial resources for CLTS and demand creation Capacity of Local Government to Steer Sanitation Demand Creation at Scale in the Nanumba South The capacity of local government and line agencies to steer sanitation demand creation at scale in the Nanumba south district using all ten parameters are presented in Figure 33. Figure 33: Capacity of Local Government to Steer Sanitation Demand Creation at Scale in Nanumba South Mobilises local government and other local leadership around sanitation Has plan for implementing demand creation activities covering the entire district (even if in phases) 4 3 Ensures that there are human and financial resources to implement demand creation activities in line with its plans (in-house or other) Uses a differentiated approach for hard to reach villages and those lagging behind Uses the data from monitoring and experiences to adjust or improve implementation when relevant Promotes standard and regularly assesses the performance of organisations engaged in demand creation Has a monitoring system that measures progress on demand creation targets and results at village and sub-district level Ensures that monitoring includes data that assesses inclusion of all groups within the villages, including people with a disability Ensures that information on progress is shared, analysed and discussed with relevant sub-district and district level stakeholders Ensures that follow-up happens at the most appropriate times of the year In Nanumba south district, a total of five sub-sustainability indicator-1 had scores of 1 and above. The highest sub-sustainability indicator-1 score of 3 relates to two indicators including: the promotion of standard and regular assessment of the performance of organisations engaged in demand creation; and ensuring that monitoring includes data that assesses inclusion of all groups within the villages, including people with disability. Three other sub-sustainability indicator-1 had scores of 1. These relates to: availability of plans for implementing demand creation activities covering the entire district; and the promotion of standard and regularly assessment of the performance of organisations engaged in demand creation. The above scores for the district are due to the existence of an implementation plan (within DESSAP) and annual sanitation action plans to make a number of villages ODF. Budgets have been assigned to it however; resources (except human resources) have never been assigned. A strategy has not been designed either. NORST and Integrad have been triggering villages in the district with regular communication between them and the district. EHO s have been visiting the communities triggered by NORST during the triggering and afterwards. They do monitor whether there is inclusion during the triggering, however, there is no clear monitoring and communicating system in place with clear indicators. After the experience with NORST they did not have the opportunity to implement the lessons learnt in other communities. 37

39 4.1.4 Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in Nandom The capacity of local government and line agencies to steer sanitation demand creation at scale in the Nandom district using all ten parameters are presented in Figure 34. Figure 34: Capacity of Local Government to Steer Sanitation Demand Creation at Scale in the Nandom Mobilises local government and other local leadership around sanitation Has plan for implementing demand creation activities covering the entire district (even if in phases) 4 3 Ensures that there are human and financial resources to implement demand creation activities in line with its plans (in-house or other) Uses a differentiated approach for hard to reach villages and those lagging behind Uses the data from monitoring and experiences to adjust or improve implementation when relevant Promotes standard and regularly assesses the performance of organisations engaged in demand creation Has a monitoring system that measures progress on demand creation targets and results at village and sub-district level Ensures that monitoring includes data that assesses inclusion of all groups within the villages, including people with a disability Ensures that information on progress is shared, analysed and discussed with relevant sub-district and district level stakeholders Ensures that follow-up happens at the most appropriate times of the year Almost all (9) sub-sustainability indicator-1 had scores of 1 and above. The sub-sustainability indicator-1 relating to planning for implementing demand creation activities covering the entire district had the maximum score of 4. The sub-sustainability indicator-1 which relates to ensuring of information on progress is shared, analysed and discussed with relevant sub-district and district level stakeholders was the only indicator that had a score of zero (0). The above scores for the Nandom district were based on the fact that the district has an extensive sanitation plan and the DESSAP to support in guiding the planning, implementation, monitoring and coordination of sanitation and hygiene related targets. There are key players in the sanitation and hygiene sector in the District, but their level of coordination has been a bit poor. In the same line, the District Assembly does not share its reports with other players in the WASH sector and other relevant stakeholders. Remote communities in the district are given priority attention so that they are attended to early in terms of interventions that require the direct presence of staff to facilitate issues on sanitation and hygiene. There is partial inclusion of people with disabilities in sanitation and programming and monitoring. Much as there is not a conclusive monitoring mechanism in monitoring the inclusion of PWDs, aged etc. gender-friendly latrine construction is of great essence to the District Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in Lawra The capacity of local government and line agencies to steer sanitation demand creation at scale in the Lawra district using all ten parameters are presented in Figure

40 Figure 35: Capacity of Local Government to Steer Sanitation Demand Creation at Scale in Lawra Mobilises local government and other local leadership around sanitation Has plan for implementing demand creation activities covering the entire district (even if in phases) 4 3 Ensures that there are human and financial resources to implement demand creation activities in line with its plans (in-house or other) Uses a differentiated approach for hard to reach villages and those lagging behind Uses the data from monitoring and experiences to adjust or improve implementation when relevant Promotes standard and regularly assesses the performance of organisations engaged in demand creation Has a monitoring system that measures progress on demand creation targets and results at village and sub-district level Ensures that monitoring includes data that assesses inclusion of all groups within the villages, including people with a disability Ensures that information on progress is shared, analysed and discussed with relevant sub-district and district level stakeholders Ensures that follow-up happens at the most appropriate times of the year In the Lawra district, eight (8) sub-sustainability indicator-1 had scores of 1 and above. The subsustainability indicator-1 relating to planning for implementing demand creation activities covering the entire district had the maximum score of 4. Two other sub-sustainability indicator-1 with scores of 3 relates to: the use of data from monitoring and experiences to adjust or improve implementation when relevant; and the use of differentiated approach for hard to reach villages and those lagging behind. The two sub-sustainability indicator-1 with zero (0) scores are: ensuring monitoring includes data that assesses inclusion of all groups within the villages, including people with a disability; and mobilisation of local government and other local leadership around sanitation. The above scores for the Lawra district were due to the following factors: Existence of DESSAP in which CLTS is included. Inclusion of CLTS in the annual district development plan. Inclusion of target number of villages to be reached with appropriate budgets in the annual district development plan Availability of human resources Inconsistent allocation of financial resources. Involvement of Government of Ghana (once and in 2012) and Care International Preparation and submission of regular reports to Care International and the regional environmental health office on CLTS activities undertaken. Existence of a monitoring team comprising actors from different agencies. There is however, no well-defined monitoring system. Natural leaders from very responsive villages are used to reach villages that are lacking behind Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in Saboba The capacity of local government and line agencies to steer sanitation demand creation at scale in the Saboba district using all ten parameters are presented in figure

41 Figure 36: Capacity of Local Government to Steer Sanitation Demand Creation at Scale in Saboba Has plan for implementing demand creation activities covering the entire district (even if in phases) 4 Ensures that there are human and Mobilises local government and other financial resources to implement local leadership around sanitation demand creation activities in line with 3 its plans (in-house or other) Uses a differentiated approach for hard to reach villages and those lagging behind Uses the data from monitoring and experiences to adjust or improve implementation when relevant Promotes standard and regularly assesses the performance of organisations engaged in demand creation Has a monitoring system that measures progress on demand creation targets and results at village and sub-district level Ensures that monitoring includes data that assesses inclusion of all groups within the villages, including people with a disability Ensures that information on progress is shared, analysed and discussed with relevant sub-district and district level stakeholders Ensures that follow-up happens at the most appropriate times of the year In the Saboba district, only three (3) sub-sustainability indicator-1 had scores of 1 and above. The subsustainability indicator-1 relating to planning for implementing demand creation activities covering the entire district had a score of 2. Two other sub-sustainability indicator-1 had scores of 1 and these relates to: ensuring availability of human and financial resources to implement demand creation activities in line with its plans; and ensuring that follow-up happens at the most appropriate times of the year. The remaining seven (7) sub-sustainability indicator-1 had zero (0) scores. The relatively low scores on sub-sustainability indicator-1 for the Saboba district were due to the following factors: Availability of (DESSAP). There is however, no emphasis on demand creation but more on what the district authorities will be doing for the communities in terms of building sanitation infrastructure Limited human resource to implement demand creation activities Assessment of organisations on demand creation is not regular and almost non-existent. Lack of a well-defined system to measure progress on demand creation at the community and sub-district level. No regular follow-up on triggered communities due to lack of fuel and other logistics Lack of reports due to inadequate monitoring Capacity of Local Governments to Steer Sanitation Demand Creation at Scale in East Gonja The capacity of local government and line agencies to steer sanitation demand creation at scale in the East Gonja district using all ten parameters are presented in Figure

42 Figure 37: Capacity of Local Government to Steer Sanitation Demand Creation at Scale in East Gonja Mobilises local government and other local leadership around sanitation Has plan for implementing demand creation activities covering the entire district (even if in phases) 4 3 Ensures that there are human and financial resources to implement demand creation activities in line with its plans (in-house or other) Uses a differentiated approach for hard to reach villages and those lagging behind 2 1 Promotes standard and regularly assesses the performance of organisations engaged in demand creation 0 Uses the data from monitoring and experiences to adjust or improve implementation when relevant Has a monitoring system that measures progress on demand creation targets and results at village and sub-district level Ensures that monitoring includes data that assesses inclusion of all groups within the villages, including people with a disability Ensures that follow-up happens at the most appropriate times of the year Ensures that information on progress is shared, analysed and discussed with relevant sub-district and district level stakeholders Six (6) sub-sustainability indicator-1 had scores of 1 in the East Gonja district with the remaining four (4) scoring zero (0). The sub-sustainability indicator-1 with scores of 1 are: Has plan for implementing demand creation activities covering the entire district (even if in phases) Ensures that there are human and financial resources to implement demand creation activities in line with its plans (in-house or other) Ensures that follow-up happens at the most appropriate times of the year Uses the data from monitoring and experiences to adjust or improve implementation when relevant Uses a differentiated approach for hard to reach villages and those lagging behind Mobilises local government and other local leadership around sanitation The scores on sub-sustainability indicator-1 for the East Gonja district were based on the fact that there are inadequate sanitation demand creation activities currently on-going in the district Discussion on the findings for sustainability indicator 1 The capacity of local government and line agencies to steer sanitation demand creation at scale in the districts were assessed using ten parameters for the districts as outlined in Table 6. 41

43 Table 6: Summary of Findings on Sustainability Indicator - 1 Score per district Detail 1. Has plan for implementing demand creation activities covering the entire district (even if in phases) 2. Ensures that there are human and financial resources to implement demand creation activities in line with its plans (inhouse or other) 3. Promotes standard and regularly assesses the performance of organisations engaged in demand creation 4. Has a monitoring system that measures progress on demand creation targets and results at village and subdistrict level 5. Ensures that follow-up happens at the most appropriate times of the year 6. Ensures that information on progress is shared, analysed and discussed with relevant sub-district and district level stakeholders 7. Ensures that monitoring includes data that assesses inclusion of all groups within the villages, including people with a disability 8. Uses the data from monitoring and experiences to adjust or improve implementation when relevant 9. Uses a differentiated approach for hard to reach villages and those lagging behind 10. Mobilises local government and other local leadership around sanitation Total score per district Average score per district KEEA Jasikan Nanumba Nandom Lawra Saboba East South Gonja Average Score

44 The overall programme area average score for sanitation demand creation (sustainable sanitation indicator 1) is 1. This is an indication that the sanitation demand creation in the districts was in a poor status. Among all the sub indicators of sustainable sanitation indicators, sub indicator 1 which is having a plan for implementing demand creation activities covering the entire district has the best average score of 2.1 followed by sub indicator 3 i.e., promoting standard and regularly assessing the performance of organisations engaged in demand creation (with average score of 1.4). The least scored (0.7) sub indicators are sub indicators 5, 6, 8 and 9. Comparing the sustainability indicator 1 score among the districts, Lawra and Nandom scored an average of (1.7) each followed by KEEA with 1.1. Saboba had the least score with an average of Sustainability Indicator 6: Improved Sector Alignment at Local Level Improved Sector Alignment at Local Level in KEEA The finding on improved sector alignment at local level in the KEEA district is presented in Figure 38. Figure 38: Findings on Improved Sector Alignment at Local Level in the KEEA District Standards and norms (related to rural sanitation) are aligned. A multi-stakeholder dialogue has started (on rural sanitation) 4 3 All relevant (local) government sector stakeholders are involved in the dialogue. Approaches (to rural sanitation) are aligned. 2 1 All relevant (local) donor (or funding) agencies are involved in the dialogue. Plans (for rural sanitation) are made jointly. 0 Relevant civil society and private sector stakeholders are involved in the dialogue. Sector targets (for rural sanitation) are set jointly by stakeholders. Sector priorities (for rural sanitation) are set jointly by stakeholders. Information and data (evidence base) are shared in the group. The findings on improved sector alignment at local level in the KEEA district showed minimal activity in this regard. Only two (2) sub-sustainability indicators had scores of 1 with the remaining eight (8) subsustainability indicator-6 scoring zero (0). The sub-indicators which scored 1 are: alignment of approaches (to rural sanitation); and alignment of standard and norms (related to rural sanitation). The basis for the scores is due to the fact that even though a multi-stakeholder platform exists at regional level, there is none at the municipal level. However, the approaches, standards and norms used by stakeholders are to some extent aligned to the national strategy Improved Sector Alignment at Local Level in Jasikan The finding on improved sector alignment at local level in the Jasikan district is presented in Figure

45 Figure 39: Findings on Improved Sector Alignment at Local Level in the Jasikan District Standards and norms (related to rural sanitation) are aligned. A multi-stakeholder dialogue has started (on rural sanitation) 4 3 All relevant (local) government sector stakeholders are involved in the dialogue. Approaches (to rural sanitation) are aligned. 2 1 All relevant (local) donor (or funding) agencies are involved in the dialogue. 0 Plans (for rural sanitation) are made jointly. Relevant civil society and private sector stakeholders are involved in the dialogue. Sector targets (for rural sanitation) are set jointly by stakeholders. Sector priorities (for rural sanitation) are set jointly by stakeholders. Information and data (evidence base) are shared in the group. In Jasikan the group was unanimous in scoring zero for indicators 1 to 7 under sustainability indicator-6 on improving sector alignment. They agreed there is no stakeholder dialogue, planning and monitoring taking place on sanitation in the district. The group however indicated that there are plans, approaches, standards and norms however they agreed that these are just elements to general issues so they scored one for indicators 8-10 in sustainability indicator Improved Sector Alignment at Local Level Nanumba South The findings on improved sector alignment at local level in the Nanumba district are presented in Figure

46 Figure 40: Findings on Improved Sector Alignment at Local Level in the Nanumba District Standards and norms (related to rural sanitation) are aligned. A multi-stakeholder dialogue has started (on rural sanitation) 4 3 All relevant (local) government sector stakeholders are involved in the dialogue. Approaches (to rural sanitation) are aligned. Plans (for rural sanitation) are made jointly All relevant (local) donor (or funding) agencies are involved in the dialogue. Relevant civil society and private sector stakeholders are involved in the dialogue. Sector targets (for rural sanitation) are set jointly by stakeholders. Sector priorities (for rural sanitation) are set jointly by stakeholders. Information and data (evidence base) are shared in the group. In the Nanumba district, only two (2) sub-sustainability indicator-6 had scores of 2 with the remaining eight (8) sub-sustainability indicator-6 scoring zero (0). The sub-indicators which scored 2 are: alignment of approaches (to rural sanitation); and alignment of standard and norms (related to rural sanitation). The scoring for the Nanumba district is based on the fact that memos have been written for the composition of a District Inter-communal Committee for Sanitation (DICS) but this has never been done. No sector priorities or targets have also been set Improved Sector Alignment at Local Level in Nandom The findings on improved sector alignment at local level in the Nandom district are presented in Figure 41. Figure 41: Findings on Improved Sector Alignment at Local Level in the Nandom District Standards and norms (related to rural sanitation) are aligned. A multi-stakeholder dialogue has started (on rural sanitation) 4 3 All relevant (local) government sector stakeholders are involved in the dialogue. Approaches (to rural sanitation) are aligned. Plans (for rural sanitation) are made jointly All relevant (local) donor (or funding) agencies are involved in the dialogue. Relevant civil society and private sector stakeholders are involved in the dialogue. Sector targets (for rural sanitation) are set jointly by stakeholders. Sector priorities (for rural sanitation) are set jointly by stakeholders. Information and data (evidence base) are shared in the group. In the Nandom district all ten (10) sub-sustainability indicator-6 had scores of 1 and above. Two indicators relating to: involvement of relevant civil society and private sector stakeholders in dialogue; and sharing of information and data (evidence base) had scores of 2. The remaining eight (8) sub- 45

47 sustainability indicator-6 scored 1. The basis for the scores is due to the fact that the District Assembly has general platform where generic developmental challenges are discussed. In periods and situations where sanitation and hygiene is identified as burning challenge, priority is given for it to be discussed with all relevant district stakeholders Improved Sector Alignment at Local Level in Lawra The findings on improved sector alignment at local level in the Lawra district are presented in Figure 42. Figure 42: Findings on Improved Sector Alignment at Local Level in the Lawra District Standards and norms (related to rural sanitation) are aligned. A multi-stakeholder dialogue has started (on rural sanitation) 4 3 All relevant (local) government sector stakeholders are involved in the dialogue. Approaches (to rural sanitation) are aligned. 2 1 All relevant (local) donor (or funding) agencies are involved in the dialogue. 0 Plans (for rural sanitation) are made jointly. Relevant civil society and private sector stakeholders are involved in the dialogue. Sector targets (for rural sanitation) are set jointly by stakeholders. Information and data (evidence base) are shared in the group. Sector priorities (for rural sanitation) are set jointly by stakeholders. The Lawra district had a score of 2 in one (1) sub-sustainability indicator-6; a score of 1 in eight (8) sub-sustainability indicator-6; and scored zero (0) in the remaining two sub-sustainability indicator-6. The basis for the scores is due to the fact that the District Assembly has general platform where generic developmental challenges are discussed. In periods and situations where sanitation and hygiene is identified as burning challenge, priority is given for it to be discussed with all relevant district stakeholders. At the regional level there is a RICCs which comes together once every 3 months. On this committee are staff of the Environmental health, Plan Ghana, UNICEF, Community development and Community water. At the District level a DICCs is in place however, they haven t had meetings for a long time. Approaches and standards and norms related to rural sanitation however are aligned mainly to the national strategy Improved Sector Alignment at Local Level in Saboba The findings on improved sector alignment at local level in the Saboba district is presented in Figure

48 Figure 43: Findings on Improved Sector Alignment at Local Level in the Saboba District Standards and norms (related to rural sanitation) are aligned. A multi-stakeholder dialogue has started (on rural sanitation) 4 3 All relevant (local) government sector stakeholders are involved in the dialogue. Approaches (to rural sanitation) are aligned. 2 1 All relevant (local) donor (or funding) agencies are involved in the dialogue. 0 Plans (for rural sanitation) are made jointly. Relevant civil society and private sector stakeholders are involved in the dialogue. Sector targets (for rural sanitation) are set jointly by stakeholders. Information and data (evidence base) are shared in the group. Sector priorities (for rural sanitation) are set jointly by stakeholders. The Saboba district scored zero (0) in all (10) sustainability indicator-6 parameters. This was due to the fact that there is no known sanitation stakeholder platform or forum in the district though some sanitation issues are sometimes raised at the district assembly meetings Improved Sector Alignment at Local Level in East Gonja The findings on improved sector alignment at local level in the East Gonja district is presented in Figure 44. Figure 44: Findings on Improved Sector Alignment at Local Level in the Lawra District Standards and norms (related to rural sanitation) are aligned. A multi-stakeholder dialogue has started (on rural sanitation) 4 3 All relevant (local) government sector stakeholders are involved in the dialogue. Approaches (to rural sanitation) are aligned. 2 1 All relevant (local) donor (or funding) agencies are involved in the dialogue. Plans (for rural sanitation) are made jointly. 0 Relevant civil society and private sector stakeholders are involved in the dialogue. Sector targets (for rural sanitation) are set jointly by stakeholders. Information and data (evidence base) are shared in the group. Sector priorities (for rural sanitation) are set jointly by stakeholders. 47

49 The East Gonja district had a score of 2 in one (1) sub-sustainability indicator-6; a score of 1 in five (5) sub-sustainability indicator-6; and a score of zero (0) in the remaining four (4) sub-sustainability indicator-6. The basis for the scores is due to the following activities in the district: Active participation and inputs by sector actors during programmes. At the District sub-committee level, the Environmental and Social Services Committee is charged with the responsibility of ensuring that, all the activities of sector actors working in the East Gonja District are harmonized and are of quality to the benchmark set for the District and the nation. At the area council and community level, town hall meetings are organized by the Environmental and Social Services Sub-committee to sensitize the community members about the activities of sector actors, their roles and the roles of the community members. The Environmental and Social Services Sub-Committee members send all communications, correspondence and the concerns raised at town hall meetings to the General Assembly for inputs and actions. Occasionally the District Interagency Coordination Council on Sanitation (DICCS) organizes WASH platforms for outstanding issues in the WASH industry to be addressed by sector actors. Sub-Committee members also organize radio programmes to discuss issues relating to WASH Discussion on the Findings for Sustainability Indicator 6 Table 7: Findings for Sustainability Indicator 6 Average Score per district Detail score Nanumba Nandom Lawra Saboba East KEEA Jasikan South Gonja 1. A multistakeholder dialogue has started (on rural sanitation) 2. All relevant (local) government sector stakeholders are involved in dialogue 3. All relevant (local) donor (or funding) are involved in the dialogue 4. Relevant civil society and private sector stakeholders are involved in the dialogue 5. Information and data (evidence base) are shared in the group 6. Sector priorities (for rural sanitation) are set jointly by stakeholders 7. Sector targets (for rural sanitation) are set jointly by stakeholders 8. Plans (for rural sanitation) are made jointly 48

50 9. Approaches (to rural sanitation) are aligned 10. Standard and norms (related to rural sanitation) are aligned Total score per district Average score per district The major finding from the process is that although districts are decentralized into political and administrative units of the government, they are not sufficiently empowered to execute their roles. There are coordination units, plans, financing, roll out and monitoring of sanitation and hygiene activities at national and region levels. But these are not cascaded to the district level apart from ad hoc trials here and there. Across the districts there is no consistent platform where stakeholders come together to plan, implement, monitor, learn and evaluate together. It was clearer for participants that absence of strong mechanism to harmonize actors effort is one of critical bottle necks to improve sanitation and hygiene service provision in the districts. Although there are not enough non-government actors in districts in the sector, the existing ones are working in isolation. 4.3 Sustainability Indicator 10: Progress in FSM - Emptying and Collection Overall Findings on Safety of Pit Emptying and Collection Figure 45 shows the different ways in which excreta is stored in the sampled households. It can be seen that in most households the excreta is contained and therefore stored in a safe way. Only in 4.5% of the households does the faeces go onto the street/field/open pit. The direct pit is by far the most popular method of excreta storage (83.9%). Water tight double chamber septic tanks are also popular (4.5% of households). Figure 45: Storage of excreta As can be seen in Figure 46, The direct pit is most common in all districts. Jasikan and KEEA have the largest number of alternative excreta storage methods. In Jasikan this is due to the fact that it had the largest percentage of households with access to sanitation. In KEEA this is due to the fact that a considerable amount of households had flush latrines which needs an alternative method of excreta storage than a direct pit. Nandom (13.5%) and Nanumba South (10.0%) saw the largest number of latrines with unsafe storage (i.e. open pit/field/street). 49

51 Figure 46: Storage of excreta across districts As can be seen in Figure 47, about half of the respondents with a below-ground pit (55.6%), had pits which were water-tight. The other half of the respondents had pits which were not water-tight and could theoretically pollute groundwater. 14% of the households with underground pits, actually had a nonwater-tight pit in which groundwater was seeping during construction. It could therefore be said that in those households there is a large danger of groundwater pollution. In the other 30.2% of households there was no groundwater seepage during construction but it is possible that there will be seepage during rainy season (if the pit wasn t dug in the rainy season) or in years with a lot of rain. Figure 47: Groundwater seepage Regarding the safety of pit emptying, it can be seen in Figure 48 that of the households that have had their pit emptied, in the majority of the cases (83.9%), this was done by someone entering the pit 50

52 without wearing full protection. Only in 3.2% was the pit-emptier actually wearing protection. At the other 12.9% of the households which had their pit emptied, a pit-emptier did not have to enter the pit and the emptying was most probably done with a suction device. Figure 48: Method of pit-emptying Figure 49 shows us that in the majority of households, the excreta was not disposed of properly after pit-emptying. In 53.1% of the households, the excreta was emptied into a hole on the compound that was left open. In 3.1% it was actually emptied into drains/water bodies or fields. In 12.5% of the households the excreta was emptied into a drum/open container and taken away. Only in 31.3% of the households was the excreta disposed of properly - either by emptying it in a whole on the compound which is then covered or by taking it away to a dumping site in a closed container/tanker. Figure 49: Disposal of excreta Other data on environmental safety As can be seen from Figure 50, quite a large percentage (29.1%) of the households had their latrine too close to a water source -less than 10m away. This means that the chance of pollution of that water source is relatively high. The other 80.9% of the households had their latrines further away. 51

53 Figure 50: Distance of latrine to nearest water source Around 34.4% of the surveyed households with latrine, had it constructed uphill of a water source. Depending on the distance from the water source and the hydrogeological soil properties this could potentially lead to pollution of the water source. For the other households (65.6%) the latrine was either downhill or at the same level as the water source. This means pollution of the water source is probably not a problem, unless the latrine is constructed too close to it. Figure 51: location of latrine with regard to nearest water source 52

54 5 CONCLUSION AND RECOMMENDATIONS The conclusions and recommendation are derived from the findings of the baseline survey. They are presented according to districts and in general. 5.1 Conclusions of individual districts East Gonja District Most of the respondents in East Gonja (60.7%) were males as compare to 39.3% who are females. Among the respondents, 41.3% were heads of households with 5.2% being female headed households. The average household size in the district is far above the national average of 4.4. The district had the highest number of households with children under two (66.4%) and ranked second with 88.5% of households with children under five years. There are also more women and girls in their reproductive ages in the district compared to the other districts. This explains the high number of children under 2 and five years in households within the district. The district ranked second (16.6%) with household with people with disability behind Jasikan (22.5%). The highest proportion of households (30.7%) in the district fell within the richest wealth quintile and also had the least proportion of households in the poorest wealth quintile. Majority (94%) of the households in the district do not have access to toilet facilities and the predominant type (38%) of toilet found in the district is pit with slab. About 4.5% of households share toilet facilities. With regards to the hygienic use of the toilets, East Gonja district recorded 1% of latrines being used as latrine and functioning as intended (working water seal/lid). East Gonja had the highest proportion of households with hand-washing station for use after defecation (1.3%), and the second highest proportion of households with hand-washing station for use during cooking/food preparation (1.1%). Regarding the sustainability indicators, the capacity of local government to steer sanitation demand creation in East Gonja is low with an average score of 0.6 out of a maximum of 4. Sector alignment is also poor with an average score of 1.3. Although in general the program is adopting community led total sanitation for creating demand it is supposed to be tailored to district context. For this project it is planned to use local leaders (Chiefs and opinion leaders) who are known to be influential in East Gonja. As SNV has been operating in the district it will be a basis to reflect on elements of success and points of improvement where it will inform this project a lesson to be learned Jasikan district Most of the respondents in Jasikan (66.3%) were males as compare to 33.8% who are females. Jasikan had the least (27.5%) proportion of respondents who were heads of households but the second highest district with proportion of female headed households (35%). The average household size in the district is far above the national average of It was among the districts with the least households with children under two years of age (32.5%). About 10% of households in the district had women and girls in their reproductive ages. This explains the low number of children less than two years in households within the district. The district had the highest proportion of people with disability (22.5%). About 10.9% of the households in the district fell within the highest wealth quintile. Jasikan was among districts with the least proportion of households (15.2%) in the poorest wealth quintile. In Jasikan, 46% of households had no toilet facilities. Most households that had access to sanitation were either using unimproved or shared latrines. The predominant type (78%) of toilet found in the district is traditional toilet. 47% of latrines in Jasikan are used as latrines and are also functioning as intended (functioning water seal/lid). The fact that a large % of the households already has an unimproved/shared latrine in Jasikan (probably due to previous interventions in the district), means the project strategy will have to be adapted. Firstly, more focus should be put in improvement of existing latrines during demand creation. Secondly, supply chain development is important, so that cheaper improved latrine options become available for households to upgrade their existing facilities. A large proportion of the latrines (7%) had an unsafe way of storing excreta. This should be tackled during posttriggering follow-up. Even- though no hand-washing facilities in were found for use after defecation, Jasikan did have the highest percentage of households with a hand-washing facility for use before cooking/food preparation (3.6%). 53

55 Regarding the sustainability indicators, the capacity of local government to steer sanitation demand creation in the district is low and sector alignment is also poor with both indicators scoring an average of 0.5 each. The neighbouring district KJB is the best performing where experience sharing visits and peer learning among environmental health staffs of the two districts will be facilitated KEEA District In KEEA most of the respondents (60.2%) were females as compare to 39.8% who are males. Among the respondents 46.1% were heads of households. The district had the highest percentage (37.1%) of female headed households. The average household size in the district is The district was among the districts with the least households with children less than two and five years. It was also among districts with the least proportion of households with women and girls in their reproductive ages. The district ranked second with household with people with disability behind Jasikan. The highest proportion of households (23.8%) in the district fell within the poorest wealth quintile. Majority (92%) of the households in KEEA had no access to toilet facilities and the predominant type of toilet in the district is flush toilet (27%). Regarding the hygienic use of the toilets, 4% of households have a latrines that is being used as latrine and functioning as intended (functioning water seal/lid). The same proportion of households had a hand-washing facility for use after defecation as for use during cooking/food preparation (0.3%). Regarding the sustainability indicators, the capacity of local government to steer sanitation demand creation in the district is low with an average score of 1.1 and sector alignment is also poor with an average score of 0.4. SNV have previous intervention where lessons from that will be informing accelerated implementation of this project. There are traditional norms in the district where community come together for collective action on communal works it will be integrated to adopt the benefit of that for this project Lawra District Lawra had the highest proportion of respondents being males (72.5%). The district also had the highest proportion of respondents who are heads of households (76.9%) with 26.9% being female headed households. The average household size in the district is 7.8. The district had the least percentage of 31.9% and 50% of households with children under two and five years respectively. Lawra had the least proportion of households with women and girls in their reproductive ages 58%. This explains the low number of children under two and five years in households within the district. The district is among districts with households with the least people with disability behind Nandom. The district had the highest proportion of households in the poorest wealth quintile (38.9%). Majority (78%) of the households in the district had no access to toilet facilities. The predominant type of toilet found in the district is pit without slab (68%). Regarding the hygienic use of the toilets, 11% of households have a latrine that is being used as latrine and is functioning as intended (functioning water seal/lid). 0% of the surveyed households had a hand-washing facility for use after defecation or during cooking/food preparation. The capacity of the Lawra district s local government to steer sanitation demand creation in the district is low with an average score of 1.7 even though it had one of the highest scores among the sampled districts. The district s sector alignment is poor with an average score of 0.6. The presence of care international with similar objective will be exploited to realize district ODF in a coordinated effort Nandom district In Nandom, 67.6% of the respondents are males as compare to 32.4% who are females. Among the respondents 39.2% were heads of households with 8.0% being female headed households. The average household size in the district is 6.9. Lawra is among districts with the least proportion of households with children less than two and five years. The district ranked third among the districts with proportion 54

56 of households with women and girls in their reproductive ages. The district had the least proportion of households (61.4%) with people above 50 years and also the least proportion of households with people with disability. Nandom had the least proportion of households in the richest wealth quintile (7.1%). The district ranked second among districts with the highest proportion of households in the poorest wealth quintile. Majority 79 %) of the households in the district had no access to toilet facilities and the predominant type (37%) of toilet found in the district is the traditional pit latrine. Regarding the hygienic use of the toilets, 13% of households has a latrine that is being used as latrine and is functioning as intended (functional water seal/lid). A large proportion of the latrines (13.5%) had an unsafe way of storing excreta. This should be tackled during post-triggering follow-up. 0% of the surveyed households had a hand-washing facility for use after defecation or during cooking/food preparation. Regarding the sustainability indicators, the capacity of local government to steer sanitation demand creation in the district is low average score of 1.7 and sector alignment is considered average with an average score of 2.2 which is the highest score among the sampled districts. The existence of large number of environmental health staff will be used as an advantage for massive intervention planned to achieve high service improvement moreover like Lawra Care international experience will be scaled up for accelerated implementation of the project Nanumba South District In Nanumba South 63.7% of the households are males as compare to 36.3% who are females. Among the respondents 72.1% were heads of households with 3.6% being female headed households. Nanumba South had the highest household size of The district is among districts with the highest proportion of households with children under two years (61.8%) and ranked first with 89.2% of households with children under five years. This is also the second ranked district with the highest proportion of households with women and girls in their reproductive ages (95.6%). This explains the high number of children under two and five years in households within the district. The district had the highest proportion of households with people above 50 years (83.3%). The proportion of households with disability was 18.7%. In Nanumba South the highest proportion of households fell in the third wealth quintile. Nanumba South had only 3% of its Households sharing their toilet facilities. Majority (96%) of the households in the district have no access to toilet facilities. The predominant type (58%) of toilet found in the district is the ventilated improved pit latrine. Regarding the hygienic use of the toilets, 3% of households have a latrine that is being used as latrine and is functioning as intended (functioning water seal/lid). A large proportion of the latrines (10.0%) had an unsafe way of storing excreta. This should be tackled during post-triggering follow-up. 0% of the surveyed households had a hand-washing facility for use after defecation or during cooking/food preparation. Regarding the sustainability indicators, the capacity of local government to steer sanitation demand creation in the district is low with an average score of 0.9 and sector alignment is also poor with an average score of 0.7. Absence of any previous intervention in the district will be leverage for swift implementation of CLTS as the community is not spoiled by subsidy and there is strong cohesion among community members. It will also give SNV a chance to test the effect of its service delivery when operating in complete product package Saboba District Saboba district had the highest proportion of respondents being males (72%). Among the respondents 40.2% were heads of households. The district had the least proportion of female headed households (2.6%). The average house household size in the district is The district is among districts with the highest proportion of households with children less than two and five years 51.9% and 80.6%respectively. This is also the third ranked district with the highest proportion of households with women and girls in their reproductive ages (94.1%). It was among districts with the least proportion of households with people above 50 years (61.8%). The proportion of households with disability was 6.5%. In Saboba the highest proportion of households (24.8%) fell in the poorest wealth quintile. Majority (93%) of the households in the district have no access to toilet facilities. And the predominant 55

57 type (78%) of toilet found in the district is the ventilated improved pit latrine. Regarding the hygienic use of the toilets, 2% of households have a latrine that is being used as latrine and is functioning as intended (functioning water seal/lid). Regarding the sustainability indicators, the capacity of local government to steer sanitation demand creation in the district is the lowest with an average score of 0.4. There is no sector alignment in district as it scored zero in all sub-indicators. Saboba is also one of the districts with a high percentage of open defecation where there is a need to reflect critically how to make an accelerated improvement. The presence of world vision is also added value. SNV is also operating in the district where the lessons will feed in to this project. 5.2 Overall conclusions and recommendations Overall Conclusions: The coverage for household toilet facilities is extremely low in all the districts where the study was conducted. 89% of the total respondents interviewed did not have access to any toilet facility for defecating, and a further 4% had a facility which was not used, resulting in a total of 93% of households not using a toilet. Only 3.4% had improved toilet facilities, including those which are environmentally safe and with fly management. 3.5% of the sanitation facilities is unimproved and a further 3.7% is shared. The JMP 2012 report revealed 44% of households to have access to shared sanitation in rural areas, however this large difference can be attributed to a difference in definition whereby the JMP counts public latrines as shared latrines but this study considered public latrine as a practice of open defecation. The JMP reported figure for access to improved sanitation in rural areas (2012) is about 4.6% higher than our figure. This difference is not very large and can be attributed to the fact that our study was only conducted in 7 districts which are perhaps not representative for the whole country. The most common latrine technology in the surveyed districts is the traditional pit latrine (35% of all latrines). The Ventilated Improved Pit Latrine and the pit toilet with slab are also common (28% and 21% respectively). Most households are aware of the importance of hand-washing after defecation and before eating. The importance of washing hands before cooking/preparing food, feeding children, and cleaning the latrine/child s potty was mentioned to a lesser extent by the households. About 99% of households did not have a hand-washing facility close to their place of defecation or cooking/food preparation. Therefore it cannot be known if their knowledge about hand-washing is actually put into practise. It was found that in general if a household had a latrine that was in use, it is functioning well. Storage of excreta is done properly in most of the cases (95.5%). Emptying of the latrine is mostly done in an unsafe manner. In 83.9% of the households that had their pit emptied, someone had to go into the pit without wearing full protection. Furthermore in more than 50% of the households, the excreta was thereafter disposed of unsafely. It was also found that about 29.1% of the latrines were built to close to a water source (less than 10m). The capacity of local governments to steer demand creation at scale in their respective districts was very low. All districts did have a DESSAP (District Environmental Sanitation Strategy and Action Plan), which mentioned sanitation demand creation. However in almost none of the districts was this actually carried out (lack of funds being the main cited reason). Furthermore, monitoring was a weak point in all districts. In most districts it hasn t been carried out due to lack of funds. If it has however, information is not shared or used to improve strategies. Mobilising local government/leaders for action in sanitation is generally not done either. Sector alignment in sanitation is even less. In most districts there is no district platform to discuss sanitation. In the districts where such a platform exists, it is only used in situations or periods when sanitation is a critical issue (e.g. cholera outbreak) Overall Recommendations: The low figures for access to sanitation emerging from this study reveal the necessity for action. Previous interventions including subsidizing latrine construction and awareness-raising have not worked sufficiently and new and improved methods have to be used. It is expected that especially demand creation through CLTS will be able to largely increase the number of households with access to at least unimproved sanitation. Improved supply chain development will hopefully pull these households further up the sanitation ladder to make sure that eventually the number of households with improved sanitation will also increase. As no strong relationships were found between head of household access to sanitation and wealth - access to sanitation, a differentiated approach per type of household does not 56

58 seem necessary. It was however found that there is some variation among districts in access to sanitation. In Jasikan, where 54% of households already have access to sanitation for example (largely unimproved and shared) relatively less attention should be put on demand creation and more on supply chain development for example. Households knowledge on the importance of hand-washing should be increased through the behavioural change component and during post-triggering follow-up. Special attention should be put on the importance of hand-washing before cooking, feeding children and cleaning of the latrine/potty. Increasing the number of hand-washing facilities is critical and households should be educated on simple ways of doing this (e.g. use of tippy tap). Functionality of latrines already seems to be sufficient, however will of course be monitored during the duration of the project. More important is the necessity of technical support during the construction of the latrine to make sure it is not constructed to close to water sources and that faeces are wellcontained. In later stages of the project a lot of attention should be placed on improved faecal sludge management to make sure entering pits without protective clothing is reduced. Strengthening the capacity of local governments is crucial to increase the sustainability of the results. Special attention should be placed on monitoring. The importance of monitoring should be understood, and tools should be in place so that collected monitoring data is useful and complete (e.g. including information about inclusion), that this information is shared and used to improve actions in the future. Furthermore it is important to set up discussion platforms on sanitation at district level to make sure that alignment among stakeholders is ensured. 57

59 REFERENCES 1. Ghana Statistical Service (2012) Population and Housing Census, summary report of final results. 2. Ghana Statistical Service (2008). Ghana Living Standards Survey, Report of the fifth round (GLSS 2005) 3. Ministry of Local Government and Rural Development, Environmental Health and Sanitation Directorate (2012). Rural Sanitation Model and Strategy (RSMS) 4. Ministry of local government and rural development (2010). Environmental Sanitation Policy (ESP) 5. WHO/UNICEF (2014). Joint Monitoring Programme (JMP) for Water Supply and Sanitation, 2014 Report 58

60 APPENDIX 1. HOUSEHOLD QUESTIONNAIRE 1. Sequence of the modules of this questionnaire: 2. Household information panel (HH) 3. Household members (HM) 4. Household characteristics /wealth index (W) 5. Sanitation (SAN) 6. Use of Sanitation (USAN) 7. Hand washing (HW) 8. Country-specific questions (C) 9. Observations HOUSEHOLD INFORMATION PANEL HH HH1. Cluster number:... HH2. Household No. :... HH3. Interviewer name and number: Name... HH4. Supervisor name and number: Name... HH5. Day / Month / Year of interview: HH6. Village: HH8A. Groundwater table in this village (metres): / / HH7. District: District 1 1 District District 3 3 HH9. What is the dominant soil-type in this village? Clay / silt:..1 Sand:.2 Gravel:.3 WE ARE FROM SNV country. WE ARE WORKING ON A SANITATION AND HYGIENE PROJECT. I WOULD LIKE TO TALK TO THE PERSON IN THIS HOUSEHOLD WHO KNOWS ABOUT SANITATION AND HYGIENE. THE INTERVIEW WILL TAKE ABOUT MINUTES. THE ANSWERS YOU GIVE WILL HELP TO IMPROVE THE PROJECT. ALL THE INFORMATION WE OBTAIN WILL REMAIN STRICTLY CONFIDENTIAL AND YOUR ANSWERS WILL NEVER BE SHARED WITH ANYONE OTHER THAN OUR PROJECT TEAM. MAY I START NOW? Yes, permission is given RECORD THE TIME AND THEN Begin the interview. No, permission is not given Complete HH10. If permission is not given, leave the house, and turn left: take the first house as the replacement of this household. Discuss this result with your supervisor. Record the time. Hour... Minutes... AFTER THE QUESTIONNAIRE FOR THE HOUSEHOLD HAS BEEN COMPLETED, FILL IN THE FOLLOWING INFORMATION: HH10. Result of household interview: Completed No household member or no competent respondent at home at time of visit 02 Entire household absent for extended period of time 03 Interview refused Dwelling vacant / Address not a dwelling Dwelling destroyed Dwelling not found Other (specify): 99 59

61 HH11. Name of respondent to questionnaire: Name: HH12. Respondent sex: Male.1 Female 2 Guidance to interviewer: All text in capital letters needs to be read aloud to the respondent All texts in italic are instructions to the interviewer /enumerator and should not be read aloud to the respondent Questions shaded blue require the interviewer to both ask the question, and observe Questions in black: questions we need to report to DFID Questions in blue: questions which provide insight, not needed for reporting to DFID HOUSEHOLD MEMBERS HM HM1. Name of head of household: HM1A. Gender of household head: Female Male HM2. Number of women aged 50 years and older: HM3. Number of men aged 50 years and older: HM4. Number of women aged years: HM5: Number of men aged years: HM6. Number of girls aged 6-14 years:... HM7. Number of boys aged 6 14 years: HM8. Number of girls aged 3 5 years: HM9. Number of boys aged 3 5 years: HM10. Number of girls aged 0 2 years: HM11. Number of boys aged 0 2 years: HM12. Total number of household members: HM13. Because of a health problem or old age, how many persons in your household have: Difficulty seeing Difficulty walking or climbing steps Difficulty with self-care such as washing or dressing? 1. No difficulty 2.Some difficulty 3.A lot of difficulty 4.Unable to do it Probe Total number of people in this household with special needs (all those with a 3. lot of difficulty and/or 4. unable to do it): 60

62 HOUSEHOLD CHARACTERISTICS / WEALTH INDEX W Note: Insert Country-specific household characteristics module here (the one shown here is for Nepal) NEPAL 2011 WEALTH INDEX QUESTIONNAIRE PLEASE DO NOT CHANGE THE QUESTION CODES, RESPONSES OR RESPONSE CODES Code Question Response codes Questionnaire code URBRU R NOTE WHETHER THE PERSON LIVES Urban. 1 IN AN URBAN OR RURAL AREA Rural...2 W01 What is the main source of drinking water for members of yourpiped WATER household? PIPED INTO DWELLING PIPED TO YARD/PLOT PUBLIC TAP/STANDPIPE TUBE WELL OR BOREHOLE DUG WELL PROTECTED WELL UNPROTECTED WELL WATER FROM SPRING PROTECTED SPRING UNPROTECTED SPRING RAINWATER TANKER TRUCK SURFACE WATER (RIVER/DAM/ LAKE/POND/STREAM/CANAL/ IRRIGATION CHANNEL) STONE TAP/DHARA BOTTLED WATER OTHER 96 (SPECIFY) 61

63 W02 What kind of toilet facility do members of your household usually FLUSH OR POUR FLUSH TOILET FLUSH TO PIPED SEWER use? SYSTEM FLUSH TO SEPTIC TANK FLUSH TO PIT LATRINE FLUSH TO SOMEWHERE ELSE FLUSH, DON'T KNOW WHERE PIT LATRINE VENTILATED IMPROVED PIT LATRINE PIT LATRINE WITH SLAB PIT LATRINE WITHOUT SLAB/ OPEN PIT COMPOSTING TOILET BUCKET TOILET NO FACILITY/BUSH/FIELD OTHER 96 (SPECIFY) W03 Do you share this toilet facility with other households? YES NO Does your household have: W04 W05 W06 W07 W08 W09 W10 W11 W12 W13 W14 W15 W16 W17 W18 Electricity? A radio? A television? A mobile telephone? A non-mobile telephone? A refrigerator? A table? A chair? A bed? A sofa? A cupboard? A computer? A clock? A fan? A dhiki/janto? YES NO ELECTRICITY RADIO TELEVISION MOBILE TELEPHONE NON-MOBILE TELEPHONE REFRIGERATOR TABLE CHAIR BED SOFA CUPBOARD COMPUTER CLOCK FAN DHIKI/JANTO

64 W19 What type of fuel does your ELECTRICITY household mainly use for cooking? LPG NATURAL GAS BIOGAS KEROSENE COAL, LIGNITE CHARCOAL WOOD STRAW/SHRUBS/GRASS AGRICULTURAL CROP ANIMAL DUNG NO FOOD COOKED IN HOUSEHOLD OTHER 96 W20 What is the MAIN MATERIAL OF THE NATURAL FLOOR FLOOR in your household? EARTH/SAND/DUNG RUDIMENTARY FLOOR WOOD PLANKS PALM/BAMBOO FINISHED FLOOR PARQUET OR POLISHED WOOD VINYL OR ASPHALT STRIPS CERAMIC TILES CEMENT CARPET OTHER 96 (SPECIFY) W21 What is the MAIN MATERIAL OF THE NATURAL ROOFING ROOF in your household? NO ROOF THATCH/PALM LEAF RUDIMENTARY ROOFING RUSTIC MAT PALM/BAMBOO WOOD PLANKS CARDBOARD FINISHED ROOFING GALVANIZED SHEET WOOD CALAMINE/CEMENT FIBER CERAMIC TILES CEMENT ROOFING SHINGLES OTHER 96 63

65 W22 What is the MAIN MATERIAL OF THE NATURAL WALLS EXTERIOR WALLS in your household? NO WALLS CANE/PALM/TRUNKS /MUD/SAND RUDIMENTARY WALLS BAMBOO WITH MUD STONE WITH MUD PLYWOOD CARDBOARD REUSED WOOD FINISHED WALLS CEMENT STONE WITH LIME/CEMENT BRICKS CEMENT BLOCKS WOOD PLANKS/SHINGLES OTHER 96 W23 How many rooms in your household are used for sleeping? ROOMS W24 W25 W26 W27 W28 W29 Does any member of your household own: YES NO A watch? WATCH A bicycle/rickshaw? BICYCLE/RICKSHAW A motorcycle or motor scooter? MOTORCYCLE/SCOOTER A three wheel tempo? THREE WHEEL TEMPO An animal-drawn cart? ANIMAL-DRAWN CART A car or truck? CAR/TRUCK W30 W31 Does any member of your household own any agricultural land? YES NO W32 How many hectares of agricultural land do members of this household own? W32 HECTARES Does your household own any livestock, herds, other farm animals, YES or poultry? NO W42 64

66 How many of the following animals does your household own? IF NONE, ENTER '00'. IF 95 OR MORE, ENTER '95'. W33 W34 W35 W36 W37 W38 W39 W40 W41 Buffalo? Milk cows or bulls? Horses, donkeys, or mules? Goats? Sheep? Chickens? Ducks? Pigs? Yaks? BUFFALO COWS/BULLS HORSES/DONKEYS/MULES..... GOATS SHEEP CHICKENS DUCKS PIGS YAKS W42 Does any member of your household YES have a bank account/ cooperative/ or other savings account? NO W43 How many people live in your YES household? NO W44 Do you own your house or any other YES house either alone or jointly with someone else? NO

67 SANITATION Now I would like to ask you some questions specifically about sanitation. SAN1. DO THE MEMBERS OF YOUR HOUSEHOLD HAVE A TOILET? SAN2. What type is it? Can you please show it to me? Record observation, circle which type applies. Circle only one. Ask if you can take photos of the toilet (outside front, inside, outside back). No toilet, practice OD 95 Use toilet 2 Flush/pour flush toilet...11 Ventilated improved pit latrine (VIP) Pit latrine with slab..13 Pit latrine without slab..14 Composting toilet..15 Urine diversion toilet..16 Bucket..23 Hanging toilet or hanging latrine 24 Country specific type, specify Country specific type, specify..26 SAN 95 USAN6 Other.99 Specify: SAN2A. Where do the faeces go? To the street, field or open pit To a pond To the river or storm water drain To a direct pit To an off-set pit To a double (alternating) off-set pit To alternating compartments (ecosan) To two sequential pits To a water tight pit To a water tight double chamber septic tan To piped sewer Other SAN3. Can rats reach the faeces in any way? No Yes SAN4. How many households use the toilet? SAN5. DOES THE TOILET PAN OR SLAB ALLOW FLIES TO GO IN AND OUT OF THE PIT? OBSERVE THE CONSTRUCTION OF THE TOILET TOGETHER WITH THE RESPONDENT. SAN5A. IS THE TOILET SLAB WASHABLE AND/OR CLEANABLE? One (only own household)...1 More than one Yes..1 No...2 No...1 Yes, cleanable, but not washable.2 Yes cleanable and washable

68 SAN6. IS THE TANK/PIT ABOVE THE GROUND? ONLY FOR HOUSEHOLDS WITH ANSWER 2 OR 3 TO QUESTION SAN6: SAN7. HOW DEEP IS THE PIT BELOW THE SURFACE? (METERS) IF UNSURE WHEN THE PIT WAS BEING DUG, WAS THE PIT DEEPER THAN THE RESPONDENT? ENUMERATOR TO MAKE AS ESTIMATE OF RESPONDENT S HEIGHT SAN8. CAN (GROUND) WATER GET IN OR OUT OF THE PIT? SAN9. When the pit was dug, was any ground water seeping in? SAN10. Does the pit or toilet leak or overflow waste water at any time of the year? Consider rainy season too. SAN11. What is the horizontal distance to the nearest water source used for drinking? SAN12. Is that water source uphill or downhill from the toilet? Yes..1 No...2 Partly 3 metres Don t know Yes..1 No 2 Don t know Yes..1 No 2 Don t know.9 8 Yes..1 No 2 Don t know.9 8 Less than 10 metres.1 Between 10 and 50 metres...2 Between 50 and 100 metres 3 More than 100 metres 4 Downhill..1 Uphill.2 At same level SAN10 67