Enabling Environment Endline Assessment: Himachal Pradesh and Madhya Pradesh, India

Transcription

1 WATER AND SANITATION PROGRAM: WORKING PAPER Scaling Up Rural Sanitation Enabling Environment Endline Assessment: Himachal Pradesh and Madhya Pradesh, India Andy Robinson April 2012 The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services.

2 By Andy Robinson This report is based on fieldwork and research funded by the Water and Sanitation Program (WSP). The fieldwork and research could not have taken place without the support and assistance of the Government of Himachal Pradesh (Rural Development Department, Irrigation and Public Health Department), the Government of Madhya Pradesh (Panchayat and Rural Development Department, Public Health Engineering Department), the Government of India, and the Water and Sanitation Program South Asia. Special thanks are due to Ajith Kumar, K. Arokiam, Lira Suri, and Nitika Surie for their kind assistance and support in India. Designated a core business area in 2011, WSP s Scaling Up Rural Sanitation is working with governments and the local private sector to develop the knowledge needed to scale up rural sanitation for the poor. The programmatic approach combines Community-Led Total Sanitation (CLTS), behavior change communication, and sanitation marketing to generate sanitation demand and build up the supply of sanitation products and services at scale. In addition, WSP works with local and national governments and the local private sector to strengthen the enabling environment including institutional, regulatory, financial, service-delivery, and monitoring capacities to achieve change that is sustainable. Starting in India, Indonesia, and Tanzania in 2006, Scaling Up Rural Sanitation is currently being implemented in over a dozen countries. For more information, please visit This Working Paper is one in a series of knowledge products designed to showcase program findings, assessments, and lessons learned through WSP s Scaling Up Rural Sanitation initiatives. This paper is conceived as a work in progress to encourage the exchange of ideas about development issues. For more information please Eddy Perez at wsp@worldbank.org or visit WSP is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP s donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. WSP reports are published to communicate the results of WSP s work to the development community. Some sources cited may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The material in this publication is copyrighted. Requests for permission to reproduce portions of it should be sent to wsp@worldbank.org. WSP encourages the dissemination of its work and will normally grant permission promptly. For more information, please visit Water and Sanitation Program

3 Scaling Up Rural Sanitation Enabling Environment Endline Assessment: Himachal Pradesh and Madhya Pradesh, India

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5 Executive Summary The Water and Sanitation Program (WSP) has been implementing the Scaling Up Rural Sanitation initiative since One of the central objectives of the program is to improve sanitation at a scale sufficient to meet the 2015 sanitation MDG targets in Indonesia, Tanzania, and the Indian states of Himachal Pradesh (HP) and Madhya Pradesh (MP). Although WSP provided similar levels of support and promoted similar approaches and tools in both HP and MP, the starting contexts were different, with HP recognized as a small, relatively progressive, and wealthy state, and MP as one of the largest and least developed states in India. Rural sanitation coverage was higher in HP, but was still low at only 28 percent in , creeping up to 34 percent by 2006; rural sanitation coverage in MP was extremely low at baseline, reaching only 10 percent in Both states faced a huge sanitation challenge, but it was clear that the larger challenge was in MP. One of the key differences between the methodology for the program in India and that in either Tanzania or Indonesia is the pre-existence of a large-scale, national rural sanitation program, The Total Sanitation Campaign (TSC). TSC is a huge and ambitious program in its current phase, the national TSC budget exceeds US$3.9 billion, with a goal in the next five-year phase ( ) of providing toilets to 115 million households. It aims to achieve open defecation free status across the country by TSC provides a broad financial, policy and institutional framework for sanitation improvement in India, but allows individual states and districts the freedom to develop local policies and interventions according to their specific needs and priorities. This freedom limits central control of program methodology, but allows more progressive local governments to develop and implement new approaches and policies. As a result, there is a wide variation in the effectiveness and outcomes of TSC in different states. Although TSC has been operating since 1999, it has promoted the elimination of open defecation and the achievement of collective sanitation outcomes only since the introduction of the complementary Nirmal Gram Puraskar (NGP) awards in In the last few years, TSC and NGP guidelines provided a well-understood framework for sanitation and hygiene improvement, with most state and district governments now actively engaged in rural sanitation promotion and sanitation-related activities. Prior to the program, WSP had established a good relationship with the Governments of HP and MP, and during the program has supported the TSC in both states, working to enhance and broaden the level of support provided: to leverage TSC resources and sector opportunities at the national level; to extend its pre-existing engagements at the state level; and to facilitate achievement of the program objectives and outcomes. Methodology A baseline assessment of the enabling environment in Himachal Pradesh and Madhya Pradesh was carried out in July and August An endline assessment of the enabling environment took place in mid-2010 using a similar methodology and interview guide to the baseline assessment. To ensure consistency in the assessment findings, WSP developed a conceptual framework for assessing the enabling environment for sanitation. This framework, developed on the basis of a literature review and discussions with key actors, consists of eight dimensions considered essential to scaling up rural sanitation, including: Policy, strategy, and direction Institutional arrangements Program methodology Implementation capacity Availability of products, tools, and information Financing and incentives Cost effective implementation Monitoring and evaluation 1 Government of India (2001) Census of India iii

6 Executive Summary Findings TSC and NGP continue to provide excellent frameworks for rural sanitation development through the provision of adequate finance, basic technical guidelines, and institutional incentives. Sanitation is a state subject, allowing considerable latitude in how these resources and mechanisms are used by local governments, and resulting in highly variable outcomes across states. Therefore, despite rural sanitation development being guided by the TSC and NGP, the enabling environment at state level has a significant impact on sanitation activities and outcomes. In 2010, rural sanitation coverage in HP is estimated to have passed 80 percent, an increase of around 50 percent in only four years; whereas coverage in MP is estimated at around 17 percent, barely 7 percent growth during the same four-year period. Given similar government programs and program support, it is significant that the HP program has accelerated dramatically over the last three years, while the MP program has struggled to reach the average coverage level in India. There was a huge difference in the scale of challenge in MP, and some credit is due as both states have managed to provide sustainable sanitation to a similar number of households over the last three years, with an additional 600,000 or so households covered in each state. However, HP is a much smaller state and achieved this coverage gain with rural sanitation expenditures of around US$8 million, compared to more than US$80 million invested in MP. While there are undoubtedly higher cost factors in the huge scale of the MP program, and in the higher proportions of poor and marginalized households, this endline assessment found that the significantly better cost-effectiveness in HP reflects a much stronger enabling environment than that found in MP. Enabling environment in Himachal Pradesh Significant improvements were apparent in the enabling environment for rural sanitation in Himachal Pradesh since baseline. Strong political support for sanitation, led by the Chief Minister, has galvanised local leaders and administrators, enabling already competent local governments to use all of their capacity and resources to address sanitation deficits. The state government stood firm on the no-subsidy policy introduced in 2005, despite concerns that HP was losing out by not utilizing the growing BPL latrine incentive funds available through TSC. There was a consensus that a demand-led approach, rather than a supply-driven and subsidized approach, was working well. This consensus was fed by widely reported open defecation free (ODF) successes and expanding evidence of the benefits of improved sanitation, which led to strengthened local government commitment to TSC implementation and rapid scaling up of progress. Regular monitoring and benchmarking of TSC progress, including spot checks by senior state officials and weekly videoconferences with the chief minister, at which TSC progress was discussed, provided incentives for district administrators to prioritize the program, and encouraged improved coordination and cooperation between local government departments. Competition between neighboring areas was also an important motivation, driven by the regular WSP benchmarking reports that the government adopted as its key performance monitoring tool. Nirmal Gram Puraskar (NGP) awards remain an important incentive for sanitation development by local governments, but the institutionalization of the state sanitation awards in HP over the last three years has been even more effective in generating political and popular support for rural sanitation improvement. The state sanitation awards target a broader group of stakeholders, including school children and women s self-help groups, and have deliberately involved elected representatives from local government in judging and presenting the awards. As a result, a large proportion of the population is familiar and engaged with the awards, which are seen to recognize and promote a Himachali vision of purity and cleanliness. Good use was made of WSP technical support, with capacity building organized in advance of strategic needs, and regular demands made for WSP support in new areas as the program progressed and scaled up. Exposure visits were used to introduce and validate new approaches, and the full-time presence of the WSP state coordinator was important in maintaining momentum and interest. Overall, a more institutional and enabling approach has been developed, with continuous sanitation development now iv Scaling Up Rural Sanitation

7 Executive Summary seen as an integral part of the government program. The vision of an open defecation free Himachal Pradesh (Nirmal Himachal) by 2012, which seemed unlikely at the outset of the program in 2007, is now viewed as a realistic and achievable goal. At baseline, two or three exceptional districts were performing well whereas today, at endline, only two or three districts out of the twelve in Himachal Pradesh are lagging behind, and even these supposed laggards report that more than half of their villages are now ODF. Enabling Environment in Madhya Pradesh There is little evidence that the enabling environment for rural sanitation has improved in MP since baseline, despite the relocation of TSC within the Panchayat and Rural Development department (PRD). Significant implementation efforts and investments have been made in rural sanitation through the program, TSC, NGP, and NREGA programs and projects, and through substantial technical support provided by UNICEF, WaterAid, and other development partners. However, this work has translated into relatively meager benefits due to the lack of high-level engagement, commitment, or priority. Political support for sanitation remains limited. There was little evidence that local leaders or administrators see sanitation improvement as a priority: the chief minister has not yet presented the 2009 NGP awards to the winning village heads, and no state sanitation awards had been made more than two years after inception. There is little involvement or coordination of TSC activities with those of other government departments, and there appears little recognition of the cross-sectoral benefits of effective sanitation improvement. While few reliable data were available, the policies and approaches adopted in MP do not appear cost-effective. Total investments in rural sanitation over the last three years are estimated to be about ten times higher than those in HP and, while TSC online monitoring data report dramatic increases in sanitation coverage, more rigorous large-scale household surveys and recent WSP assessments suggest that many of the latrines built through TSC in MP are not being used. In addition, the use of multiple program subsidies to finance latrine construction means that the leverage ratio is also low program investments are not leveraging much household investment in latrines which is limiting the scale and spread of improved outcomes. WSP has undertaken similar activities to strengthen the enabling environment in both HP and MP, including exposure visits, capacity building, performance benchmarking, targeted assessments, and sharing of best practices. This approach proved successful in HP, where local government was receptive and engaged in the process but has had only limited success in MP. While some of the problems stem from the more challenging context in MP, the conclusion of this assessment is that the failure of the state government to embrace critical elements of the approaches promoted by the program such as the need to move away from a supply-driven approach toward a demand-based total sanitation approach limited high-level recognition of the problems and prevented the reforms required to improve the enabling environment. Enabling Environment at National Level One of the lessons from the HP and MP assessments is that high latrine subsidies can create implementation problems because of the temptation to revert to supply-driven approaches and short-circuit demand creation processes. The rising BPL incentive in MP has increased the use of supplydriven approaches, which in turn has diminished efforts to generate genuine demand for latrines or to encourage user involvement in the process. In contrast, the zero hardware subsidy adopted in HP, which resulted from the decision not to use the BPL incentive funds provided by the TSC, encouraged local governments to develop cost-effective approaches to demand generation and institutional support, and ensured that households who built latrines felt ownership, responsibility, and pride in their facilities. The recent WSP rapid assessment of TSC processes and outcomes provided good evidence of the association between process quality and TSC project performance. Discussions with the Department of Drinking Water Supply (DDWS) revealed that support for the total sanitation approach, which was relatively low in central government at baseline, has increased substantially as evidence of the higher sustainability and cost-effectiveness of this approach over more supply-driven approaches has emerged. However, DDWS has little authority to impose specific approaches and tools v

8 Executive Summary on independent state and district projects, and is thereby restricted to knowledge management and advocacy activities to share best practices, highlight implementation issues, and strengthen accountability for program outcomes. Nirmal Gram Puraskar NGP continues to be a controversial program. Recent evaluations by UNICEF and others found NGP-awarded villages with low sanitation coverage and significant levels of open defecation, raising questions about the integrity of the NGP verification process and the sustainability of sanitation outcomes generated by the NGP awards. This assessment concludes that the positive effects of NGP in generating political attention to sanitation improvement, and in galvanizing local government activity, far outweigh the problems associated with the process. NGP fulfils its original function well, in that it creates incentives for local governments to achieve collective sanitation outcomes and it draws considerable political attention to rural sanitation improvement. NGP was never meant to be a mechanism for ensuring the long-term sustainability of these outcomes. Since baseline, NGP has been strengthened to add some emphasis to sustainability, but a complementary program is needed to provide the long-term institutional support and monitoring that will ensure more sustainable improvements in rural sanitation. WSP Enabling Environment Role The WSP team played an important role in developing the enabling environment for rural sanitation at both the national and at the state level in HP. However, it has had only limited success in influencing the enabling environment in MP, and it lacks the staff capacity to implement parallel support programs in a number of other Indian states that have asked WSP for assistance of the type provided by the program. The WSP team acknowledged that it became apparent over the last year or so that the program in MP lacked the high level political influence required to shift the policy on latrine subsidies and supply-driven approaches or to generate real political engagement with both TSC and NGP programs. As a result, many of the lower level activities related to program implementation have not been as successful or as cost-effective as hoped. The lesson appears to be that implementation support should not be scaled up until the government is fully engaged and some minimum enabling environment conditions are met; otherwise there will be a significant opportunity cost to any investment. Potential to Achieve Sanitation MDG The 2015 MDG for sanitation is to halve the proportion of the population without access to basic sanitation (using a 1990 baseline). The lack of sanitation data disaggregated by state makes it difficult to estimate the 1990 baseline, but it has been assumed that 1990 rural sanitation coverage in MP was close to the national average of 7 percent, which would set the 2015 MDG for rural sanitation at 54 percent coverage; and the 1990 baseline in HP was around 15 percent, setting the MDG at 58 percent. At the end of the program, it appears that HP has already surpassed its 2015 MDG target. The 2008 District Level Household and Facility Survey (DLHS) reported rural sanitation coverage of 53 percent, while recent estimates suggest that coverage has passed 80 percent in In MP, the 2008 DLHS found that rural sanitation coverage had increased to only 10 percent, while recent forecasts suggest that coverage is unlikely to be much higher than 17 percent in At the current rate, which is around 2.5 percent increase in rural sanitation coverage per year, MP will not reach its MDG until Key Lessons The success of the HP TSC project, to which the program contributed, has shown that, under the right conditions, rapid and large-scale sanitation progress is possible in only a few years; and that ODF success rates need not be limited to the 35 percent suggested by previous implementation experiences. When the enabling environment is well developed, and strong political support drives implementation, universal sanitation can become a realistic and achievable goal within a relatively short period. This endline assessment found that political support and priority were central to the success of TSC and NGP programs in HP. While the reasons for the development of this political support are complex, it seems likely that the early successes provided by a combination of progressive state vi Scaling Up Rural Sanitation

9 Executive Summary sanitation policies and exceptional leadership in Mandi District were sufficient to demonstrate that new approaches worked and that rapid sanitation improvements were possible. In addition, there was some convergence between the aims of TSC, Himachali cultural mores, and a growing environmental movement, which made sanitation improvement a politically viable and attractive cause for leaders like the chief minister. Recommendations As a result of this endline assessment of the enabling environment, there are specific recommendations for support to non-performing states. The experience in MP suggests that where the enabling environment is not supportive or developed, the initial focus should be on the development of model districts rather than large-scale implementation or technical assistance, so that local approaches and successes can be showcased to increase support for rural sanitation improvement. The intention is to limit investment until the enabling environment improves, and to use program funds to reward improved performance and good governance (for example through scaling up in model districts) rather than spreading efforts thin before supportive conditions are in place. Wherever possible, model districts should introduce evidence-based approaches to challenge supply driven implementation and subsidy cultures, attempt to demonstrate that poor households can build improved sanitation facilities without up-front subsidies, and that more sustainable outcomes result from the generation of genuine demand and ownership for household latrines. Recommendation 1: Reformulate the Total Sanitation Campaign TSC was designed as a framework for five-year district projects. It therefore assumed an intensive, campaign-mode approach suited to a short lifespan. In practice, it has already run for 10 years in some districts, and looks likely to operate on a long-term basis in many more. Furthermore, it was developed from the more technical and constructionoriented Central Rural Sanitation Program (CRSP), whereas the emphasis is now largely on behavior change and public health issues. As such, the program design should be reformulated to reflect the longer-term objectives of sanitation improvement, and to incorporate a more public health-based framework for measuring sanitation and hygiene outcomes. In addition, TSC guidelines, which have been evolving gradually as TSC itself changes, should be developed into a more formal rural sanitation policy one that is relevant for all rural sanitation interventions not just those under TSC. A rural sanitation policy based on TSC guidelines would provide opportunities to involve stakeholders from other sectors and encourage an evidence-based policy development process building on the strengths of TSC, without being limited by its programming needs. Recommendation 2: Develop More Effective High-level Advocacy In order to present Government with clear, consistent, and evidence-based messages that are designed to influence high-level decision makers, development partners should work to harmonize their advocacy, enabling environment, and performance assessment activities. In particular, reliable cost-effectiveness data should be collected and used more widely to demonstrate the wasted investments and opportunity costs of some current sanitation strategies and implementation approaches, and the greater effectiveness and sustainability of alternatives. Recommendation 3: Recognize That One Strategy Does Not Fit All Better information and data on latrine usage, sustainability of behavior change, and targeting accuracy (i.e. success in improving sanitation for the poorest households) are required to develop strategic plans to meet the government s sanitation targets. In particular, efforts need to be made to identify hard-toreach areas and groups, to examine issues that limit the costeffectiveness and sustainability of sanitation improvements, and to recognize that different strategies, resources and tools are required in different contexts and stages of development. Recommendation 4: Encourage a Two-stage Incentive System At endline, the HP experience clearly demonstrates the benefits of a two-stage process, whereby the momentum and support generated by widespread ODF achievement has vii

10 Executive Summary developed the comprehensive enabling environment required for rapid progress towards the harder-to-achieve environmental sanitation and hygiene improvement requirements of the NGP award. It is recommended that WSP encourage other progressive states to employ a twostage process to provide further evidence of the benefits of this approach, with a longer-term view to convincing the Department of Drinking Water Supply (DDWS) to formalize the inclusion of a two-stage approach in TSC guidelines. Recommendation 5: Invest in Cost-effectiveness Data The publication and dissemination of reliable evidence of wasted investments and opportunity costs remains one of the most powerful motivators for government reform and improvement, especially when those costs relate to emotive issues like children s health, environment, and poverty. More effort is needed to collect and analyze information on sanitation program costs, outcomes, and impacts into simple cost-effectiveness measures and advocacy materials that can be used to encourage competition among districts and states, to identify optimal strategies, and to influence high-level decision and policy makers. Recommendation 6: Incorporate Latrine Usage and Sustainability into Benchmarking Systems While latrine usage and sustainability data are not as easy to collect as information on the number of latrines built, it is important that sanitation programs begin to work toward routine monitoring and benchmarking of sanitation outcomes. Initially, it may be necessary to undertake annual rapid assessments in order to generate latrine usage and sustainability data that can inform annual performance reviews, but eventually this data should be collected as part of routine public health monitoring systems. Recommendation 7: Develop State Capacity for Knowledge Management Exposure visits and horizontal learning events were identified as the most important knowledge management tools for local governments. At present, local governments are reliant on agencies like WSP and UNICEF to organize these visits and events, which often makes them dependent on external program finance and constrained development partner capacity. The development of state capacity to organize knowledge management events should form part of the program exit strategy in both states, through the formulation of a phased annual knowledge management program that outlines the diminishing role to be played by WSP. Local governments will require some hand-holding during early events, but the additional value provided by these events should allow the development of sustainable mechanisms to finance and manage them, while WSP gradually builds local capacity for their planning and facilitation. viii Scaling Up Rural Sanitation

11 Contents Executive Summary... iii Abbreviations and Acronyms... xii Definitions... xiv I. Introduction... 1 II. Assessment Framework and Methodology Assessment Dimensions Methodology of Assessment Sampling Protocol... 4 III. Context General Health Sanitation and Hygiene Legal Framework... 7 IV. Total Sanitation Campaign Evolution of the Total Sanitation Campaign TSC Methodology TSC Latrine Subsidies TSC Incentive Framework V. Baseline Findings Himachal Pradesh: Sanitation Coverage at Baseline Madhya Pradesh: Sanitation Coverage at Baseline Baseline Assessment Findings VI. Endline Findings Policy, Strategy, and Direction Institutional Arrangements Program Methodology Implementation Capacity Sanitation Goods, Services, and Information Financing Cost-Effective Implementation Monitoring and Evaluation VII. Conclusions Enabling Factors in HP Disabling Factors in MP Return to the CRSP? Enabling Environment at the National Level Nirmal Gram Puraskar ix

12 Contents 7.6 WSP Enabling Environment Role Potential to Achieve Sanitation MDG Key Lessons VIII. Recommendations References Annexes 1: Assessment Meetings and Activities : Terms of Reference for Consultancy : Endline Interview Guide : Program Benchmarking Assessments by District, MP Figures 1: Infant Mortality Rates : Trend in Rural Sanitation Coverage India : Improved Sanitation Coverage in Rural Areas, HP : Improved Sanitation Coverage in Rural Areas, MP : Latrine Usage in HP and MP : Access to Improved Sanitation Since 1995 by Wealth Quintile Tables 1: Program Areas and Number of Beneficiaries : TSC Components: Revised Earmarking and Funding Pattern : Comparative TSC and NGP Performance : Enabling Environment Improvements: Policy, Strategy, and Direction : Enabling Environment Improvements: Institutional Arrangements : Enabling Environment Improvements: Program Methodology : Enabling Environment Improvements: TSC Implementation Capacity : National Growth in Nirmal Gram Puraskar Awards : State Growth in Nirmal Gram Puraskar Awards : Enabling Environment Improvements: Finance and Incentives : Enabling Environment Improvements: Cost-Effectiveness x Scaling Up Rural Sanitation

13 Contents 12: TSC Physical Progress: Individual Household Latrines : TSC Physical Progress: Institutional Toilets : Enabling Environment Improvements: Monitoring and Evaluation : Geographic Areas and Beneficiaries xi

14 Abbreviations and Acronyms Anganwadi ADC APL BDO BPL BRC CBO CCDU CLTS Crore CRSP DC DDWS DLHS DLM DRDA DWSM GoI GP(s) Hhd HP IEC JMP Lakh MDG M&E MP MVSSP NREGA NGO NGP Nirmal Watika NRDWP NRHM ODF Panchayat PHED PRD Childcare center Assistant District Collector (also known as Assistant District Magistrate) Above Poverty Line Block Development Officer Below Poverty Line Block Resource Centers Community-Based Organization Communication and Capacity Development Unit Community-Led Total Sanitation 10,000,000 (ten million) Rupees Central Rural Sanitation Program District Collector (or District Commissioner, or District Magistrate) Department of Drinking Water Supply District Level Household and Facility Survey District Level Monitoring (program of TSC) District Rural Development Agency District Water and Sanitation Mission Government of India Gram Panchayat(s), local political body Household Himachal Pradesh Information, Education and Communication WHO-UNICEF Joint Monitoring Program for Water Supply and Sanitation 100,000 (one hundred thousand) Millennium Developmental Goals Monitoring and evaluation Madhya Pradesh Maharishi Valmiki Sampoorn Swachata Puraskar (State Sanitation Reward Scheme) National Rural Employment Guarantee Act Non-Governmental Organization Nirmal Gram Puraskar (Clean village award) Clean Garden National Rural Drinking Water Program National Rural Health Mission Open Defecation Free An elected body at village level. Public Health Engineering Department Panchayat and Rural Development Department xii Scaling Up Rural Sanitation

15 Abbreviations and Acronyms PRI RDD RGNDWM RSM SSA SDM SLWM SRSP SWSM TSC UNICEF WHO WASH WSP ZP Panchayati Raj Institutions (local government system) Rural Development Department Rajiv Ghandi National Drinking Water Mission Rural Sanitary Mart Sarva Shiksha Abhiyan (SSA) Education for All program Sub Divisional Magistrate Solid and Liquid Waste Management State Rural Sanitation Program State Water and Sanitation Mission Total Sanitation Campaign United Nations Children s Fund World Health Organization Water, Sanitation and Hygiene Water and Sanitation Program (South Asia) Zila Parishad (district council) xiii

16 Definitions To ensure a common understanding of the concepts and terms used in the report, the following definitions are provided: CLTS: Community-Led Total Sanitation (CLTS) is the original variant of the total sanitation approach, a process to inspire and empower rural communities to stop open defecation and start using sanitary toilets, without offering external subsidies for the purchase of hardware such as toilets pans and pipes. 2 CLTS uses a participatory analysis of community sanitation to identify key triggers to motivate a community to take collective action to improve its sanitation status. Handwashing: Hands become contaminated with fecal material after anal cleansing, or after cleaning children s bottoms or handling their feces. Rinsing with water alone is not enough to remove sticky microbe-containing particles from hands. Some form of soap is required: hands need to be rubbed with soap and water until fully covered with soapsuds, and then rinsed off with water. Hygiene promotion: A planned approach to prevent diarrheal disease (and other health problems) through the widespread adoption of safe hygiene practices, e.g. campaigns to encourage regular handwashing at appropriate times. Note: hygiene promotion is usually a much broader intervention than sanitation promotion, which focuses solely on the safe management and disposal of excreta. Informed choice: Demand-based programming places the community in the role of decision-maker in the selection, financing, and management of their water supply and sanitation system. In order to effectively implement a demand-responsive approach, the government should take the role of facilitator and provide informed choices to the community regarding the development and construction of sound infrastructure and services, taking into account local financial, technical, environmental, social, and institutional factors. Informed choices are provided in participatory sessions, covering technology and service options based on willingness to pay, and provide insight on the service provision schedule and know-how, management of funds and responsibilities, and management of services. Program software: Activities that support and promote the provision of program services and facilities, for example: media campaigns, capacity building activities, or community hygiene promotion sessions. Note: program software must be differentiated from program hardware (infrastructure), which includes tangible program products and facilities such as toilets, soakaways, and handwashing facilities. Rural: That which is not urban, with urban spaces in India defined as towns (places with municipal corporations, municipal area committees, town committees, notified area committees or cantonment boards); also, all places with 5,000 or more inhabitants, a population density not less than 390 persons per square kilometer, or at least threequarters of the adult male population employed in pursuits other than agriculture. Sanitation: Interventions for the safe management and disposal of excreta, with the principal safety mechanism being the separation of excreta from all future human contact. The term improved sanitation is used in this report to denote private facilities that provide safe management and disposal of excreta. The WHO-UNICEF Joint Monitoring Program (JMP) offers the following simple definitions 3 of improved sanitation facilities that provide sustainable access to basic sanitation : Pit latrine with slab, Ventilated improved pit latrine, Composting toilet, and Flush or pour-flush to latrine pit, septic tank, or piped sewerage. Unimproved sanitation facilities, which do not provide adequate access to basic sanitation, include: 2 Kar JMP xiv Scaling Up Rural Sanitation

17 Definitions Pit latrine without slab (open pit), Shared or public sanitation facilities, Hanging latrine, Bucket latrine, and Flush or pour-flush to elsewhere (street, yard, ditch, open drain, or other location). Sanitation marketing: An approach that utilizes the power of the small- and medium-scale private sector in the provision of sanitation services and uses techniques of commercial marketing and behavior change communication to create demand. Sanitation promotion: Encourages the safe management and disposal of excreta through the widespread adoption of safe sanitation facilities and practices, for example, programs promoting the construction and universal use of improved sanitation facilities. Scheduled castes (SCs): Historically disadvantaged, low ranking, hereditary classes of Indian society, now under formal government protection. Scheduled tribes (STs): Tribal communities now under formal government protection, with key characteristics being traditional occupation of a definitive geographical area, culture that includes tribal modes of life including tribal language, customs, traditions, religious beliefs, arts, and crafts. Total sanitation approach: A community-wide approach whose main aim is universal toilet use (total sanitation) in each community covered. The total sanitation approach focuses on stopping open defecation on a community-bycommunity basis through recognizing the problems caused to all by open defecation within and around the community, and ensuring that every household uses either their own affordable toilet, or a shared toilet situated close to their home. The total sanitation approach is a broader variant of Community-Led Total Sanitation (see definition above) that may involve financial incentives (e.g. post-construction subsidies provided by the Total Sanitation Campaign in India); the promotion of broader environmental sanitation objectives such as drainage and solid waste management; and the promotion of hygiene improvement activities such as handwashing. xv

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19 I. Introduction The Water and Sanitation Program (WSP) has implemented the Global Scaling Up Rural Sanitation (TSSM) project since One of the central objectives of the program is to improve sanitation at a scale sufficient to meet the 2015 sanitation Millennium Developmental Goals (MDG) targets in Indonesia, Tanzania, and the Indian states of Himachal Pradesh (HP) and Madhya Pradesh (MP). A consultant was contracted to perform an endline assessment of programmatic and institutional conditions (referred to by the program as the enabling environment) needed to scale up, sustain, and replicate the total sanitation and sanitation marketing program approaches in two Indian states, HP and MP. The Terms of Reference (TOR) are detailed in Annex 2. This report is the main output of that consultancy. The baseline assessment of the enabling environment was completed in May and June 2007, during the start up phase of the overall program. This follow up endline assessment was carried out three years later in mid-2010, following a oneyear extension of the program from its original mid-2009 end date. The purpose of the endline assessment is to: Assess the extent to which the enabling environment for scale up and sustainability have improved by the end of the program; Recommend what should be done to address any gaps identified by the assessment during the remainder of the program implementation period, or in the future if a follow-on program is undertaken; and Determine whether an appropriate enabling environment is in place to meet the 2015 MDG sanitation target, and assess whether these conditions are likely to be sustained. The fundamental determination that the endline assessment should clarify is if, in India (and specifically these two Indian states) the enabling environment has been institutionalized to support scaling up in a sustainable manner, and whether that scale up can continue after 2010: without assistance, with less assistance, or with difference assistance from the program. This report presents the main findings and recommendations from the endline assessment of the ability of the enabling environment to scale up, sustain, and replicate sanitation improvements in HP and MP, India. 1

20 II. Assessment Framework and Methodology In order to improve the comparability of the findings from the assessment in India with those from the assessments in Indonesia and Tanzania, a common assessment framework was developed by the WSP headquarters team and its specialist advisors in Washington DC. The assessment framework consists of eight dimensions that are considered essential to scaling up, sustainability, and replication of the total sanitation and sanitation marketing approaches in rural areas: Policy, strategy, and direction Institutional arrangements Program methodology Implementation capacity Availability of products, tools, and information Financing and incentives Cost effective implementation Monitoring and evaluation Definition of Scale-up: Increase the scale, rate of provision, and sustainability of sanitation services to reach the threeyear 2010 targets in the program and the MDG targets for 2015 (see Table 1). 2.1 Assessment Dimensions The eight assessment dimensions 4 represent a conceptual framework for assessing scalability and sustainability Policy, Strategy, and Direction Establishing a shared vision and strategy and ensuring the political will to implement a program is the starting point for scale up. Developing this shared vision and strategy in a collaborative manner is also the foundation for coordination and for creating motivation all levels. Policy is defined as the set of procedures, rules, and allocation mechanisms that provide the basis for programs and services. Policies set the priorities and often allocate resources for implementation. Policies are reflected in laws and regulations, economic incentives, and the assignment of rights and responsibilities for program implementation Institutional Arrangements In order for the total sanitation and sanitation marketing approaches to be scaled up, the right institutions must be in place with all key roles and functions covered and clearly understood. These institutions must also have the resources to carry out their roles. In addition to clear roles and responsibilities, institutional arrangements include the mechanisms for actors at all levels to coordinate their activities and establish partnerships between the public, private and non-governmental organization (NGO) sectors, and between communities and local governments. TABLE 1: PROGRAM AREAS AND NUMBER OF BENEFICIARIES (MILLIONS) Program Areas (population) People without Access to Sanitation in 2006 (estimate)* People Who Will Gain Access to Sanitation During Three- Year Program (estimate) Additional Access to Sanitation Needed to Meet 2015 MDG Targets** Tanzania (26.7 million rural) East Java, Indonesia ( million) HP, India (5.5 million rural) MP, India (45 million rural) Total * Best estimates given poor status of data ** Accounts for population growth estimates 4 The baseline report included nine assessment dimensions, but the Partnerships dimension was particular to the handwashing project and was therefore merged with the institutional arrangements dimension for this endline assessment. 2 Scaling Up Rural Sanitation

21 Assessment Framework and Methodology Program Methodology The program methodology consists of the program rules, specific activities, and their timing and sequence. Each country will adapt and apply the program methodology making it specific and appropriate to the country context. A workable program methodology that is clear and agreed upon by all key stakeholders is a key programmatic condition Implementation Capacity At all levels institutions must have the capacity to carry out their roles and responsibilities. Institutional capacity includes adequate human resources with the full range of skills required to carry out their functions, an organizational home within the institution that has the assigned responsibility, mastery of the agreed upon program methodology, systems and procedures required for implementation, and the ability to both monitor program effectiveness and make continual adjustments Availability of Products, Tools, and Information The ability of target consumers to adopt the promoted behavior(s) is highly dependent on the existence and availability of products, tools, and information that respond to consumer preferences and their willingness and ability to pay for them. Any and all relevant products and services need to be considered, specific to each country situation Financing This dimension assesses the adequacy of arrangements for financing the programmatic costs. These costs include training, staff salaries, transportation, office equipment and supplies, and the development of communication and education materials as well as programmatic line items in budgets for program and promotion activities Cost-effective Implementation Although it will not be possible to assess the cost-effectiveness of the approach or how best to achieve economies of scale and scope until the end of the program, data must still be collected during implementation to make this determination at the end of the program. Therefore, the focus in this assessment category is to ensure that information will be collected from the outset and that the capacity to collect the information is in place that systems and procedures for collecting cost information and the capacity to use and collect the information exist Monitoring and Evaluation Large-scale sanitation programs require regular monitoring and periodic evaluation and, perhaps more importantly, the willingness and ability to use the monitoring process to make adjustments in the program. Effective monitoring will identify strengths and weaknesses in the program methodology, implementation arrangements, and cost efficiencies. Overall monitoring responsibility must be at the highest level of the program, but must be based on information collected at the local government or community level. 2.2 Methodology of Assessment An international consultant carried out the endline assessments in India with support from the WSP state Coordinator for MP 5 during the fieldwork in both HP and MP, with overall direction and support from the WSP Country Task Manager for the program (Ajith Kumar) and the WSP team. The endline assessments were conducted through a series of one-to-one interviews with key stakeholders at national, state, division, district, block, Gram Panchayat (GP), and village level. Based on the assessment framework, a generic interview guide was prepared, and was further revised and developed by the consultants and the program team in order to match the questions and language more closely to local contexts and norms. The India-specific interview guide was used in each interview, although some dimensions and questions were not considered relevant (or appropriate) to some stakeholders (e.g., asking local retailers about national strategy issues). All the dimensions of the assessment framework were covered, but not by every stakeholder. The interview guide is included as Annex 3. Primary data sources were main stakeholders and partners for the in-country program work, including but not limited 5 Appointed in May 2007 for a three-year period, now working as a short-term consultant. 3

22 Assessment Framework and Methodology to government agencies, international agencies, international non-governmental organizations (NGOs), local NGOs, private-sector businesses, and community-based organizations (CBOs). These primary data sources were contacted at all appropriate levels: national, state, district, and local. Secondary data sources comprised key documents, and potential influencers or secondary implementers such as media, ministries with no direct involvement, advocacy groups and so on. 2.3 Sampling Protocol Sampling was purposive for all primary data sources. Criteria for selection for both interviews and self-reports included stakeholders that: Had participated in a sanitation program (or related program) for at least six months; Represented a main workforce type a decisionmaker, an implementer, or a mid-line supervisor or manager of the program; and Represented one of the different levels of the organization that are involved in the program: national, regional, district, and local. The stakeholders interviewed and the main assessment activities are listed in Annex 1. District Selection Process Due to the limited time available, only two districts were visited in each state. Based on program performance information provided by the program team, one above-average district and one below-average district were selected in both HP and MP. 6 High and low performing districts were not included in the sample frame as the exceptional contexts and institutional conditions in these districts are unlikely to be replicated in other districts. However, representatives from high-performing districts were invited to a stakeholder review and learning event held in each state at the end of the fieldwork period in order to capture learning from the innovations and successes in these areas. In HP, the following two districts were randomly selected for assessment from each of the two middle performance quartiles of the WSP benchmarking data: Kullu (ranked 9th out of 12 districts = randomly selected below average district) Una (ranked 6th out of 12 districts = randomly selected above average district) During the assessment, a review of the benchmarking data revealed that Kullu district had been wrongly ranked due to an error in the automatic benchmarking spreadsheet. Kullu is the highest ranked district for household latrine coverage (104 percent of TSC target achieved in May 2010); has achieved 99.5 percent ODF coverage (203 out of 204 GPs have been declared ODF); and has the best financial efficiency with an expenditure of only Rs 0.55 lakh per ODF community (US$1,220). 7 Unfortunately, no score was allocated to Kullu for its financial efficiency, and it has not yet applied for many Nirmal Gram Puraskar or clean village awards (NGP) awards, 8 thus it was graded as a below average performer. Following a correction to the financial efficiency score, which awards an over-large 15 points to the top performer in this category, Kullu was re-ranked as the second best performing district. In contrast, the benchmarking data suggested that Una district was an above average performer, yet it was found during the fieldwork to be one of only three lagging districts in HP. Again, the financial efficiency score appears to be the main culprit here Una was the second best performer on financial efficiency, achieving 193 ODF gram panchayats (GPs) despite spending only 21 percent of its TSC allocation, thereby gaining an additional ten benchmarking points that carried it into the above average category. In MP, the following two districts were randomly selected for assessment from each of the two middle performance quartiles of the WSP benchmarking data: 6 The project team developed a performance benchmarking system that ranked district sanitation performance, and was utilized for cluster randomized sampling of one district from each of the two middle performance quartiles (excluding the best performing and lowest performing quartiles). 7 At the time of the endline assessment in September 2010, the official exchange rate was: US$1 = Indian Rupees (Rs) 45 8 Thirty-five percent of the benchmarking score is allocated for NGP achievements (15 percent for the number of NGPs achieved, 10 percent for the percentage NGP coverage, and another 10 percent for the NGP success rate in the last year). 4 Scaling Up Rural Sanitation

23 Assessment Framework and Methodology Jhabua (ranked 24th of 48 districts = randomly selected above average district) Chhindwara (ranked 27th of 48 districts = randomly selected below average district) Jhabua district reports high performance in household latrine coverage and school sanitation coverage, with TSC online monitoring data suggesting 124 percent latrine achievement (top ranked in state) and 101 percent school toilet achievement (2nd ranked in state), but these apparent outputs are not matched by its outcome-based indicators. Jhabua ranks 23rd for the number of NGPs achieved; 30th for NGP coverage; 37th for NGP success rate; and 29th for financial efficiency. The lower outcome and financial efficiency indicators suggest either that the latrine output data have been over-stated, or that they have not translated into sustainable outcomes, both of which support the classification of this district as above-average (rather than the higher classification implied by the reported household latrine coverage data). Chhindwara district is a lower performer than Jhabua in terms of outputs, but has similarly average to below average outcome achievements. However, Chhindwara s performance has been unusually turbulent: a supportive and committed district collector led a successful program that achieved 21 of its current total of 27 NGP awards during , but the district then failed to get its TSC proposal approved due to bureaucratic issues and was without financing for almost 18 months. During this time the campaign stalled and little progress was made. As a result, the number of NGP applications has declined over the last three years: 120 in 2008, 74 in 2009 (largely re-applications from failed 2008 applicants), and only 57 applications in 2010 (including 40 GPs re-applying for the third time). 5

24 III. Context 3.1 General Himachal Pradesh (HP) HP is a small state in the mountainous northwest section of India, bordered by Tibet to the east and Jammu and Kashmir to the north. The lowest point in the state is at an altitude of 450m above sea level, and the highest reaches 6,500m. As a result, some parts of HP experience extremely cold winter temperatures. The state is divided into 12 districts, which contain 75 blocks and 3,243 Gram Panchayats (GPs). It is a predominately rural state, with 90 percent of the population (5.5 million people) living in rural areas. About 25 percent of the population belongs to scheduled castes. HP has one of the highest per capita state incomes in India, deriving from a strong economy built around agriculture, hydroelectric power, and tourism. HP also receives substantial remittances, particularly from army personnel and other Government of India (GoI) officials. A 2005 Transparency International survey ranked HP as the second least corrupt state in India, after Kerala out of twenty states assessed in the survey Madhya Pradesh (MP) MP is often called the Heart of India because of its landlocked location in central India. Until 2000, when the state of Chattisgarh was carved out from its bounds, MP was the largest state in India. It is now the second largest Indian state, covering 308,000 square kilometers, and is the seventh most populous with a total of about 60 million inhabitants. Its huge land area means that the population density in MP is 40 percent lower than the national average. 9 In 2003, MP formed three additional districts by further sub-dividing existing districts, bringing the state total to 48 districts, which contain 313 blocks and close to 23,000 GPs. There is a significant tribal population in MP: 89 blocks (28 percent) are considered tribal blocks, and one third of all children attend residential tribal schools. Furthermore, incomes are low and MP is reported 10 to have the lowest per capita expenditure on food of all Indian states, reflecting widespread poverty and lack of livelihood security. The 2008 District Level Household and Facility Survey (DLHS 2008) published by the Ministry of Health and Family Welfare reported that 35.7 percent of rural households in MP are in the lowest wealth quintile in India, compared to only 0.8 percent of rural households in HP. The same survey also found that only 8 percent of rural households in MP live in pucca houses (made from permanent materials), compared with 42 percent in HP. The previously mentioned Transparency International survey rand MP as the third most corrupt state out of twenty states assessed in the survey. 3.2 Health Despite its rural nature, HP has above average human development indicators for India, and is bettered only by Kerala in both infant mortality rate (36 deaths per 1,000 live births) and literacy rate (77 percent). MP has low human development indicators: the underfive mortality rate is the highest of any state in India at 137 deaths per 1,000 live births 11 (compared with an all-india average of 95 under-five deaths per 1,000), and reaches as FIGURE 1: INFANT MORTALITY RATES Infant deaths per 1,000 births Key Himachal Pradesh All India Madhya Pradesh Source: NFHS I, II, III According to the 2001 Census of India, MP has a population density of 194 persons per sq. km compared with average 324 per sq. km in India. 10 National Council for Applied Economic Research (NCAER), 1999 India: Human Development Report 11 National Family Health Survey II (mortality rates for the five year period preceding the survey) 6 Scaling Up Rural Sanitation

25 Context high as 152 deaths per 1,000 live births (15 percent) in rural areas. Infant mortality rates in Madya Pradesh have dropped by 19 percent since the 1998 National Family Health Survey (NFHS), but they remain 23 percent higher than the all- India average (see Figure 1) and almost double those in HP. 3.3 Sanitation and Hygiene The practice of open defecation has long been traditional in rural India. According to the 2001 Census data, only 22 percent of the rural population in India owned latrines (see Figure 2). In addition, the supply-driven nature of previous sanitation interventions such as the Central Rural Sanitation Program (CRSP), in which highly subsidized sanitation facilities were provided to rural households unconvinced of their benefits, meant that a large number of these latrines were not used Scale of Challenge Simple linear projections of rural population growth show that in order to achieve the target of universal sanitation by 2012 accelerated progress is required. National progress has been reasonably good, with some surveys estimating that 2.8 million individual household latrines (IHLs) were constructed annually over the period. However, at that rate, universal sanitation would not be achieved until In addition, latrine usage remains a problem sample surveys carried out by Government of India (GoI) FIGURE 2: TREND IN RURAL SANITATION COVERAGE INDIA Proportion of Rural Households with Latrines (%) Year 1995 Source: India Assessment 2002 (PC) and Census of India assessment teams in 478 districts (under the district level monitoring program) indicate that latrine usage rates are only around 80 percent nationally, with significant variations across and within states. 3.4 Legal Framework The Constitution of India determines that water supply, sanitation and other public health services are state responsibilities. However, the 73rd and 74th Constitutional Amendments allow states to pass the responsibility and powers for water supply and sanitation down to local governments. In HP, the Himachal Pradesh Panchayati Raj Act 1996 (updated 2001) states that sanitation is a local body (GP) function, but prior to TSC few GPs were aware of their responsibility or showed any interest in undertaking sanitation activities. Specifically, GPs are responsible for: Sanitation, Clearing of roads and drains, Organizing school health check-up programs, Reporting the outbreak of gastroenteritis and any other epidemic, Construction and maintenance of village drains and disposal of wastes, and Prevention and control of water pollution. In MP, the Panchayati Raj and Gram Swaraj Act 1993 delegates responsibility for rural water supply and rural sanitation to the Gram Sabha, 12 including: Sanitation, Regulation of the construction of household latrines, urinals, drains and water closets, and Construction, maintenance and clearing of public streets, latrines, drains, and other public facilities. Despite the existence of a Model Public Health Act 1987 (revised) prepared by the Government of India, and the clear responsibility of the state for public health services, neither HP nor MP has adopted a Public Health Act. As a result, there is no legislative framework for the regulation of public health services in the state. 12 General village-level body consisting of persons registered in the electoral rolls 7