Sanitation INNOVATION. December Introduction. Achieving improved sanitation: a review of key themes and challenges.

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1 December INNOVATION INSIGHTS Sanitation Introduction Achieving improved sanitation: a review of key themes and challenges Case Studies Case 1. Mosvold Hospital Sanitation Programme Case 2. The Northern Cape Household Sanitation Programme Case 3. The Ethekwini Water and Sanitation Programme Concluding comments Introduction Good sanitation is essential for the dignity, health and well-being of everyone. Good sanitation extends far beyond access to an acceptable toilet and the safe disposal of human waste; it includes practices that support good hygiene and a healthy living environment. More than 18 million people in South Africa lack access to an adequate sanitation facility. Government is giving priority attention to sanitation improvement, and has set 2010 as the target date by when all sanitation backlogs must be eradicated. The Constitution assigns responsibility to local government for service provision. Meeting the 2010 sanitation target is therefore primarily the responsibility of municipalities, with support from other spheres of government. Historically, municipal sanitation services focused on urban areas. Responsibility for sanitation provision in other settlement areas was often fragmented or unclear, with the result that the largest sanitation backlogs in South Africa occur in rural areas. This Insight reflects on the findings of three award-winning innovation projects that highlight some important lessons for municipalities who are tackling the challenges of providing sustainable sanitation services in areas where flush toilets are not feasible over the short term. The Insight goes on to highlight some key policy issues that arise from these case studies. The three projects are: Mosvold Hospital Sanitation Programme - a rural community sanitation improvement programme run as an integral part of a broader primary health programme and facilitated by community health workers attached to the hospital This Insight is produced by the Centre for Public Service Innovation (CPSI) and was made possible through funding support from the Ford Foundation and access to the Impumelelo Innovations Award project database. This Insight is part of a series aimed at improving service delivery through innovation. See the back page of this publication for more information about the series. The publication is targeted at practitioners and policy-makers and shares lessons and experiences of award winning service delivery projects. This Insight was prepared for the CPSI by Kathy Eales (Counterpoint Development, cc.). Opinions expressed are those of the author and do not represent the views of the CPSI.

2 Sanitation Northern Cape Household Sanitation Programme - a provincial programme that brought government departments and municipalities together to build a common vision for sustainable sanitation in the small towns of the province The ethekwini Water and Sanitation Programme - providing an integrated water and sanitation 'package' for peri-urban and rural settlements that is affordable and simple to maintain over the long term. The national policy framework shaping sanitation has changed since these projects were initiated. New issues and challenges have emerged on the sectoral agenda. Yet the lessons of these projects remain relevant. The challenges they sought to address remain a part of the current agenda. This Insight therefore begins with a short introduction to sanitation improvement and current challenges from the perspective of municipalities. This will help to locate the issues raised by these case studies within a broader context. Achieving improved sanitation: a review of key themes and challenges For most people, sanitation is first and foremost an issue of personal dignity, privacy and convenience. In a context of historical discrimination and poverty, sound sanitation facilities have become an important index of development and of the quality of life of people. Municipalities are giving increasing priority to sanitation issues as they grapple with the challenges of vast service backlogs, growing settlements, aging infrastructure, and the real meaning of poverty. Sanitation improvement is about more than providing a toilet infrastructure. It has a major public and primary health component, and calls for close co-ordination between technical, health and social development personnel. Sanitation also straddles several sectors - housing and settlement development, water services, water resource and environmental management, primary and preventative health care, education, local economic development, municipal finance, and so on. This approach becomes clearer when some of the components of a durable sanitation improvement approach are reviewed. 1. Requirements for sanitation improvement Conventional approaches to sanitation improvement focus on delivering and servicing infrastructure. Residents - the end-users - often play a minor role in planning services and in weighing the implications of different service packages. They also receive little information on the linkages between sanitation, hygiene and health - let alone how to keep their toilet systems working. Any toilet system is vulnerable to malfunction and, when things go wrong, the municipality is often blamed and held responsible. There is a widespread assumption that good sanitation means a flush toilet, and that government must therefore provide flush toilets for all. The reality is that sanitation backlogs in South Africa are so vast that it would take many decades to provide flush toilets to everyone. In the face of so many competing developmental priorities, universal waterborne sanitation is not achievable by 2010 with available funds. In many areas, a phased approach is necessary, with incremental improvements over time. Choosing a suitable and appropriate sanitation strategy is about choices: how to offer the benefits of better sanitation to the greatest number of people, as swiftly as possible, with limited available funds. Each of the projects described below offers residents a basic toilet alongside health and hygiene awareness information, as part of a broader developmental programme. In the Mosvold Hospital and Northern Cape sanitation programmes, local residents were offered a partial capital subsidy and they proved willing to contribute the balance needed to construct a simple dry toilet. In peri-urban settlements on the edge of ethekwini Unicity (formally called Durban Metro), residents have accepted urine diversion toilets now as opposed to a promise of a flush toilet sometime in the future, possibly decades from now. The case studies highlight the importance of working closely with representatives of households who need better sanitation. They describe ways of educating users about the problems that cause blockages and system failures. They underline the importance of planning ahead so that the long-term requirements for maintenance and sustainability are factored in from the start. 2. Sanitation and health Good toilets are necessary, but not sufficient, for managing human waste safely. Cholera, for example, can be spread through poor hygiene, even where there are good water and sanitation facilities. 2

3 Sanitation The Mosvold Hospital Sanitation Programme exemplifies this approach. It placed a strong emphasis on primary health, community development and local self-reliance. Similarly, the Northern Cape Household Sanitation Programme implemented this approach in the small scattered settlements of Namaqualand and the dry interior. Diarrhoeal diseases spread through poor sanitation and hygiene kill more children under five than just about any other single cause. Worms, parasites and faecal-oral diseases cause lasting damage to the growth and development of small children, and undermine the development potential of our country. Poor sanitation raises particular risks for people who are HIV positive as their weakened immune systems are less resistant to infections and disease. Good facilities help to ease the burden of home-based care. 4. From household assistance to service delivery The 2003 Strategic Framework on Water Services includes sanitation and largely supersedes the 2001 Sanitation White Paper. It suggests a very different trajectory for sanitation improvement. The emphasis is on ongoing service provision, rather than on backlogs alone, and on the provision of services by local government, rather than through community and household initiatives supported by external agencies. Moreover, subsidies via national government departments for basic household sanitation have now been replaced by full funding through the Municipal Infrastructure Grant, which is directly administered by municipalities. Good sanitation is about putting barriers in place to prevent the transmission of disease-causing organisms found in waste. At the centre of good sanitation are people and their practices, not just infrastructure. The Mosvold Hospital Sanitation Programme approached sanitation improvement as a component of a broader health improvement programme, which aims to reduce suffering caused by cholera, malaria, diarrhoea and other water and sanitation-related diseases. Toilet construction was just one part of this programme. 3. The sector has moved decisively from the household assistance programme envisaged by the 199 and 2001 sanitation policy document to a municipal delivery programme. The context of community sanitation programmes Sanitation backlogs are greatest in South Africa's rural areas. Until the late 1990s, there was no effective rural local government, particularly in the former homeland areas. Household sanitation improvement programmes were therefore either localised initiatives, supported by donor funding, or run through the Department of Water Affairs' Community Water Supply and Sanitation programme. Municipalities did not play a huge direct role in sanitation provision in rural areas, as responsibility for addressing water and sanitation in these areas rested with DWAF from 1994 to the early 2000s. In practical terms, the emphasis of many municipalities is on infrastructure delivery against daunting targets, rather than broader sanitation improvement. The real tension in the sector is how to address both, at scale. 5. Sanitation and Integrated Development Planning Until very recently, sanitation was approached in a very fragmented way, with rural programmes run quite separately from urban services, and often with different funding criteria, funding streams, and programme approaches. In conjunction with the transformation of local government and the strengthening of municipal service delivery capacity, a more coherent and integrated approach to sanitation planning and project implementation is beginning to emerge. Supporting this is the Municipal Infrastructure Grant (MIG), which enables municipalities to implement projects identified in their Integrated Development Plans (IDP) against secure, defined three-year budgets. Rural sanitation projects funded by DWAF were managed through village sanitation committees, and local builders were trained to help householders build new toilets or improve their existing toilets. There was strong emphasis on sanitation as a component of primary health: good sanitation was promoted as a household responsibility, with simple education campaigns around practices that help to break the cycle of water- and sanitation-related diseases. This approach lies at the heart of the 2001 White Paper on Basic Household Sanitation, which was first drafted in 199. It draws heavily on the lessons of international experience, chief of which is that toilets are just one component of an effective sanitation programme Effective sanitation, health and hygiene programmes now rest on close communication and co-ordination between provincial and municipal health personnel on 3

4 Sanitation the one hand, and the technical and social development sections of the Water Services Authority (WSA) on the other hand. This underpins an integrated approach to sanitation improvement, which in turn supports better health and long-term service sustainability through effective user education. The profile of sanitation within the IDP is growing. This allows for closer integration across sectors - sanitation and water, housing, health, local economic development, and so on. A growing number of municipalities are now developing strategies for integrated sanitation improvement, premised on a long-term vision, secure medium-term funding, and consensus on what their immediate priorities and resources are. The ethekwini case study highlights an example of effective long-term planning for integrated water and sanitation service provision in conjunction with a number of local economic development initiatives. Case studies The following case studies illustrate innovative good practice in improving basic household sanitation. Case 1 - Mosvold Hospital Sanitation Programme Mosvold Hospital is a 24-bed provincial hospital in the town of Ingwavuma in rural northern KwaZulu-Natal. Through a network of clinics, it serves a population of about people spread over a big region. Poverty in the area is acute. Malaria and cholera are endemic, and HIV prevalence rates are high. Mosvold Hospital has a long tradition of promoting primary health, with a range of projects focusing on nutrition, food gardening, and sexual and reproductive health care. With funding from the Department of Health, the hospital trained over 140 community health workers - 'onompilos' - to support primary health improvement through promoting health and hygiene awareness and early recognition of diseases. In 199, with funding from AusAid and assistance from the Mvula Trust, the hospital developed a sanitation project to encourage and subsidise the building of sturdy, hygienic VIP toilets in 13 of the Ingwavuma region's 51 districts. This became known as the Inqalabutho Sanitation Programme. The overall goal of the project was to improve the health of the community through the reduction of water- and sanitation-related diseases. The focus of the project was on building household toilets, but the activities of the project spread much wider. Through the work of the onompilos, who were paid by the Department of Health, residents were given information on how to identify, prevent and treat water- and sanitation-related diseases. Part of this education was the promotion of correct construction, the proper use of toilets, the promotion and construction of garbage pits, the safe storage and use of water, and the promotion of healthy methods of food preparation and storage. The project initially provided a subsidy of R700. However, in later phases this was reduced to R00 in line with the emerging sanitation programme funded by DWAF. Householders had to make a significant contribution to toilet construction. They were responsible for all costs over the subsidy amount, and had to dig the pit for the toilet, according to project specifications. They had to collect water for toilet construction, collect building materials from a central point and help the builder with construction. Householders were not paid for their contributions. Project funds subsidised essential building materials only, such as cement, vent pipes, seats, and so on. Households could reduce their cash contribution by collecting stones and other local materials for building. The project was co-ordinated through the Mosvold Hospital. Each of the 13 participating settlement areas had its own Sanitation Project Steering Committee (SPSC), which was supported closely by Mosvold Hospital staff. SPSC members were responsible for visiting registered households and advising on the layout of toilets, checking the pit was dug to the correct size, arranging for collection of materials like cement, supervising builders, checking the slab and superstructure, and arranging for the builders to be paid. Local traditional leaders gave active support, and the local councillor served as a member of the project steering committee. The project enjoyed such strong support on the ground that it completed its first target of 1 98 toilets by mid-1998, almost a year ahead of schedule, with strong demand from other households for support. Further donor funds were secured from AusAid for a second phase for 720 toilets. The intention was that DWAF would take responsibility for funding the continuation of the project once the pilot phase had been completed. 4

5 Sanitation The Mosvold project relied on external donor funding, and was unable to secure public funds to extend the sanitation improvement programme. It found itself caught between the objectives of the donor agency and the objectives of the new municipality. AusAid saw its role as supporting a finite pilot project that would then be replicated by government, while the new District Municipality wanted to fund projects in other areas. Without funds for ongoing toilet construction, the project came to end. Nonetheless, the benefits of the project continue to be felt through improved awareness among local residents of the linkages between hygiene and health, and the importance of good sanitation practices in breaking the cycle of water- and sanitation-related diseases. This was considerably more than a toilet-building project, and the benefits have extended far beyond the provision of toilets. Unfortunately, government funds were not made available to continue the Mosvold project once the AusAid funds were exhausted. By 2000, decision-making authority over the use of public funds lay with the District Municipality, and it resolved that limited programme funding should be made available to areas that had not yet benefited from a sanitation improvement programme. Without funding for toilet construction, the Mosveld sanitation project came to an end. Postscript Although the Inqalabutho project ended, the approach and methodology were replicated and strengthened in the nearby KwaNyawo area of Ingwavuma. A close NGO partner of Mosvold, the African Medical Research Foundation (Amref) provided funding to take forward Mosvold's pioneering sanitation work. A prominent member of the Mosvold sanitation team was seconded to co-ordinate the Amref-funded team. Detailed evaluations of this project in 2002 and 2003 affirmed the value and social impact of this integrated, health-centred, community-based approach to sanitation improvement. Policy issues The Mosvold / Inqalabutho Sanitation Programme was one of the first to be implemented in line with the recommendations of the 199 draft White Paper on Sanitation. This policy document, endorsed by six key national departments, outlined a health-focused, demand-driven, community-based approach to sanitation improvement. In terms of project methodology, this is one of the classic examples of good practice in South Africa. The challenge is to replicate this approach at scale. The Amref project evaluation reported one very sobering finding: Without a significant improvement in the quality and quantity of water, and the care of people living with HIV/AIDS and HIV prevention, the gains made by the provision of sanitation will not reflect in improved overall health status of the community" (Tyers and Zondi, 2003). Since 2000, municipalities have taken up their service delivery mandate with increasing vigour in rural areas. Massive pressure to address service backlogs as rapidly as possible is leading to an emphasis on toilet infrastructure, rather than integrated health improvement. Limited resources are being spread across as many settlements as possible, which compromises impact and undermines economies of scale. Improved sanitation cannot prevent HIV/AIDS-related chronic diarrhoea. However, it underlines the importance of good sanitation in mitigating some of the harsher impacts of the virus by reducing the risk of opportunistic infections and easing the burden of care. The health focus of the Inqalabutho and KwaNyawo projects was supported by a large contingent of community health workers who were trained by Mosvold Hospital and funded by the Department of Health. This category of auxiliary health workers is unique to Northern KwaZulu-Natal. Ideally, this approach should be extended to other parts of the country. Their contribution to the success of the sanitation programme was profound, elevating the project to an integrated health improvement campaign, with lasting impact. Lessons The benefits of the project extended far beyond the provision of toilets. The project was led by a health improvement perspective. Advocacy and awareness raising formed a large part of the project, with an emphasis on teaching people about good hygiene and sanitation practices. Considerably more work is needed to improve toilet use by children in remote areas. All too often parents discourage their children from using the new toilets, for fear they will make them dirty, or that children will fall into the pit. The new National Health Act assigns responsibilities for sanitation-related hygiene promotion to Environmental Health Practitioners (EHPs), now located within municipalities. The reality is that preventative health care is poorly resourced throughout the health sector, and par- 5

6 Sanitation ticularly so within municipalities. Sanitation-related support is just one of many EHP responsibilities. Serious attention must be given to funding community-based auxiliary health workers who can support sanitation improvement and other aspects of primary and public health. Strengthened health and hygiene linkages are particularly urgent, given the rising prevalence of HIV infection. Improved awareness of the linkages between good hygiene, sanitation and related disease prevention can support wellness in those who are most susceptible to infections and diseases. Finally, it must be noted that there is declining support for household contributions in municipal projects. Many municipalities maintain that requiring households to contribute their labour without payment contradicts municipal job creation objectives, while the time required to mobilise household inputs can delay project progress. The Mosvold project offers a different perspective. Strong community involvement meant the project finished ahead of schedule, while unpaid household labour allowed limited funds to reach a wider number of people. The debate around appropriate household contributions in the era of municipal service provision is complex and contentious. Perhaps the new emphasis on a reciprocal People's Contract will prompt fresh thinking on a constructive balance between supply-led and demand-responsive approaches to infrastructure provision. Case 2 The Northern Cape Household Sanitation Programme More than a third of the population of the Northern Cape live with toilets that are below acceptable standards. Some have nothing, some use crude pit toilets, and some rely on a municipal bucket system. Bucket toilets are particularly unpleasant when the bucket collection vehicle breaks down and delays the collection of full buckets. The Northern Cape Household Sanitation Programme brought together provincial and municipal role players to improve sanitation provision, health education and community development in small rural communities. The Department of Water Affairs and Forestry was the lead agency. However, the success of the programme was built on partnerships. Close working relationships developed between the Office of the Premier, DWAF, the provincial departments of health and of housing and local government, the District Councils of Diamantveld and Bo Karoo, the Mvula Trust (a major NGO), and project implementation teams. Lessons learnt from the Mosveld project - where the Mvula Trust also played a role - were applied and extended in the Northern Cape. Poverty levels are high in this dry region, and water is a precious resource. Sustainability is a key concern for municipal and provincial role players, and so the 'hardware' component of the programme focused on providing dry toilets: Ventilated Improved Pit (VIP) or urine diversion toilets. These do not require running water, chemicals or replacement parts, and have very low maintenance costs. This programme pioneered the use of urine diversion toilets in South Africa, introducing them in areas where hard rock made it almost impossible to dig deep enough pits to make VIP toilets viable. Rural communities were invited to participate in the programme. Those who were interested were asked to elect a committee to oversee the project. The implementing agents began by explaining the scheme and providing basic health and hygiene information. Several demonstration toilets were built at a house or school to provide examples of different top structures and toilet systems. DWAF provided a capital subsidy of R00 per household, and householders contributed the balance. Local residents were trained to build the toilets. Community members were trained as fieldworkers and hygiene promoters. Through interactive methodologies like PHAST (Participatory Hygiene and Sanitation Transformation), local residents were guided to identify health and sanitation problems in their communities that they could change. Schools were targeted for health and hygiene promotion campaigns. Administration of the project was in the hands of the committee, supported by the implementing agent. They received training in simple management and project administration, and then managed a dedicated bank account opened in the name of the project. Some project committee members went on to support programmes in other communities. At least three firms of emerging consultants were established. These firms provided valued work to previously unemployed local community members. At a celebration of the achievements of the sanitation project in the small Namaqualand settlement of Nourivier in July 2000, the Premier of the Northern Cape endorsed dry sanitation, including urine diversion

7 Sanitation toilets, as an acceptable, affordable and sustainable alternative to bucket toilets where flush toilets are not feasible. The province became the first to launch a bucket eradication programme, and is well on target to eradicate all buckets by 200. Finally, environmental health practitioners (EHPs) can play a decisive role in strengthening the health and hygiene impacts of a sanitation programme. In fact, EHPs now play a leading role in sanitation improvement in the province's Kgalagadi District Municipality. The programme also steered an effective farm-dweller sanitation pilot project, which led to improved sanitation for over families. Environmental health practitioners played the leading role, despite their limited numbers and the vast distances they had to travel. Policy implications No single toilet technology is appropriate in all areas. Local solutions are needed which take into account the availability of water, the depth of the water table, ground conditions, the capacity of the waste treatment works and, crucially, affordability to households and municipalities. It is possible to build acceptance for non-conventional technologies when households are given choices and the implications of the different choices are explained to them. Postscript The close working relationships forged through this provincial programme are now an important resource for municipal sanitation programmes. DWAF and the Department of Housing and Local Government work closely together to assist municipalities in planning sustainable water and sanitation projects funded through MIG. Particularly in arid areas where water is limited, pragmatism is needed around service options for water and sanitation. The close working relationships and consensus built between different role players has been activated in guiding municipalities to provide sustainable water services. Municipalities are able to advise and support each other in resolving practical problems. For example, toilet doors on stand-alone structures are a critical but neglected aspect of sanitation improvement because without a door that closes, the toilet offers no privacy and will not be used. Some municipalities have concluded that galvanised steel pivot doors last longer than wooden doors on toilets, as many residents neglect to repaint or varnish their doors. Others maintain that steel doors can get bent out of shape if left to swing in high wind. Similarly, municipalities are learning how to manage nitrates that build up from urine because of low and erratic rainfall: wide shallow pits or soakaways are dug to keep the nitrates in the root zone, where they can be taken up by plants. Case 3 The ethekwini Water and Sanitation Programme ethekwini has a proud history of continuous innovation in water services - straddling new technologies, user education programmes, project implementation and management systems, and support to emerging contractors. Two examples are highlighted here. The ethekwini Sewage Education Programme Traditionally, urban sanitation has been approached as an issue of infrastructure and technical services, with reticulated waterborne sanitation as the default. Good sanitation requires good user education - not just promoting understanding of how good sanitation helps to combat disease, but practical information on how to keep a toilet working and avoid system failures. This applies equally to flush toilets and dry toilets. Lessons Dry sanitation can become an acceptable option for community members when the benefits of affordability and - more importantly - sustainability are explained to them. The support of pragmatic, high-profile leaders - notably the Premier of the Northern Cape - greatly helped to build acceptance of dry sanitation as an alternative to bucket toilets where flush toilets are not feasible. ethekwini's Sewage Education Programme - an Impumelelo Award winner - used street theatre, posters, school visits and community meetings to build an understanding of how sewer systems work and how to avoid blockages. They also educated users on their role in keeping the system working. Close co-operation and co-ordination between government departments and municipalities helps to build a coherent vision of sanitation improvement, and facilitates cross-learning. ethekwini's approach shows that money invested in educating users leads to massive cost savings over time: Users are spared the cost and inconvenience of blockages, and the municipality spends less time and money fixing blockages and spills. 7

8 Sanitation Affordable water and sanitation in ethekwini's peri-urban and rural settlements There is a widespread expectation that waterborne services can, and should, be extended to all urban settlements, both formal and informal. Yet the practical requirements of waterborne sanitation are complex: sufficient and reliable supplies of water, reticulated connections to each house, sewer systems, waste treatment capacity, servicing and maintenance capacity, billing and administrative systems, and secure funding for ongoing operation and maintenance. It might take many years before the municipality has the capital funds to address the bulk and connector infrastructure requirements of full reticulation. Where does that leave households in the interim? The Bester's Camp experience The real costs of waterborne sanitation are not the upfront capital costs, but the ongoing monthly costs of water, treatment and system maintenance. All too often, these costs are proving to be more than either the household or the municipality can afford. ethekwini adopted the approach that a robust and reliable dry toilet now might serve the needs of a poor family better than the promise of a flush toilet at some undefined time in the future. After extensive consultation with local residents, VIP toilets were piloted in the 1990s in formalising settlements like Bester's Camp on the edge of ethekwini's Umlazi township. Residents were offered several technology options, and chose VIPs because of their reliability and low running costs. However, this choice was not without problems. In time, the toilet pits filled up. There was no room to dig replacement pits, and so the municipality provided a costly desludging service to empty the pits. But settlement densities grew rapidly in Bester's Camp. Today, there are many full pits that cannot be reached by vacuum tankers: the terrain is steep, there are few roads, and paths and stairways are narrow. This raises complex questions on how to ensure sustainable sanitation in this dense settlement. The Bester's Camp experience has powerfully shaped the municipality's thinking. It forced home the recognition that provision of infrastructure is just the beginning of service provision. The real challenge is ongoing provision of services that are affordable and which can be maintained. It led ethekwini to base its choice of an alternative technology on its operation and maintenance requirements, not its capital cost. Applying the lessons of experience beyond 'the waterborne edge' Durban Metro pioneered delivery of 200 litres of water daily to each peri-urban house by means of a 200-litre ground tank, filled once a day with clean drinking water from a reticulated low-pressure water system. This generated a volume of wastewater which could be absorbed on-site without requiring sewers, and was compatible with an on-site VIP toilet. In 2000, municipal demarcation extended the boundaries of the old Durban Metro by 8%. This included households in low-density peri-urban and rural settlements, many of them living under traditional authority systems. An outbreak of cholera late in 2000 and in 2001 underlined the urgency of improving services in these areas. Following an extensive process of information sharing and debate between technical officials and councillors, the new ethekwini Unicity decided that waterborne sanitation would not be provided throughout the entire Unicity. The costs of installation and servicing were affordable neither to poor households nor the municipality. Moreover, long-term running costs far outweighed short-term installation costs. Consequently, a 'waterborne edge' was defined: beyond its boundaries, on-site sanitation would be the default. ethekwini decided against VIPs as the norm beyond the 'waterborne edge'. Over time, pits fill, and there is often not enough space on-site to build a replacement pit. The only alternative is to desludge these pits. Regular emptying is not affordable to most households, and prohibitively expensive to the municipality. Many areas are simply inaccessible to the city's vacuum tankers. Instead, ethekwini developed a form of dry sanitation that would be simple for households to maintain themselves: a ventilated, improved urine diversion toilet, which is safe, reliable and affordable. The simple design of the system separates faeces from urine. Urine drains away to a soakaway, while the excreta collect in a shallow bin beneath the pedestal. 8

9 Sanitation The faeces dry out rapidly, particularly if soil is added regularly to absorb moisture. Like dried cow manure, dried human faeces do not smell. Users are responsible for removing and burying dry odourless faeces. The introduction of the new technology was preceded by extensive consultation and information sharing with councillors, ward representatives, traditional leaders and residents. Community acceptance was promoted by: Working closely with a project-level steering committee, where women are represented and which the local councillor supported Projects are planned, approved and scheduled far in advance of work on the ground. This allows for comprehensive consultation and preparation long before construction begins, and pre-empts most of the problems that slow delivery costs. Costs are minimised through internal project management, and by restricting the use of consultants to specialist geohydrological, ISD and auditing services. Bureaucracy is minimised by preparing an overall business plan for the whole water and sanitation programme, with funding applications for specific projects limited to essential project data only. Data collection, and progress and financial reporting are limited to essential data only. Having a Technical Steering Committee to quickly resolve day-to-day problems Selecting and training educators from the community Using labour-intensive methodologies, providing training to local builders and initiating local brickmaking manufacture Maintaining strict quality control Lessons Visiting each household. A project educator visited houses at least three times: at the start of the project, on completion of the toilet, and six months after handover. The education programme covered basic hygiene, and an explanation of how the toilet worked, how to operate and maintain it, and how to remove and bury the waste material. Waste removal is needed generally every nine to twelve months. Creative and pragmatic leadership is necessary to promote and support innovation on the ground. ethekwini's Water and Sanitation Unit has worked closely with the city's political decision makers to develop a vision of service provision that meets the needs of all its residents. Technical officials have engaged closely with councillors, explaining the technical requirements and implications of different systems, and have worked with them to build acceptance of the agreed approach amongst their constituents. Detailed assessment through house-to-house surveys indicates that most households are well satisfied with this system. Where problems are noted - for example, where households do not fully understand the operating principles of their urine diversion toilets - remedial interventions are identified and implemented. Technical interventions need to be planned and implemented within a broader understanding of the requirements for sustainability. Service provision must be informed by a frank assessment of what both households and the municipality can afford. This includes capital costs as well as long-term operation and maintenance costs. The Water and Sanitation Programme has been refined extensively: Provision of basic-level water and sanitation services in a single programme allows for greater project efficiency and social impact. Community members are generally pragmatic and willing to accept innovative technologies and approaches when their needs and aspirations are acknowledged, and when they are given an opportunity to engage in informed discussion around their options. Close interaction between the programme team and local leaders is necessary to build this trust and understanding. The Unicity is well on track to meet its water services delivery targets by Ongoing refinements All projects are initiated and implemented using standardised procedures: a structured methodology for prioritising projects, an implementation protocol, standardised enquiry documents for geohydrological and institutional and social development (ISD) consultants, standardised education material for user education and health and hygiene, independent auditing of all aspects of delivery and acceptance by households. 9

10 Sanitation New settlements need to be planned so that long-term service requirements can be addressed. Where VIP toilets are provided, plot sizes need to accommodate space for a replacement pit. Alternatively, every plot needs to be accessible to desludging equipment. Ongoing monitoring and evaluation are needed to assess user satisfaction and highlight issues and problems that need to be addressed. This in turn leads to further refinements and strengthening of overall programme. Long-term planning is essential to provide a coherent and consistent approach. It also allows an appropriate time frame to build understanding on the grounds of the project's objectives. ethekwini is adamant that basic water and sanitation should be delivered as a single package, and not be installed separately. This allows more cost-efficient delivery, and ensures that water installations are compatible with on-site sanitation. A comprehensive health and hygiene education programme is able to leverage the benefits of both water and sanitation provision. All too often, these education programmes accompany stand-alone water or sanitation projects, and the full health benefits are not achieved because either the water supply or sanitation facility is inadequate. Policy implications Technical services need to be provided within a much broader integrated development perspective. Services must be affordable both to households and to the municipality, and the long-term operating and maintenance requirements must inform planning and provision. Water and sanitation services need to be integrated and compatible in all settlement types. All too often, service upgrades in existing settlements tackle water and sanitation separately, and water is usually given priority. Unrestricted high-pressure house connections need wastewater disposal systems, and this often rules out on-site dry sanitation options. Flush toilets are not affordable to poor households without massive subsidies. A combined water and sanitation delivery package is the ideal, but this is not always feasible or affordable, as municipal decision makers are under pressure to spread limited available resources as widely as possible. Strong linkages are needed between technical and health personnel to ensure that the health and hygiene benefits of improved water services are realised. This is particularly important in a context of high HIV prevalence for reducing exposure and vulnerability to the pathogens to which HIV-positive people are particularly susceptible. This has important co-ordination and funding implications. Finally, it should be noted that urine diversion systems require the co-operation and acceptance of users. They are not culturally acceptable to everyone, particularly where people have had bucket toilets in the past. However, urine diversion system (UDS) toilets offer at least three important benefits. Firstly, the separated faeces dry rapidly and are odourless, and so the toilet can be installed inside the house. This offers greater privacy, convenience and safety. Secondly, UDS toilets can be installed in areas where it is not possible to dig a deep pit because of rock or a high water table. Thirdly, the dried excreta are easy to remove regularly, and so emptying the waste bin is far simpler than desludging a pit. Cape Town is now planning to pilot a similar system in areas where a high water table and dense settlement rule out VIP toilets. Significantly, it plans to provide a municipal collection service, so that households do not have to remove and bury their waste themselves. Conclusion There have been many developments in the water and sanitation sector since the projects described here were initiated. Sanitation improvement is now run by municipal Water Services Authorities, rather than through national or provincial programmes, and municipalities are now responsible for sanitation in all areas, not just towns. Yet the core lessons of these projects remain relevant. Sanitation improvement is about more than providing a toilet infrastructure. It has a major public and primary health component, and calls for close co-operation between technical and health personnel. It offers opportunities for broader human and economic development. Sanitation straddles several sectors - housing and 10

11 Sanitation settlement development, water services, local economic development, municipal finance, and so on. Co-ordination across sectors and between municipal sections is vital. Service planning must be rooted in a pragmatic assessment of the resources available, and the operating and maintenance requirements of different systems. Abbreviations CPSI DWAF EHP IDP ISD MIG NGO SMIF VIP Addressing service backlogs is an urgent priority. However, the sustainability of those services is critical. Without user acceptance, and user understanding of the vulnerabilities of the toilet systems installed, the benefits of municipal investment in sanitation improvement will be short-lived. The Centre for Public Service Innovation Department of Water Affairs and Forestry Environmental Health Practitioner Integrated Development Plans Institutional and Social Development Municipal Infrastructure Grant Non-governmental organisation Special Municipal Innovation Grant Ventilated Improved Pit toilet Glossary of terms Bucket toilet - A crude system where excreta fall directly into an open bucket beneath the toilet seat or bench. The bucket is then collected weekly (or less frequently) by sanitation workers who must carry the bucket to an awaiting collection truck, empty it and replace it with a clean bucket. The waste is then removed for disposal elsewhere. Spillages are inevitable, and the collection system frequently breaks down. The system does not comply with government's definition of a minimum acceptable level of service. The pursuit of national poverty eradication goals and ongoing developments in water sector policy call for ongoing innovation in technologies, approaches and administrative arrangements. Municipalities, who are now at the forefront of water and sanitation services delivery, need to build on the innovations described above, as well as break new ground in addressing the challenges they face. A Special Municipal Innovation Fund (SMIF) has been launched to encourage innovation in the municipal sphere. This initiative falls within the Municipal Infrastructure Grant (MIG) programme of the Department of Provincial and Local Government (DPLG), and is managed and supported by the Centre for Public Service Innovation (CPSI). The CPSI can provide the resources necessary to test ground-breaking initiatives, particularly those that adopt an integrated approach to service delivery, or that promote and encourage local economic development. Urine diversion toilet - A dry toilet designed to separate urine from faeces. Urine drains away to a collection tank or soak pit, and the solids collect in a container beneath the pedestal. The solids dry out, becoming odourless and more manageable for secondary disposal - through burial, compositing, or collection and treatment elsewhere. VIP toilet - A considerable advance on a simple pit toilet: it is robust, safe and comparatively odourless. It has a pit that is stabilised to prevent it from collapsing, a sturdy floor slab, a well-designed pedestal which will not foul, a seat lid that is kept mostly closed to minimise fly access, and a tall ventilation pipe to remove odours, with a fly screen at the top to prevent flies escaping from the pit to spread pathogens. The type of top structure is entirely secondary to the functioning of the toilet. Its major purpose is to offer the user privacy, dignity and an attractive facility. Acknowledgements The contributions of Richard Holden, Linda Tyers and Jacques Rust are acknowledged with appreciation. Linda Tyers and Alpheus Zondi, (2003), Eyethu Sanitation Project: Evaluation and Documentation, unpublished report for the African Medical Research Foundation. 11

12 ABOUT THE SERIES Effective responses to the many developmental challenges facing South Africa - combating poverty, dealing with disease, providing reliable services, and so on - require a significant level of experimentation and innovation. Old approaches are not always appropriate to address new challenges, a new institutional environment, or other changes. Reflecting on the last decade, there has been no scarcity of experimentation and innovation. In many cases, individual projects have provided the evidence to spur on re-thinking of service delivery arrangements and to improve policy and practice. In some cases, South African initiatives have contributed to shaping global thinking on particular issues - for example, the Working for Water project. Innovation is vital if we are to meet our development challenges. There is growing acceptance, too, of the importance of other measures when dealing with development challenges. These include a stronger emphasis on: Acknowledging and rewarding innovation or simply good practice Introducing systems that encourage learning and knowledge sharing Ensuring that policies and strategies are informed by practical experiences on the ground, i.e. the concept of evidence-based policy-making. The Centre for Public Service Innovation (CPSI) has been established with a specific mandate to unlock innovation in public service delivery. An important task in this regard is to identify innovations in service delivery that have proven to be successful and sustainable, and to assess how these innovations can be replicated elsewhere, or how they can be mainstreamed. In this way, the innovation can be taken from one part of the country to another, or it can be institutionalised in the area where it was started. Better still, it becomes the dominant way, nationally and internationally. However, the experiences and findings of service delivery and innovation specialists have shown that replication and mainstreaming are far more difficult to achieve in practice. On this basis, the CPSI has created a work programme dedicated to enhancing our understanding and ability to replicate and mainstream successful innovations. With funding from the Ford Foundation, the CPSI has initiated this series of short Service Delivery Innovation Briefs. Each brief focuses on a different area of service delivery. The brief combines an exploration of key challenges within that sector and looks at the lessons that can be learnt from award-winning cases where a different or innovative route was chosen. Where possible, the brief identifies crucial policy questions that may require attention and debate. The case studies are drawn from the Impumelelo Innovations Award database. The database is managed by the Impumelelo Innovations Award Trust and contains more than a examples of alternative approaches to service delivery in a range of service delivery areas as well as projects focused on poverty alleviation. The database includes nominations as well as approximately 120 award winners from the first five years ( ) of the awards programme. The Impumelelo Innovations Award is primarily an awards programme. As such, the projects that are conferred with an award only address some of the many challenges faced within a specific area of service delivery. Despite this limitation, they do form an important basis for policy and practice. In addition, they assist in identifying improvements that can be replicated or mainstreamed, or help to spur on more innovations. Published by Centre for Public Service Innovation (CPSI) Tel: Fax: cpsi@sita.co.za This Publication was supported by the Ford Foundation