Government of Andhra Pradesh Rural Water Supply and Sanitation Department

Government of Andhra Pradesh Rural Water Supply and Sanitation Department Andhra Pradesh Rural Water Supply and Sanitation Project Under The World Bank Assistance Study on Sanitation and Hygiene Promotion Final Report April 2009

Table of Contents Table of Contents... 2 List of Acronyms... 5 1 Introduction... 7 1.1 Background... 7 1.1.1 Objectives... 7 1.1.2 Components... 8 1.2 Need for SHP Study... 8 1.2.1 Objectives of the study... 8 1.3 Scope of Work and Key Tasks... 9 1.4 Approach and Methodology... 9 1.4.1 Sampling Rationale... 10 1.4.2 Research Tools... 12 1.5 Organization of the Report... 12 2 Global and National Scenario on Sanitation... 13 2.1 What is Sanitation... 13 2.2 Global Scenario... 13 Source: Web at UNICEF, 2004.... 14 2.2.1 Facts About Sanitation Source... 14 2.2.2 International Year of Sanitation... 16 2.3 National Scenario... 17 2.3.1 Environmental Sanitation and Personal Hygiene... 17 2.4 Profile of Andhra Pradesh... 18 2.4.1 Geographic and Physiographic Profile... 18 2.5 Demographic Profile... 18 2.6 Regional Socio-cultural Variations... 19 2.7 Primary Data... 20 2.7.1 Sex Ratio... 20 2.7.2 Religion and Caste Composition... 20 2.7.3 Ration Cards... 21 2.7.4 Literacy... 22 2.7.5 Land and Assets... 23 2.7.6 Dwelling... 24 2.8 Salient Features and Issues for the Project... 24 3 Sanitation Status in Andhra Pradesh... 25 3.1 Introduction... 25 3.2 Rural School Sanitation... 26 3.3 Status of Water Borne Diseases... 27 3.4 Incidence of Water Borne Diseases... 27 3.5 Primary Data on Sanitation... 28 3.5.1 Usage... 29 3.5.2 Reasons for not Using Latrines... 30 3.6 Open Defecation... 30 3.6.1 Site... 31 3.7 Environmental Sanitation... 31 3.7.1 Solid Waste Disposal... 31 3.7.2 Waste Water Disposal... 32 3.7.3 Sewage Disposal... 33 Page 2

3.7.4 Fodder Waste/ Dung Disposal... 33 3.7.5 School Sanitation... 34 3.8 Awareness of Water Borne Diseases... 35 3.9 Water Handling Practices... 35 3.10 Personal Hygiene... 36 3.11 Availability of Medical Facilities... 38 3.12 Elements of Sanitation... 39 3.13 Issues... 39 4 Sanitation Policies and Programs of Andhra Pradesh... 41 4.1 Total Sanitation Campaign... 41 4.1.1 Lesson Learnt... 41 4.2 NGP... 41 4.3 Shubhram... 42 4.4 Indiramma Program... 43 4.5 Partnership with other agencies... 43 4.5.1 CLTS Approach... 44 4.5.2 CLTS Process... 45 4.5.3 Triggers Approach... 45 4.5.4 Shifts from Traditional Approach... 46 4.5.5 Partnering with SERP - IKP... 47 4.6 Institutional Arrangements... 47 4.7 Institutions related to Policy, Planning and M&E... 48 4.7.1 Secretary, RWSS... 48 4.7.2 SWSM, DWSM, MWSC and VWSC... 48 4.7.3 Panchayat Raj Institutions... 52 4.7.4 Tribal Related ITDA and VTDA... 53 4.8 Implementation and Operations - RWSS Department... 54 4.8.1 Engineer-in-Chief... 54 4.8.2 Chief Engineers... 55 4.8.3 SEs and EEs... 55 4.8.4 DEEs and AEEs/AEs... 55 4.8.5 Manpower... 56 4.9 Key Strengths and Weaknesses of RWSSD... 56 4.9.1 Key strengths... 56 4.10 Issues for Consideration... 57 5 Approach for APRWSSP... 59 5.1 Introduction... 59 5.2 Objectives of Sanitation and Hygiene Promotion... 60 5.2.1 Project Focus... 60 5.3 Strategy... 61 5.4 Implementation Arrangements... 64 5.5 Monitoring and Evaluation... 66 5.6 Budget... 66 Page 3

List of Tables Table 1: Region wise sample details... 11 Table 2: Research Tools... 12 Table 3: AP Demographic Profile... 19 Table 4: Religious Composition by Region... 21 Table 5: Region wise Caste Composition... 21 Table 6: Region wise Ration Cards Details... 21 Table 7: Region wise Education among Male Family Member... 22 Table 8: Region wise Education among Female Family Member... 22 Table 9: HH possess Wet Land... 23 Table 10: Region wise HH Assets Details... 23 Table 11: Region wise Type of House Structure... 24 Table 12: Region wise HH Having Electricity Connection... 24 Table 13: Status of Rural Sanitation Coverage in AP... 25 Table 14: Rural School Sanitation Status in AP... 26 Table 15: Cases of Water Borne Diseases in AP in Last 5 Years... 27 Table 16: Households by Incidence of Water Borne Diseases in Last 6 Months... 28 Table 17: Region wise Households with Latrine... 28 Table 18: Households by Latrine Usage... 29 Table 19: Gender and Usage of Latrine... 29 Table 20: Reasons for not using latrines... 30 Table 21: Defecation Practice of those who do not own Latrines... 30 Table 22: Site of Open Defecation... 31 Table 23: Children Defecation... 31 Table 24: Households by Solid Waste Disposal... 32 Table 25: Households by Waste Water Disposal... 32 Table 26: Household by Sewage Disposal... 33 Table 27: Households by Fodder Waste/Dung Disposal... 33 Table 28: School Sanitation Status in Sampled Villages... 34 Table 29: Girl Sanitation Facilities in Schools in Sampled Villages... 34 Table 30: Working Condition of School Latrine... 34 Table 31: Households by Knowledge About Water Borne Diseases... 35 Table 32: Households by Water Treatment Methods... 35 Table 33: Households by Drinking Water Handling Practices... 36 Table 34: Households by Hand Wash Practices... 36 Table 35: Agent for Wash Hands... 37 Table 36: HH Members take Bath... 37 Table 37: Gender and Bathing Habits... 37 Table 38: Availability of Medical Facilities in Sample Villages... 38 Table 39: Number of Awards Winning GPs in AP During Last 3 Years... 42 Table 40: Manpower of RWSS department... 56 Table 41: Institutional Arrangement for Implementation of Sanitation Component. 64 Table 42: Budget for Sanitation and Hygiene Promotion of APRWSSP... 66 Page 4

List of Acronyms AP Andhra Pradesh APL Above Poverty Level APRWSSP Andhra Pradesh Rural Water Supply and Sanitation Project BC Backward Class BCC Behaviour Change Communication BPL Below Poverty Level CDD Community Driven Development CE Chief Engineer DEE Deputy Executive Engineer DPSU District Project Support Unit DRP District Resource Persons DWSM District Water and Sanitation Committee EE Executive Engineer E-in-C Engineer-in-Chief FGD Focus Group Discussions GP Gram Panchayat GPWSC Gram Panchayat Water and Sanitation Committee HH Households HNU Health and Nutrition Unit IEC Information, Education and Communication IHSL Individual Household Sanitary Latrine IKP Indira Kranti Patham ISL Individual Sanitary Latrines MP Mandal Parishad MRP Mandal Resource Persons MTP Medium Term Program MWSC Mandal Water and Sanitation Committee PD Project Director PIP Project Implementation Plan PRI Panchayat Raj Institutions RWSS Rural Water Supply and Sanitation RWSSD Rural Water Supply and Sanitation Department SC Scheduled Caste SE Superintendent Engineer SERP Society for Elimination of Rural Poverty SLWM Solid and Liquid Waste Management SO Support Organizations SPSU State Project Support Unit SSC Secondary School Certificate ST Scheduled Tribe SWSM State Water and Sanitation Mission Page 5

TSC UGD VWSC WB Total Sanitation Campaign Under Ground Drainage Village Water and Sanitation Committee The World Bank Page 6

1.1 Background 1 Introduction Government of Andhra Pradesh through the Rural Water Supply and Sanitation Department (RWSSD) is currently preparing a Rural Water Supply and Sanitation Program (APRWSSP) under the World Bank assistance. This APRWSSP presents the Rural Water Supply and Sanitation (RWSS) sector investment program and implementation action plan, referred to as the Medium Term Program (MTP), for realising the goals of the vision of GoAP for the RWSS sector by 2013. It would serve as a financial action plan for channelling investment funds and other resources for integrated rural water supply and sanitation development in the state for the program period. In 2006, GoAP issued RWSS sector vision and policy. Key features of the Vision are: Devolution of funds, functions and functionaries to the Panchayat Raj Institutions (PRIs); Enforcement of full recovery of Operation and Maintenance (O&M) cost and sharing of capital cost (taking into consideration affordability, particularly by disadvantaged groups); and Improvement of the "accountability framework" by clarifying roles and responsibilities of various actors of the RWSS sector at the state, district and village level, including responsibilities for policy formulation, financing, regulation, construction, operations and maintenance. This vision has introduced two major changes. They are: Transfer of responsibility for planning, design and construction of the RWSS infrastructure and the operation of the RWSS service to the PRIs and communities Evolution of the role of RWSSD into that of a provider of technical assistance to the PRIs. 1.1.1 Objectives The objective of this APRWSSP is to increase access of rural communities to reliable, sustainable and affordable Rural Water Supply and Sanitation (RWSS) services. APRWSSP aims at coverage of 1878 Not Covered (NC) and 199 No Safe Source (NSS) habitations with water supply. Coverage of 766 Partially Covered (PC) habitations in five years during the MTP is the target for Rural Water Supply. This project will also carry out some augmentations and improvements to Single Village Schemes (SVS) and Multi Village Schemes (MVS). The targets for sanitation suggest provision of soak pits and household toilets, in 2843 habitation, Under Ground Drainage (UGD) & Solid and Liquid Waste Management (SLWM) facilities for 55 Mandal headquarters, and sullage drains with pavement for major GPs covered under the project. Page 7

1.1.2 Components Three components of APRWSP are: Policies, Institutional Reforms and Capacity Building Investment Monitoring and Evaluation Parameters of outcome indicators for monitoring are defined as follows: Percentage habitations with improved drinking water and sanitation services Percentage rural households with access to safe and adequate water supply throughout the year Percentage rural households adopting improved hygiene and sanitation practices; and Improvements in cost recovery, and collection efficiency; contributions to capital and O&M Costs As a part of the project preparation, the GoAP carried out the study on Sanitation and Hygiene Promotion (SHP) to develop a strategy with an implementation plan to achieve the set sanitation goals under the proposed project. This report outlines the findings of the SHP study. 1.2 Need for SHP Study The objective of the sanitation and hygiene promotion study is to assist the GoAP to further develop the sanitation and hygiene component as an integral part of the proposed AP Rural Water Supply and Sanitation Project, based on the baseline information and strategic decisions taken by the state. 1.2.1 Objectives of the study The purpose of the proposed study is to formulate a comprehensive & realistic assessment of the sanitation and hygiene promotion status in the state by developing and updating the available data. Further it is expected that the study outputs will contribute to the development of an appropriate Sanitation and Hygiene Promotion Strategy in lieu of the proposed RWSS Medium Term Sector Program planned for 2009-14. The specific objectives of this study are: To asses the current sector status of the sanitation and hygiene promotion component and To identify issues that merit attention from the perspective of developing a sanitation strategy for the proposed AP Rural Water and Sanitation Program. Page 8

1.3 Scope of Work and Key Tasks This study attempts to understand the broader requirements of provision of sanitation and hygiene promotion services in a sustained manner, promoting a demand responsive approach and facilitating reforms across the sector. Specifically assessments related to the current sector status and the commitment of the major role players in the Sector were made while also identifying gaps and deliverables. In addition the following issues were also assessed; Implementation of the TSC/SHP program in the State: Modalities of the GOI, State and Donor funded sanitation and hygiene programs, achievements, failure, expenditures incurred. Specific visits to two NGP awarded GPs to assess the success of the changed approach of transferring construction of sanitation facilities into changed hygiene behavior. Inclusion of the latrine component and other hygiene aspects, if any into the Indiramma Housing program Evidence of visible Triggers for behavior change with regards to sanitation and its integration into the socio economic culture of the people. Specifically the study attempted to review the following: Available technical options for sanitation and hygiene promotion including the IHL, School sanitation, Anganwadi sanitation Community Latrines, Solid Waste Management, Liquid Waste Management, RSMs, PCs keeping in mind the different regions and terrains Available Technical, Institutional and financial arrangements Requirement of resources Behavior- practice and triggers that motivate behavior change Existing IEC/HRD strategies Existing M&E systems Capacities of the PRIs, the authority they enjoy, resources available (financial, human) and the mandate required for integration of service delivery keeping in view the future requirements to coordinate the health/hygiene/sanitation/water supply programs in future. 1.4 Approach and Methodology A combination of methodologies was adopted to carry out this study that comprised the following steps. Desk review: At the outset, all the documents related sanitation policies of the national and state governments, guidelines, government orders, progress reports and other relevant documents were reviewed Page 9

Interactions with stakeholders: In addition to the desk review detailed discussions were held with various stakeholders at state as well as the district levels covering the policy makers, implementing officials, NGOs, training institutes, and external support agencies like Water and sanitation program South Asia (WSP-SA), UNICEF etc Focus group discussions: Detailed focus group discussions were held with elected representatives, community leaders, members of SHG, GPs and VWSCs in the selected villages with a semi structured check lists. The FGDs helped the study team to assess the potential impacts of the ongoing sanitation programs, issues and challenges related to the water supply and sanitation programs. Participatory Rural Appraisal techniques: The study team conducted PRA exercises to understand the sanitation situation using the social mapping, sanitation walk/ transact walks, small group discussions for triangulation of the findings and discussions with individual households in the sample villages Coordination with other studies and integration of the data from baseline assessment: A holistic perspective was gathered by i) coordinating with other agencies and ii) by integrating data from the baseline assessment conducted by Center for Excellence in Management and Technology Pvt. Ltd. (CEMT), which preceded this study. State level workshop on scaling up of Shubram communities in AP : The Study team participated in a two day state level workshop on sanitation attended by state level officials of RWS and PR department, member Secretaries of the DWSCs, Chief Executive Officers (CEOs), District Panchayats officers, representatives from District support units, other states and WSP-SA. Detailed deliberations were held on achievements, plans, challenges, issues and way forward during the workshop. 1.4.1 Sampling Rationale During the study a multi stage stratified random sampling process was adopted to ensure participation of all groups of stakeholders and beneficiaries in providing the inputs for the assessment. The sample villages were selected representing each of three regions viz. Coastal Andhra, Rayalaseema and Telangana. Of the total of 34 habitations in 31 Mandals the region-wise distribution is Telangana (14) Coastal Andhra (11) and Rayalaseema (9). The list of sample villages is given as Annexure 1. Table 3 below furnishes the district-wise and Mandal-wise distribution of habitations. Page 10

Table 1: Region wise sample details Region District No. of Mandals Andhra Region Srikakulam 3 3 West Godavari 3 3 Rayalaseema Region Chittoor 3 3 Kadapa 3 3 Kurnool 2 3 Telangana Region Karimnagar 3 3 Mahaboobnagar 2 3 Rangareddy 3 3 Fluoride Affected Villages Nalgonda 5 5 Prakasam 4 5 GRAND TOTAL 31 34 No. of Habitations Type of Sanitation Facilities: Villages with different types of sanitation facilities like ISLs, drains, SWM systems, etc. were chosen to represent the reality on the ground. Availability and Quality of Water: Scarcity and poor quality of water, both pose a significant challenge to the state of Andhra Pradesh. Out of the sample of 34 habitations measures were taken to include under served villages and fluoride affected villages (10), thus factoring in quantity and quality problems of water in the state. Type of Source: The water supply schemes in Andhra Pradesh have both surface water and groundwater as sources. The sample covers both types of sources. In the sample, 25 schemes depend on groundwater and 9 schemes depend on surface water. Tribal Coverage: Andhra Pradesh has substantial tribal population and has scheduled areas too. The sample includes both the aspects. There are 20 villages with tribal population in the sample. Page 11

1.4.2 Research Tools The details of tools and techniques used for the assessment study are presented in table below. Table 2: Research Tools S. No. Techniques Tools/ Instruments Respondents 1 Social Mapping 2 Household Survey 3 Focus Group Discussions 4 Public Consultations Checklist Household Interview Schedule/ Questionnaire Checklist Checklist Community Members from the habitations to be benefited / affected by the project, PRI Members, etc. Community Members from the habitations to be benefited / affected by the project Community Members from the habitations to be benefited / affected by the project, PRI Members, etc. Community Members from the habitations to be benefited / affected by the project, PRI Members, etc. Both quantitative and qualitative data analysis techniques were employed during the assessment study. Required software packages (Microsoft Access, SPSS etc.) were used for carrying out the collation, data coding, analysis and generation of outputs. 1.5 Organization of the Report This report is organized under 5 chapters. This first chapter gives the introduction to this report. It includes background, objectives, scope of the physical activities, need for study, scope of work and key tasks. The second provides a macro perspective of global and national scenario on sanitation and the physical and demographic profile of the state, while the third chapter gives sanitation status in Andhra Pradesh. The fourth chapter presents the sanitation policies and programs in Andhra Pradesh including the institutional arrangements present. The fifth chapter gives the approach and strategy and budget for the APRWSSP. Page 12

2.1 What is Sanitation 2 Global and National Scenario on Sanitation The general perception of sanitation is the disposal of human excreta and construction of latrines. The World Health Organization defines it as Control of all those factors in man s physical environment which exercise or may exercise a harmful effect on his health, physical development and survival. Water and Sanitation is one of the primary drivers of public health. Lack of sanitation is a serious health risk and an affront to human dignity. It affects billions of people around the world, particularly the poor and disadvantaged. Public health interventions that secure adequate sanitation in communities prevent the spread of disease and save lives. They raise the quality of life for many, particularly women who are often in charge of domestic tasks, and face personal risks when they relieve themselves in the open. Sanitation is a basic need and a way to ensure better health. The United Nations has declared 2008 as the International Year of Sanitation to make it a priority for governments, organizations, civil society and private partners worldwide. 2.2 Global Scenario In 2002, about 1.1 billion people (17% of the global population) lacked access to improved water sources, while 2.6 billion people (42% of the global population), lacked access to improved sanitation. o Five of the top ten killer diseases of children aged 1-4 years in rural areas are related to water and sanitation. These are Diarrhea, Malaria, Schistosomiasis, Trachoma and intestinal worms (Roundworm, whip worm, hookworm). o The annual mortality due to diarrhea is 1.8 million; of which close to 90% are children under 5, mostly in developing countries. o Similarly, the annual mortality due to malaria is 1.3 million, of which over 90% are children under 5. Much of this mortality and morbidity may be attributed to diseases of poor sanitation and poor personal hygiene. As per the United Nations Report, India stands lowest (33%) in terms of sanitation coverage in the South Asian Region. Access to water and sanitation in different countries in south Asia region is presented in the table below. Page 13

Table: Access to Water and Sanitation in South Asia, 2004 Total Rural Country Population % Access to Water % Access to Sanitation % Population % Access to Water % Access to Sanitation Afghanistan 28574000 39 34 76 31 29 Bangladesh 139215000 74 39 75 72 35 Bhutan 2116000 62 70 91 60 70 India 1087124000 86 33 72 83 22 Maldives 321000 83 59 71 76 42 Nepal 26591000 90 35 85 89 30 Pakistan 154794000 91 59 66 89 41 Sri Lanka 20570000 79 91 79 74 89 Source: Web at UNICEF, 2004. 2.2.1 Facts About Sanitation Source 1. Around 2.6 billion people lack access to adequate sanitation globally. The regions with the lowest coverage are sub-saharan Africa (37%), southern Asia (38%) and eastern Asia (45%). Underlying issues that add to the challenge in many countries include weak infrastructure and scarce resources to improve the situation. 2. Lack of sanitation facilities forces people to defecate in the open, near water sources, or in open areas. This increases the risk of transmitting disease. About 1.1 million liters of raw sewage is dumped into the Ganges in India every minute. One gram of faeces in untreated water may contain 10 million viruses, one million bacteria, 1000 parasite cysts and 100 worm eggs. This simply indicates the magnitude of the problem. 3. Examples of diseases transmitted through water contaminated by human waste include diarrhea, cholera, dysentery, typhoid, and hepatitis A. In Africa, 115 people die every hour from diseases linked to poor sanitation, poor hygiene and contaminated water. 4. Health-care facilities need proper sanitation and health practitioners must observe good hygiene to control infection. Worldwide, 5% to 30% of patients develop one or more avoidable infections during stays in health-care facilities. 5. Each year more than 200 million people are affected by droughts, floods, tropical storms, earthquakes, forest fires, and other hazards. Sanitation is an essential component in emergency response and rehabilitation efforts to stem the spread of diseases. 6. Studies show that improved sanitation reduces diarrhea death rates by a third. 7. Adequate sanitation encourages children to attend schools, particularly girls. Access to latrines raises school attendance rates for children. Provision of separate sanitary facilities contributes to girls enrolment in schools. Page 14

8. Hygiene education and promotion of hand washing are simple. Cost-effective measures that can reduce diarrhea cases by up to 45%. Even when ideal sanitation is not available, instituting good hygiene practices in communities will lead to better health. Proper hygiene goes hand-in-hand with the use of improved facilities to prevent disease. 9. The economic benefits of sanitation are persuasive. For every one unit of money invested in improved sanitation, ensures 9 times return in value. Those benefits are experienced specifically by poor children, and in the disadvantaged communities that need them most. 10. The Millennium Development Goals target 75% global sanitation coverage by 2015. The cost to reach the milestone is estimated at US$ 14 billion annually through the period. Among other health gains, sanitation is estimated to reduce diarrhea cases by 391 million worldwide each year. Millennium Development Goals (MDGs) The MDGs stand for a renewed commitment to overcome persistent poverty and address many of the most enduring failures of human development. Halving the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015, is one of the targets defined for achieving the MDGs. The overall MDGs and Water & Sanitation-specific MDGs are shown in the diagram below: Millennium Development Goals 1. Eradicate extreme poverty and Hunger 2. Achieve universal primary Education 3. Promote gender equality and Empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria and Other diseases 7. Ensure environmental Sustainability 8. Develop a global partnership for Development Water & Sanitation Targets Target 9: Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources Target 10: Halve by 2015 the proportion of people without sustainable access to safe drinking water and sanitation Target 11: By 2020 to have achieved a significant improvement in the lives of at least 100 million slum dwellers In adopting the Millennium Development Goals, the countries of the world pledged to reduce by half the proportion of people without access to safe drinking water and basic sanitation. The results so far are mixed. With the exception of sub-saharan Africa, the world is well on its way to meeting the drinking water target by 2015, but progress in sanitation is stalled in many developing regions. In the water supply and Page 15

sanitation sector, monitoring progress towards achieving the MDG targets is essential for maintaining and putting into practice the political commitment both of national governments and the international community. However, background information on the water supply and sanitation sector remains unsatisfactory; and the reliability of existing statistics is uneven. 2.2.2 International Year of Sanitation The United Nations has proclaimed the period 2005-2015 to be the International Decade for Action Water for Life, and the year 2008 as the Year of Sanitation, with the aim of injecting some urgency into strategies for achieving the water and sanitation targets. This aims to stimulate open dialogue on every level while creating a context for political leadership and government commitments to allocate greater resources for sanitation for the poor, stressing the positive impact on health and gender equity. The Objectives of IYS are given below: Increase awareness and commitment from actors at all levels, both inside and outside the sector, on the importance of reaching the sanitation MDG, including health, gender equity, economy and environment issues via compelling and frank communication, robust monitoring data, and sound evidence. Mobilize Government(from national to local) existing alliances, financial institutions, major groups the private sector and the UN agencies via rapid collaborative agreements on how and who will undertake needed steps now. Secure real commitments to review, develop and implement roadmaps and national plans to scale up sanitation programs and strengthen sanitation policies via the assignment of clear responsibilities for getting this done at the national and international levels. Encourage demand driven sustainable and traditional solutions, and informed choices by recognizing the importance of working from the bottom up with practitioners and communities. Secure increased financing to jump start and sustain progress via commitments from National budgets and development partner allocations. Develop and strengthen institutional and human capacity via recognition at all levels that progress in sanitation toward the MDGs involves interlinked programs in hygiene, household facilities (such as toilets and washing facilities) and wastewater treatment. Community mobilization, the recognition of women s key role and stake along with an appropriate mix of software and hardware interventions are essential Enhance the sustainability and therefore the effectiveness of available sanitation solutions, to enhance health impacts, social and cultural acceptance, technological and institutional appropriateness, and the protection of the environment and natural resources. Promote and capture learning to enhance the evidence base and knowledge on sanitation which will greatly contribute to the advocacy and increase investments in the sector. Page 16

2.3 National Scenario According to 2001 Census, 64% of total population and 78% of the rural population does not have access to any form of sanitary facility. However, according to National Family Health Survey (NHFS) of 2006, 44.5% of the total population and 26% of the rural population had access to toilet. Latest estimates of the Department of Drinking Water Supply indicate that the rural sanitation coverage has since increased to about 50% by the beginning of 2008. Infant Mortality Rate (IMR) in rural India is as high as 57 per thousand live birth (NFHS, 2006) while the under 5 child mortality rate is 74. Over 44% of children under the age group of 5 are malnourished in the country. About 2.1 million child deaths occur every year in India, which is the highest figure for any single country in the world. Compared to urban areas, infant mortality rate is very high in rural areas and especially for the age group 1-4, the rural rate is twice as high as the urban rate (NHFS, 2006). Much of this mortality and morbidity may be attributed to diseases of poor sanitation and poor personal hygiene. Children suffering from frequent diarrhea, remain malnourished, physically and mentally underdeveloped and susceptible to other ailments. Ascariasis (Roundworm disease), a common childhood ailment in India adds to severe malnutrition, vitamin deficiency, and other conditions that may call for expensive diagnostic and treatment procedures. De-worming may give only temporary relief, because in areas with poor sanitation recurrent infections are almost a certainty. 2.3.1 Environmental Sanitation and Personal Hygiene Practice of open defecation by 56% of rural families (2007) contaminates the soil, the surface water and even the ground water with the disease-causing micro-organisms. Household refuse containing decomposable garbage, animal dung etc, indiscriminately dumped in the villages allows uncontrolled breeding of flies, and harbor rats and other pests. Waste water from different domestic and community sources not drained properly, favor breeding of mosquitoes. Contaminated drinking water is the commonest medium for transmission of diseases like diarrhea, cholera, typhoid, dysentery, polio, hepatitis etc. and yet the safety of drinking water is not given the due importance. Food and drinks are not properly protected against dust and invasion of flies and other insects. Most of the rural kitchens equipped with traditional chullahs emit smoke that contains noxious gases endanger the health of the users, especially the pregnant mothers and children. Basic items of personal hygiene, proper hand washing with soap etc are often neglected. Page 17

2.4 Profile of Andhra Pradesh Andhra Pradesh is the fifth largest state in India both in geographical area (an area of 2, 76,754 sq. km, accounting for 8.4 % of India's territory) and population wise (76.21 million accounting for 7.41 % of India s population of 1028 million). AP lies between 12 o 41' and 22 o longitude and 77 o and 84 o 40' latitude. It forms the major link between the north and the south of India. It is bounded by Madhya Pradesh and Orissa in the north, the Bay of Bengal in the east, Tamil Nadu and Karnataka in the south and Maharashtra in the west. AP has the longest coastline of 972 km in India. There are three main regions in the state i) Coastal Andhra ii) Rayalaseema and iii) Telangana with 22 districts, 1104 Mandals and 21856 GPs. 2.4.1 Geographic and Physiographic Profile The state is endowed with a variety of physiographic features ranging from high hills, thick forests, undulating plains to a coastal deltaic environment. The state has the advantage of having most of the east flowing rivers in the heart of the state bringing in abundant supplies of surface water from the Western and Eastern Ghats and Deccan Plateau up to the Bay of Bengal. The major, medium and minor rivers that flow through the state number about 40. Of these, the most important rain fed rivers are Godavari, Krishna, Pennar, Thungabhadra, Vamsadhara and Nagavali. Nearly 75% of its area is covered by the river basins of the Godavari, Krishna and Pennar, and their tributaries. There are 17 smaller rivers like the Sarada, Nagavali and Musi, as well as several streams. Godavari and Krishna are the two major perennial rivers, and with their extensive canal system, provide assured irrigation. The rainfall is influenced by both the south-west, north-west and north-east monsoons. The average annual rainfall in the state is 925 mm. A majority of the rainfall in AP is contributed by south-west monsoon (68.5%) during the months June to September, followed by north-east monsoon (22.3%) during the months October to December. The rest (9.2%) of the rainfall is received during the winter and summer months. The rainfall distribution in the three regions of the state differs with the season and monsoon. The influence of the south-west monsoon is predominant in the Telangana region (764.5 mm) followed by Coastal Andhra (602.26 mm) and Rayalaseema (378.5 mm), where as, the north-east monsoon provides a high amount of rainfall (316.8 mm) to Coastal Andhra area followed by Rayalaseema (224.3) and Telangana (97.1 mm). There are no significant differences in the distribution of rainfall during the winter and hot weather periods among the three regions. 2.5 Demographic Profile Andhra Pradesh is the most populous state in south India although the decadal growth rate is showing a declining trend. Some of the important demographics of the state are compared to all-india averages to ascertain the state s relative performance and presented in the table below. Page 18

Table 3: AP Demographic Profile Item Andhra All-India Pradesh Total population (Census 2001) (in million) 76.21 1028.61 Decadal growth rate (Census 2001) (%) 14.59 21.54 Crude Birth Rate (SRS 2006) 19.00 24.10 Crude Death Rate (SRS 2006) 7.00 7.50 Total Fertility Rate (SRS 2004) 2.00 2.90 Infant Mortality Rate (SRS 2006) 59.00 58.00 Maternal Mortality Ratio (SRS 2001-2003) 195.00 301.00 Female Sex Ratio (Census 2001) (per 1000 males) 978.00 933.00 Population below poverty line (%) 15.77 26.10 Schedule Caste population (in million) 12.34 166.64 Schedule Tribe population (in million) 5.02 84.33 Literacy rate (Census 2001) (%) 61.11 65.38 Female literacy Rate (Census 2001) (%) 50.40 53.70 Human Development Index (HDI)* 0.609 0.621 Gender Development Index (GDI)* 0.595 0.609 Planning Commission, Government of India, March 2002 2.6 Regional Socio-cultural Variations The three regions vary in terms of history, geography, social and cultural aspects. While the Telangana was part of the princely Hyderabad State ruled by Qutub Shahis, Moghals and Nizam before the Independence, the coastal Andhra and Rayalaseema were under the British rule. Before the colonial days, Srikrishnadevaraya and his dynasty ruled the Rayalaseema, and Gajapathis and others ruled the Andhra region. Geographically, Andhra area is coastal region endowed with fertile soils due to alluvial deposits of Godavari and Krishna rivers, whereas the Telangana region stands on Deccan plateau with large sections of stony terrain. The Rayalaseema is a dry region with patches of black-cotton soil, but not fertile. As mentioned above, the Andhra region gets more rainfall due to monsoons, the Telangana and Rayalaseema gets less rainfall. Linguistically, Telangana is heavily influenced by Urdu and Muslim culture, the official language of the government and the religion of the rulers respectively. To some extent there is an influence of Maharashtrian culture also. In Rayalaseema, the boarder districts of Chittoor and Ananthapur are influenced by Tamil and Kannada. The Andhra region has very little influence of other languages. The extension of Eastern Ghats provides forest cover and hill-ranges in the state, and it is mostly found in the Telangana district (25.4%) and less in Andhra (17.4%) and Rayalaseema (10.2%). These forests and hills are abodes of tribal populations of the state. Andhra Pradesh state has 33 scheduled tribes who contribute 6.60 percent to the total population. Their concentration is high in Telangana districts such as Adilabad (16.74 %), Nalgonda (10.55%), Warangal (14.10%), and Khammam (26.47 %). The tribal population is more only in Visakhapatnam district (14.55%) in Andhra region. In Rayalaseema Page 19

districts the percentage of tribal populations is low. All these tribal groups in most of the cases have their own dialect and distinct cultural practices. They generally live in hill areas depending on the shifting cultivation, collection of forest produce, hunting and so on. There are villages in all areas exclusively inhabited by tribes mostly in scheduled areas, and in some villages there is multi-ethnic population mostly in non-scheduled areas. Thus, these three regions are different in several ways: forests and hills, plain terrains, tribal and non-tribal composition, fertility of soils, wet and dry lands, distinctive cultural practices etc. 2.7 Primary Data This chapter gives the socio-economic profile, details such as family type and size, of the households in the sampled habitations. 2.7.1 Sex Ratio The total number of males and females in the villages selected for the study consists 7,358 and 7,080 respectively, bringing the male and female ratio to 962 females for 1000 males. The overall state sex ratio is 978 females to 1000 males. Compared to the all India average of 933 female for 1000 males, Andhra stands out better. 2.7.2 Religion and Caste Composition Overall Situation: About 91% of the interviewed households practice Hinduism, about 6% belongs to Islam and about 3% follow Christianity, thus making 9% of the total population as non-hindus. Regional Variation: Telangana region has the largest Hindu population (93%), followed by Andhra region with 88% and Rayalaseema with 88%. Rayalaseema region has the highest Muslim population (11%), where as Andhra has the lowest (1.28%); Telangana falls somewhere in between with 5.27%. Andhra region has the highest Christian followers with about 11%, Telangana stands second with 1.54% and Rayalaseema has less than 1% of Christian population. Close to 95% of the Hindu population lives in fluoride affected area, where as the proportion is only about 4.57% and 1.31% among Muslims and Christians respectively. Page 20

Table 4: Religious Composition by Region Religious Composition by Region Fluoride Andhra Rayalaseema Telangana Affected Total % % % % Freq % Hindu 87.85 87.77 93.06 94.12 2733 91.10 Muslim 1.28 11.15 5.27 4.57 182 6.07 Christian 10.87 0.96 1.54 1.31 83 2.77 Others 0.00 0.12 0.13 0.00 2 0.07 Total 100 100 100 100 3000 100 Overall situation: About 42% of the interviewed households belong to backward classes, while 26% belong to general category. 23% of the interviewed households belong to Scheduled Castes and 9% Scheduled Tribes. Regional variation: The similar pattern of high percentage of the population belonging to marginalized sections is also seen between the three regions, although there are minor variations in the distribution. Table 5: Region wise Caste Composition Andhra Rayalaseema Telangana Total % % % Freq % General 33.26 36.21 14.01 774 25.80 SC 29.00 16.07 24.29 693 23.10 ST 9.17 12.11 14.40 277 9.23 BC 28.57 35.61 47.30 1256 41.87 Total 100 100 100 3000 100 As the SCs and STs live a little away from the main village where higher and lower castes live, and their population is sizable, there is a demand for an inclusive policy. 2.7.3 Ration Cards Possessing ration cards is an indicator of the financial status of the household. Among interviewed households about 90% hold BPL (Below Poverty Line) cards, 7% have APL cards and 4% do not have any cards. Table 6: Region wise Ration Cards Details Andhra Rayalaseema Telangana Total % % % Freq % BPL 91.47 90.89 91.13 2693 89.77 APL 5.97 6.95 5.27 196 6.53 No Card 2.56 2.16 3.60 111 3.70 Total 100 100 100 3000 100 Page 21

2.7.4 Literacy Overall situation: About 17% of the male family members are illiterates. About 40% had high school education and 20% have studied upto SSC. About 11% have studied up to Intermediate and 7% up to degree level. Diploma holders, post graduates and professionals are the lowest at 2.70%, 1.43% and 1.20% respectively. Regional variation: Significant variation in educational attainment is observed between the three regions. For example, Andhra has the highest percentage of illiterates (23%) as compared to Rayalaseema (17%) and Telangana (19%). However, Andhra region has also the highest percentage of male family members who have studied up to class IX (51%), where as in Rayalaseema and Telangana it stands at 32% and 37% respectively. Table 7: Region wise Education among Male Family Member Andhra Rayalaseema Telangana Total % % % Freq % Illiterate 22.81 17.03 19.92 513 17.10 I-IX Class 50.53 32.13 37.40 1191 39.70 SSC 8.74 23.02 19.02 595 19.83 Intermediate 7.68 12.47 14.14 332 11.07 Diploma 3.20 3.60 1.03 81 2.70 Degree 5.33 8.15 6.43 209 6.97 PG 1.07 2.28 1.67 43 1.43 Professional 0.64 1.32 0.39 36 1.20 Total 100 100 100 3000 100 Overall situation: Among the female members the illiteracy rate is 36%. Very insignificant numbers of females have received education up to post graduation (0.63%) and professional level (0.33%). Regional variation: Female illiteracy rate is highest in Telangana (41%), lowest in Andhra (29%) and Rayalaseema stands in between with 34% of female being illiterates. Table 8: Region wise Education among Female Family Member Andhra Rayalaseema Telangana Total % % % Freq % Illiterate 28.78 34.17 40.87 1068 35.60 1-9 Class 52.67 38.85 35.73 1271 42.37 SSC 7.46 14.99 11.44 342 11.40 Intermediate 7.04 7.07 7.46 186 6.20 Diploma 2.13 0.36 0.13 18 0.60 Degree 1.49 3.12 3.21 86 2.87 PG 0.21 1.08 0.77 19 0.63 Professional 0.21 0.36 0.39 10 0.33 Total 100 100 100 3000 100 Page 22

2.7.5 Land and Assets Among the interviewed households about 27% possesses wet land for irrigation. Telangana has the highest (43%) possession of wet land followed by Rayalaseema (26%) and Andhra 11%. fluoride affected villages (22%) and Andhra region (11%). Table 9: HH possess Wet Land Andhra Rayalaseema Telangana Total % % % Freq % Yes 11.09 26.02 43.19 804 26.80 No 88.91 73.98 56.81 2196 73.20 Total 100 100 100 3000 100 Household assets range from ownership of low value items such as bicycles (40%) to high value durables like two wheelers (11%), three wheelers (1.27%), four wheelers (0.8%) tractors (1.43%) and televisions (41.20%). Table 10: Region wise HH Assets Details Andhra Rayalaseema Telangana Total % % % Freq % Cycle 64.18 22.18 43.57 1217 40.57 Two Wheeler 18.55 5.64 13.37 334 11.13 Three Wheeler 1.49 0.36 1.80 38 1.27 Four Wheeler 0.43 0.24 1.03 24 0.80 Radio/ Tape Recorder 5.33 14.27 9.64 303 10.10 Television 56.50 33.21 38.05 1236 41.20 Fridge 5.76 3.72 3.98 124 4.13 Tractor 1.71 1.32 1.93 43 1.43 Gas Connection 33.05 8.63 21.98 586 19.53 Carts 2.35 10.07 1.93 147 4.90 Telephone 10.23 8.87 6.30 238 7.93 Mobile Phone 14.50 15.83 28.53 618 20.60 Cable Connection 55.65 18.11 29.95 931 31.03 Page 23

2.7.6 Dwelling Among the interviewed households 39% live in pucca houses and 47% live in semipucca houses while the rest live in kutcha houses. Table 11: Region wise Type of House Structure Region wise Type of House Structure Andhra Rayalaseema Telangana Fluoride Affected Total % % % % Freq % Kutcha 20.04 18.82 5.14 14.36 423 14.10 Semi-pucca 40.30 40.65 61.05 43.85 1406 46.87 Pucca 39.66 40.53 33.80 41.78 1171 39.03 Total 100 100 100 100 3000 100 Although most houses have electricity connection, only 85% answered in the affirmative and rest preferred to answer in the negative. Table 12: Region wise HH Having Electricity Connection Region wise HH Having Electricity Connection Andhra Rayalaseema Telangana Fluoride Affected Total % % % % Freq % Yes 90.62 75.06 84.32 91.84 2551 85.03 No 9.38 24.94 15.68 8.16 449 14.97 Total 100 100 100 100 3000 100 2.8 Salient Features and Issues for the Project The following salient features emerge form the secondary social economic profile of the state and primary data on the sample population given above: Literacy: The literacy rates in general are low in comparison with the national averages. It is pertinent to note that the female literacy rate is particularly lower than the national average. This has a direct bearing on the IEC campaigns and women s participation. Poverty: Poverty levels are quite high with nearly 90% possessing BPL cards. A large number of households depend on manual labor (agriculture labor) for livelihood. This is pertinent to rural water & sanitation, especially with the issue of ability to pay for the operation and maintenance costs. Communication: The potential reach of mass communication is quite high because of wide ownership of mass communication equipments (television, radio, mobile phones and land phones) in the villages. Thus use mass media holds a potential key to reach large masses through IEC. Page 24

3 Sanitation Status in Andhra Pradesh 3.1 Introduction The Government of Andhra Pradesh is implementing Total Sanitation Campaign (TSC) in 22 districts. Historically, the state had sanitation programs under various schemes like CRSP, HUDC assisted sanitation program etc. After launching of the TSC in the state, the coverage of household toilet has risen to 58 %, surpassing the national average. During the last two years 153 GPs of the state have received NGP awards. On the flip side, in spite of high toilet coverage, the state has received only 3% of total NGPs awarded in the last three years. There is an immediate need to scale up these efforts. GoAP has integrated the sanitation component in the ongoing INDIRAMMA housing scheme. The state has also earmarked funds for solid and liquid waste management (environmental sanitation facilities). The state has launched an annual competition, Shubram rewards program, amongst the Gram Panchayats in the state, to reward them with the title of Cleanest Gram Panchayats. The awards provides financial rewards at different levels (Mandal, district, division and state), based on competition, to PRIs that have been most successful in improving the safe and hygienic disposal of excreta, solid waste and waste water. In addition, cleanest MPs and ZPs in the state will also be awarded. Each district has adopted different approaches to scale up sanitation including CLTS approaches by few districts with technical assistance from WSP-SA The progress achieved under the TSC program (up to May 2008) is presented in the table below. About 53% of total HHs has been covered by TSC, of which 45% HH are above poverty line and only 58% are below poverty line. Table 13: Status of Rural Sanitation Coverage in AP Progress achieved so far in sanitation sector as per TSC (May 2008) Category Total Households Households with IHHL % Coverage Households Below Poverty Line 6521091 3763039 57.71 Households Above Poverty Line 3629688 1618591 44.59 Total Households 10150779 5381630 53.02 The 2001 census data indicates the following: Only 27% of have bathrooms within their houses. Consequently, 73% bathe near water points, with limited or no privacy. Only about 6% households are connected to closed drainage and 35% are connected to open drainage. 59% do not have drainage facilities. Page 25

The lack of latrine and drainage facilities are greatly contributing to the environmental degradation in and around the villages and posing direct threat to their health. 3.2 Rural School Sanitation Details of SCHOOL TOILETS Achieve d in Andhra Pradesh 113861 57421 2372 1999 24515 8729 1969 12624 13888 1325 2001-2002- 2003-2004- 2005-2006- 2007-2008- Total Target 02 03 04 05 06 07 08 09 Figure 1; Details of School Toilets Achieved in AP Table 14: Rural School Sanitation Status in AP School Sanitation Status S No Category Total 1 Total No Schools 113861 2 Schools with Toilets 57421 3 % age Coverage 59.21 Out of 113861 schools (both Government and private) in rural area about 59% schools have sanitation facilities. And there is separate facility available for girl students in higher Secondary Schools. Page 26

3.3 Status of Water Borne Diseases The Department of Health has identified the Acute Diarrhoeal (including GE & Cholera), Viral Hepatitis and Enteric Fever as three water born diseases. The following table shows number of cases of water borne diseases in the past five years. Large number of cases of Acute Diarrhoeal (Including GE & Cholera) was reported in 2003. Similarly viral hepatitis in 2004 and enteric fever in 2005 were reported. Table 15: Cases of Water Borne Diseases in AP in Last 5 Years Cases of Water Borne Diseases in Last 5 Years Acute Diarrhoeal S No Year (Including GE & Cholera) Viral Hepatitis Enteric Fever 1 2003 1637915 23065 151882 2 2004 1361790 29590 148827 3 2005 1619537 29293 172549 4 2006 1331818 22990 129177 5 2007 1516818 10302 124414 3.4 Incidence of Water Borne Diseases Using recall method, responses were sought from the community members as to how many people suffered from diseases in the last six months? The responses are tabulated below. Overall situation: The overall incidence indicates high prevalence of Typhoid (4.75%), closely followed by Malaria (4.04%), while other diseases showing a low incidence of occurrence, ranging from 0.79% to (GE) to 0.37% (diarrhea). The low reporting of diarrhea runs contrary to the known statistics. This is primarily because i) the survey is conducted during April May, before the onset of monsoon, when the incidence is low and ii) weak memory recall. Regional variation: High incidence of Typhoid was reported in Rayalaseema region (39.73%), as compared to 4.39% in Andhra and 4.75% in Telangana region. Rayalaseema also reported high incidence of Malaria (14.35%). Following the overall state trends, the incidence of diarrhea was reported to be far lower than the actual incidence. Page 27