How evidence-based advocacy is raising the bar on sanitation (Story of Change)

When Nandom, a district in the far North-West of Ghana, became the first in the country to be awarded open defecation free status in June 2019, it raised the national bar on sanitation.

This remarkable accomplishment in one of the poorest regions of Ghana bears testimony to the power of effective political leadership and multi-stakeholder action, and to the value of evidence-based advocacy in changing opinion and policy.  It demonstrates that the local know-how and strategies are in place for Ghana to realise its ambition of becoming an open defecation free country by 2030.

A strategy on the next steps towards better sanitation is already underway in Nandom, and the district is setting an example of how an open defecation free country can be sustained. In doing so, it is raising hopes that the U.N. Sustainable Development Goals’ (SDG) target of universal access to sanitation for all is within Ghana’s reach.

This is a story about how one district is inspiring a country.

Check out this video: The story of Nandom and the place of advocacy, featuring Theresa Swanzy Baffoe, WASH Advisor, SNV Ghana.

Setting the scene

In 2014, when SNV  started its flagship, DFID-funded, Sustainable Sanitation and Hygiene for All Results Programme (SSH4A) in Ghana, 79% of residents in the Nandom district still practised open defecation. This reflected the sanitation situation across Ghana, where a vast majority (83%) of people lack access to a toilet in rural areas and one in five still practice open defecation, thereby risking faecal-related diseases such as cholera, diarrhoea and typhoid.

However, within just two years, 68 of Nandom‘s 88 communities had been verified as open defecation free. Many residents had been convinced of the benefits of basic sanitation and widespread political support had led to improved investment in sanitation infrastructure.

This progress was a result of effective collaboration between SNV and a wide spectrum of district government and community members. Underpinning it was an effective strategy: SSH4A was implementing its four-pillared approach to building sanitation systems and capacities in rural areas across eight countries in Africa and Asia. The pillars included creating increased demand for better sanitation, developing the sanitation supply chain and securing finance, promoting behaviour change, and providing governance support to strengthen inclusiveness and ensure sustainability.

Waves of change

By the time a second SNV programme - the DGIS-funded Voice for Change Partnership (V4CP) programme - started working across eight districts in Ghana in 2016, positive change in Nandom was already in motion. However, work was far from complete. The V4CP programme's focus on evidence-based advocacy was needed to strengthen systems structures, to increase funding for the sanitation sector, and to ensure lasting behaviour change by amplifying leadership from both the district government and the Traditional Authority.

What is more, political changes threatened to unravel the substantive progress made so far. This was a critical time in Ghana, with national and local elections across the country leading to a change in Government leadership in early 2017. Political support for sanitation weakened in the Nandom district, because its newly appointed leader was unconvinced that it should be prioritised above other pressing issues.

The power of collaboration

To sustain the momentum towards Nandom becoming an open defecation free district, everyone involved in improving sanitation agreed that they must pull together and re-engage local political leaders.

The V4CP set about identifying a local partner organisation to join its programme. By the time the Honorable Aasonglenang Thaddeus Arkum was appointed as the new Chief Executive of the Nandom District Assembly[i] in May 2017, it was working with the Integrated Action for Community Development (INTAGRAD) - a local civil society organisation that was a key advocate for sanitation in the Assembly.

In addition, SNV saw that combining SSH4A’s effective strategy and integrated approach with V4CP’s focus on evidence-based advocacy, capacity building of local civil society, and the strengthening of governance systems, would amplify its ability to influence Nandom’s new leaders. Therefore, the two SNV programmes agreed to work in tandem to push for district-wide open defecation free status, as a first step towards safely managed sanitation.

Drawing on SSH4A’s four pillars approach, the V4CP programme set about engaging the private sector in order to strengthen sanitation governance and systems, to increase demand for sanitation and handwashing facilities, and to make low cost toilets more readily available. In partnership with the District Planning Committee Unit (DPCU), the Environmental Services Unit and key sanitation and health advocates in Nandom, a multi-sector plan was developed that included roles to play across all levels of society.

Evidence for advocacy

For this plan to be effective, hard evidence was required to engage the minds that mattered in the District Assembly. SSH4A’s four-year programme was due to close in Ghana in March 2018. To measure its impact, it conducted a survey into levels of access to sanitation in its programme’s districts in November 2017. In Nandom, 284 households were interviewed across 19 communities. The results of the survey were positive; an open defecation rate of 0% was found within these communities, compared to the baseline figure of 79% in 2014.

A few months later, the V4CP programme undertook a further assessment into satisfaction levels related to sanitation and hygiene service delivery in Nandom. It included the views of community focus groups in its survey and measured the ability of the District Assembly to improve sanitation services. The services were measured based on four key principles; affordability, accessibility, relevance of the services to citizens and the quality of services.

The results proved that the previous leaders’ support for sanitation had been well-received by community members. However, they also revealed that sanitation and hygiene service delivery had mostly been undertaken by the District Assembly, as opposed to the private sector. This was contrary to Ghana’s environmental sanitation policy, which states that 60-80% of services should be delivered through the private sector. In response, INTAGRAD pushed the district’s private sector to become more engaged in sanitation issues, in order to ensure increased access and sustainability.

The fresh evidence of community satisfaction and improved access levels to sanitation provided by the SNV surveys showed the District Government just how successful the push for better sanitation in Nandom had been. It proved to be a powerful tool for advocacy to garner increased support for sanitation and health and helped inspire the district’s new officials.

Empowering the community

Meanwhile, the positive impacts of a new initiative, District Sanitation and Hygiene Advocacy Teams (DSHATs) were becoming evident. Set up by Intervention Forum, another civil society organisation working as part of the V4CP in Ghana, DSHATs had managed to increase citizens’ engagement with officials in other districts. Comprised of community members, they were providing a valuable conduit for the authorities to engage with citizens, while offering knowledge on how to improve and sustain better sanitation.

What are DSHATs?

District Sanitation and Hygiene Advocacy Teams (DSHAT) are citizens’ volunteer teams. They are comprised of 12 members who represent selected communities, women’s groups, youth groups, unit committees, landlord associations, Area/Zonal Council Chairpersons and Persons with Disability (PWDs).

Members work with the district authorities and the community and are responsible for evidence-based advocacy on sanitation and hygiene issues. And these teams are supported by V4CP CSOs in their work.

To strengthen citizen’s engagement, the V4CP programme set up a DSHAT in Nandom and advised its members on how to engage the District Assembly so that they could push citizens’ access to safe sanitation facilities up the political agenda.

The combination of the DSHAT team’s efforts, coupled with the fresh evidence, the influence of traditional community leaders, as well as the V4CP programme’s continuous engagement in the district and its participation in the DPCU, created a powerful wave of advocacy. By March 2018, 80 of Nandom’s communities were certified open defecation free. Just eight remained.

Such strides of progress inspired a response from the new District Chief Executive. At a district planning meeting in June 2018, he agreed to reboot investment in sanitation and to keep it high on the political agenda. Recollecting this moment, Freda Naatu, The Upper West Regional Environmental Health Officer said:

“In the development of the sanitation investment plan in June 2018 for the final push, the active participation of all the key players emphasized the importance of sanitation to the district. I was extremely glad to be part of the process.”.”

– Freda Naatu, The Upper West Regional Environmental Health Officer

The last push to end open defecation in Nandom had begun.

Leaving no one behind

Reaching the remaining communities presented a challenge, yet the insights gleaned from the SSH4A survey provided the next key to progress. The results had revealed that it was mainly households with elderly residents that continued to have low access to sanitation. It was clear these households needed additional support for Nandom to achieve district-wide open defecation free status.

Although the V4CP had asked the Traditional Authority to help vulnerable households in the past, it had refused because it strongly believed in the concept of ‘self-help’. Yet attitudes towards support for the vulnerable were changing across Ghana. Following the poor results of a sanitation survey for the SDG baselines in 2017, the Government of Ghana shifted its focus and set the target of becoming an open defecation free country by 2030. In order to achieve this, it created new national guidelines on how to provide support for vulnerable households in order to facilitate sanitation access for all: a new ‘pro-poor’ concept was rising, based on the ambition of ‘leaving no one behind’.

The last hurdle

This set the backdrop for the next pivotal moment of change; a district planning meeting in October 2018. By then, continuous engagement within the district, along with the revised sanitation investment plan, had increased the number of open defecation free certified communities in Nandom from 80 to 84. Now there were only four more to go.

During the meeting, which was attended by all of the key district stakeholders, the V4CP used the SSH4A survey results once again as evidence that the district must support the elderly if it wanted to become completely open defecation free. In light of this evidence, along with the new national guidelines to help vulnerable households access better sanitation, the governing District Assembly acknowledged the high number of elderly people living in Nandom who were unable to afford a toilet. They not only agreed to help, but to lead the process.

The District Assembly used the SSH4A survey results to identify 160 households without toilets that needed additional support. At the same time, the V4CP held further dialogues with the Traditional Authority. The village Chiefs agreed not only to help the elderly, but to lead in allocating support, given their neutrality in political interests.

Importantly, because the survey underlined Nandom’s sanitation success compared to the rest of Ghana, it also helped support V4CP programme’s advocacy case for a new by-law to oblige landlords to construct sanitation facilities and penalise open defecation offenders. The District Assembly agreed to the new by-law at this meeting. Its enforcement, often led by the Traditional Authority, led to increased toilet provision across the district.

Within months, the regional environmental health unit and the external independent verifiers sampled communities from the 88 communities in the district. In June 2019, they confirmed that this stage in Nandom’s sanitation journey was complete; all the communities were verified as open defecation free. The District Chief Executive has applauded SNV for its support in this achievement, especially its focus on pushing for increased interactions with citizens.

V4CP’s INTAGRAD representative, Nurudeen Ibrahim, said:

“I felt the process of getting the sanitation by-law reviewed and approved in the Nandom district was the surest way to ensuring total sanitation. Yet the stage at which we are now never came on a silver platter, instead it was preceded by a series of one-on-one and broad stakeholder engagements. We first had to set the agenda at a stakeholder coordination meeting until it became a major topic for discussion and brainstorming. We closely followed up duty-bearer commitments and actions which finally brought about the approval of the sanitation by-law by the General Assembly.”

– Nurudeen Ibrahim, INTAGRAD

He continued, “However, to ensure its effective implementation, there is the need for the District Assembly to strongly involve traditional, religious and opinion leaders and the private sector while leveraging support of community champions and ambassadors. There is also the need to avert any political interference that could thwart the efforts breaded. In a nutshell, I will say that this is a great leap to ensuring compliance and the concomitant improvement in total sanitation delivery.”

Scaling up achievement

Nandom’s status as the first open defecation free district in Ghana is contributing to changing the country’s sanitation outlook. By February 2019, a multi-stakeholder, post-open defecation free strategy had been developed by the district authorities, with support from the Regional Environmental Health Officer and SNV.

The plan aims to establish the framework for developing an all-inclusive, effective, and locally feasible environmental sanitation strategy and action plan. It also focuses on sustainability plans for gains made and on a further push for access to safely managed sanitation facilities, with an emphasis on more resilient facilities. Critically, it looks at issues of coordination at all levels especially with citizen participation.

This move reflects how the District Government is taking ownership of sanitation and is responding to SNV’s recommendations of the need for concrete plans to ensure that its open defecation free status is sustained. It also shows it is poised to push the district further, towards the status of safely managed sanitation.

Rita Nyorka, a Planning Officer for Nandom District, reiterated this commitment. “Nandom district is finally open defecation free and it brings a lot of joy to all the efforts that have been put into this. To me, the journey has started and we will put in all efforts to ensure that we sustain and improve this enviable status,” she said.

Sustaining progress

Today, all of Nandom’s 56,742 residents have access to a toilet and the District Government is developing a full range of safe sanitation services by securing investment from the private sector, for services such as the construction of resilient sanitation facilities.

SNV will continue to support the district’s efforts to strengthen local structures in implementing the post open defecation free strategy until September 2020. The formation of the DSHATs and the continuous engagement with the private sector for improved sanitation technologies will help ensure the gains so far continue to be built upon.

According to the Regional Environmental Health Officer, Freda Naatu, Nandom’s achievement should be attributed to the high level of commitment by the District Assembly and its wide spectrum of stakeholders, including development partners and traditional authorities. She said: “I look forward to supporting Nandom to effectively implement the post open defecation free plan and move towards sanitised levels.”

Yet this is just the end of a chapter, it is not the end of the story.

Although Nandom is seen as the beacon of hope for improved sanitation in Ghana, there is a lot more to be done. For example, there are significant and growing concerns about funding for sanitation and hygiene. The budget for sanitation does not correspond with expenditure and activities are often done on a ‘good will’ basis by committed parties.

Both the District Government and the wider community must work hard to maintain this issue as a top priority and additional must be provided in order to sustain progress towards improved sanitation and hygiene services.

Who we are

The Voice for Change Partnership strengthens the capacities of civil society organisations to foster collaboration among relevant stakeholders, influence agenda-setting and hold the government and private sector accountable for their promises and actions. It is funded by the Dutch Ministry of Foreign Affairs.

[i] Ghana’s sub-national governance structures are characterised by a three-tier structure: the Regional Coordination Council; the Metropolitan or Municipal or District Assemblies (MMDAs); and the Area Councils, which represent the lowest and most basic unit in the structure. The District Assembly, which is headed by the District Chief Executive, was created as the pivot of administrative and developmental decision-making in the district and is the basic unit of government administration. The Assembly is assigned with deliberation, legislative as well as executive functions, and established as a monolithic structure. It is assigned the responsibility of bringing about integration of political, administrative and development support.