Universal access and use of sanitation & hygiene services, what works? In a new Dgroup discussion that runs from 30 March to 20 April 2017, we exchange thoughts about which groups are still to be adequately or equitably reached by current service delivery models, particularly in areas where sanitation coverage is increasing. We have had a great start of the discussion with the first topic 'Understanding the last mile' generating over 25 contributions from 20 people across 11 countries in Africa and Asia.
The ’last mile’ is context-based with different meanings at village, district, national, regional and global level. Participants in the discussion had equally different views as to whether activities were reaching the last mile, especially in terms of achieving open defecation free (ODF) and beyond, and whether the last mile was far from reality. When viewed as part of the Bottom of the Pyramid market, globally we are yet to sufficiently even reach the other parts of the pyramid with the aspired products and services. So how can we conceptualise the last mile; is it ODF or is it for example a sustainable healthy environment? If it’s the first then we are perhaps not even halfway, if it’s the latter then indeed we may never reach it.
Uneven progress is unavoidable, but for different reasons
Almost universally, the participants felt that uneven progress towards universal access and usage in sanitation and hygiene was inevitable with current practice, but for a variety of reasons. "It’s a process and not an event. It cannot be reasonably expected that different people and communities have similar levels of motivation, ability and opportunity nor that stakeholders have the same level of investment or experience to move equally towards improved sanitation and hygiene." Using an example from Bhutan which has a clear non-subsidy approach, whilst the poorer and more vulnerable households are motivated to build and use, the general trend is that the wealthier households end up constructing a quality toilet first. Here though, a participant felt it was a time bound issue as eventually once annual incomes from cash crops become available, or savings are accrued or voluntary labor was provided, the remaining groups do construct.
Several felt it related to issues such as project bound thinking and was an inevitable outcome of being target driven. It was argued that for instance in Kenya, where projects are driven by numbers they may prioritise the ‘low hanging fruits’, quick or easy wins and will inevitably take more time to reach the geographically inaccessible or politically unstable communities. "If everyone’s focus were to shift to reaching the most disadvantaged groups and not necessarily on turning as many districts ODF as possible, no one would be left behind."
Many of the participants argued that uneven progress was unavoidable if we approach things with a business as usual attitude. Others linked it to a current failure to be inclusive and discrimination. "It is unavoidable while we continue to see the issue of equality/integration/disability/pro-poor as separate interventions or add-ons." Some felt it reflected systemic discriminatory behaviors and beliefs that permeate different dimensions of society. Recognising this and identifying and acknowledging where these discriminatory behaviors and resulting unevenness are, is an important first step to addressing them. This linked to the view that the challenging aspect is when the same type of group is consistently being left behind, because that suggests a discriminatory use of investments or significant programmatic biases or blind spots.
Taking a market development perspective, some people felt that given the bottom of the pyramid is not economically attractive, entrepreneurs prefer breaking even before serving the last mile. As such, until we have a model that sufficiently serves the middle class it’s hard to reach the last mile. Whilst others agreed with the importance of the market, they also raised that the influence of the government is just as important and within this, regulation has a role to play.
Which groups are visible in the last mile? Which are not?
Participants shared a range of groups that commonly included the elderly, people with disability (PWD), single headed households, people living with HIV/AIDs (PLWHA), ethnic minorities, socially excluded castes and the poorest wealth quintiles. They also shared a range of context specific examples such as people living in flood prone areas, remote areas, areas without adequate access to land/space, floating communities and internally displaced people (e.g. floods, conflicts). There was also a further grouping beyond these that related to attitude and personal choice.
Specific examples were shared from Nepal of groups that were considered less visible, being social excluded groups and castes. The example of double discrimination, such as women with disabilities was shared along with the reality that the transgender community may still be invisible in household data where for example they may be unable to share the household toilet if they are rejected by their families.
Girls discussing menstrual hygiene materials
Groups are identified through a combination of ways
A combination of approaches that progressively zoom in on the different issues/groups in different contexts were shared. "There are standard ways that measure progress using disaggregated data for the groups that, in each context, are known to be typically more vulnerable and discriminated, for example by gender, disability, wealth, etc. They can be furthered by focused studies and consultations to understand the nuances within each of the groups, their specific challenges, needs, aspirations and preferences." Examples of the use of formative research studies and specific consultations and the need to understand these nuances where shared from Bhutan, Indonesia and Cambodia.
In practice, access data at a national level was most likely to be disaggregated by poverty including using officially registered households. Beyond this, examples were shared in which project or local level data was being further disaggregated by gender, wealth quintile and disability and in Nepal where ethnicity and caste was also considered within a VDC. This was not consistent though. In other countries, for example in Kenya, "survey data is available on latrine coverage and access however it is rarely disaggregated in the context of people with disability, widows/ widowers, elderly, ethnic composition or even income levels". Such information was felt to be better found closer to the communities, such as with Community Health Workers.
Zooming in, Nepal provided examples that illustrated the importance of not generalizing and of recognizing diversity within not only communities, but also clusters of households and within households. A practical range of examples and reasons across 4 households being left behind were shared – from poverty, to attitudes, to houses under construction or tenanted. The issue was also raised how 'one house one toilet' thinking in the drive for ODF has created problems for people with disabilities (PWDs) within the households. Participants also challenged the group to think about the needs of women and girls during menstruation in which issues of social exclusion may prevent her from accessing sanitation and hygiene services on a regular basis.
Identifying groups at different times was also valued. In Indonesia during implementation, the best source of information on this was the communities themselves, the village leaders, local social groups (like women’s groups) and the government staff involved in CLTS triggering and follow up. Through them, it was understood that different challenges occur (and sometimes overlap) and it’s important to identify and distinguish these because they require different mitigation strategies. It’s important to identify and understand this diversity.
Gaps in information available to decision makers
Visibility (and recognition) of specific groups needs in relation to sanitation and hygiene was linked to the availability of data. Poverty and disability being the key examples in this. In Indonesia it was felt that at the local level of government there was an overall perception that challenges in sanitation progress are mostly due to poverty. This was in part due to the reality that data about poverty levels is available and often the poor households are clearly identified and targeted by specific government programmes. The focus on poverty though obscured the fact that there are other types of groups and other type of dynamics that affect universal access and are also worthy of investment. It also led to assumptions about the ability of subsidies to provide the solutions. In Bhutan, formative research highlighted that the absence of data on disability (and on women in decision making) led to a lack of resource allocation and prioritizing by decision makers.
Most contributors felt that there was inadequate information available to decision makers about these groups or households, sanitation and hygiene needs, aspirations and preferences. In Ethiopia, it was felt that it was also a matter of political priorities and weak social support systems. Finally, in Cambodia it was felt that at the national level information about disparities in sanitation coverage was minimal but also questioned if it is indeed their roles to know about these disparities? Or is it rather that national actors should factor in this diversity at local level to empower local actors to lead sanitation interventions to reach all households.
Read the proceedings of our Learning Event on Rural Sanitation: “Universal access and use of sanitation and hygiene services, what works?” here.