Learning what works for sanitation : revisiting sanitation successes in Cambodia

38733 Learning What Works for Sanitation Revisiting Sanitation Successes in Cambodia An International partnership to help the poor gain sustained access to improved water supply and sanitation services Water and Sanitation Program East Asia and the Pacific (WSP-EAP) July 2002  ACKNOWLEDGMENTS The present study was carried out with funds from the Rural Water Supply and Sanitation Planning and Capacity Building (PCB) Project in Cambodia supported by the Swedish International Development Cooperation Agency (SIDA) and executed by the Ministry of Rural Development (MRD) of the Royal Government of Cambodia. This report is based on site reports, photographs and participatory assessment results from communities, recorded by researchers from SAWAC (a local consulting agency) and the Ministry of Rural Development- from the central government level and the Provincial Departments of Rural Development of Kompong Spue and Battambang. The study was carried out under the overall management and supervision of the PCB Project, especially Dr. Chea Samnang, Director of MRD's Department of Rural Health Care and manager of the PCB project, and Leo Goulet, Chief Technical Advisor to the project. Technical assistance for the methodology, training for researchers, documentation support and some photographs wereprovidedbyNilanjanaMukherjeefromWSP-EAP'sregionaloffice.BruceGrossprovidedadditionalphotographs for the cover and text pages. Peer reviewers Caroline van den Berg, Richard Pollard, Peter Feldman and Bouy Kim Sreang provided valuable comments and questions for further consideration. Field Team in Cambodia: MRD Bouy Kim Sreang, Soth Rathana, Leang Solitha, Un Khan PDRD Chao Sokha, Chan Silain, Hang Thy SAWAC Chhun Bunarin, Sour Sethy, Roath Mullika, Men Neary Socheat  Context for the Study Photo : Bruce Gross Why does sanitation progress lag? specific settings. Unfortunately, there is very limited knowledge of successful sanitation interventions available During the past two decades, the water portion of the to policy makers. This study presents the experiences of water and sanitation sector has made substantial gains. communities that have experienced relatively successful Heavy investment since the 1980s has brought clean interventions in Cambodia - both during the period of water supply to millions in East Asia and around the world, the assistance program and in the years since. From the but public health gains have been far lower than experiences of these villages in Cambodia, policy makers anticipated because progress on the sanitation front has can draw insights about what works and why, and use lagged. that knowledge to create strategies to bridge the gap between national policy and local practice. East Asian governments have tried to incorporate lessons from the limited impact of sanitation interventions in other parts of the globe in forming their own national strategies Who has the answers? and policies for the sub-sector in the 21st century. But avoiding past mistakes is not enough. Sanitation If policies are to make an impact at the community level, improvements are household and community issues, and, it makes sense to conduct research at the community thus require recognition of specific situational social and level. Participatory assessment studies such as this one cultural factors. The key to public health gains requires bring into the policy development process the voices of investigating not just failures elsewhere but what makes an excluded principal stakeholder group - the intended sanitation interventions succeed, in country-and culture- users of services, the poor men and women from rural 1  communities in different parts of the country. Through from government personnel, NGOs, donor agencies such studies, their voices can reach national debates, and private sector agencies engaged in the sector. raise questions about existing policies, and suggest alternatives that so-called experts may not otherwise WSP-EAP is privileged to assist the process of sector consider. policy development, improvement and implementation in Cambodia, Laos and Indonesia, Philippines and Policy development needs to follow this participatory Vietnam. The values guiding this work are: optimal model at all levels, utilizing the knowledge and talent stakeholder participation; informed choice by all of stakeholders, rather than relying on a few top national concerned; national leadership and ownership of the bureaucrats and international consultants. This study, process and learning generated; national capacity executed and analyzed by a team of Cambodian development; bottom-up and horizontal knowledge stakeholders and assisted technically by the Water and sharing. Sanitation Program East Asia and the Pacific (WSP-EAP), is a tool designed to promote stakeholder participation. For ultimate impact on the country's people, who learns Similar studies have been carried out with country teams what lessons from what local situations and exchanges and communities in Indonesia and Vietnam. The can be of vastly greater importance than whether the findings of these studies are discussed and debated at learning generated adds unique new insights to the national stakeholder workshops where conclusions and global store of sector knowledge. This report documents recommendations for policies and strategies emerge the learning gained by sector stakeholders in Cambodia. Nilanjana Mukherjee WSP-EAP 2  Learning What Works for Sanitation Revisiting Sanitation Successes in Cambodia Contents Introduction - A Quest for Understanding ............................................................................................... 4 1. Who has Access to Sanitation? ...................................................................................................... 10 2. What Factors Influenced Demand for Household Toilets? ................................................................ 13 3. Was There a Change in Sanitation Behavior?................................................................................. 17 4. What Benefits Matter Most to Users? .............................................................................................. 21 5. Was Sanitation Coverage Linked to Hygiene Awareness and Practices? ........................................... 26 6. What Factors Influence Behavior Change? ..................................................................................... 29 LESSONS LEARNED ............................................................................................................................. 32 ANNEXURE A ...................................................................................................................................... 34 3  Introduction - A Quest for Understanding Photo : Nilanjana Mukherjee T he Cambodian countryside has been ravaged by defecation. Funding for Sanitation and Hygiene civil war resulting in destroyed infrastructure, promotion and activities has been limited, and has not impassable roads, broken bridges and an in the past been a priority in budget allocation. economy that is struggling to recover. The Khmer Rouge Cambodian development activities supported by displaced many villagers from their communities in the international donors have focused on other areas such 1970s. Then again thousands fled to camps on the Thai- as public infrastructure including water supply, agriculture Cambodian border when the Khmer Rouge collapsed in and small co-operatives such as rice and buffalo banks. 1979. In the 1980s people remaining in Cambodia struggled to survive, scraping the soil for food and hand Since January 1999 the Ministry of Rural Development digging wells for water. In 1993 people began to return (MRD) has been developing a "Rural Water Supply and from the border camps, settling back into their original Sanitation (RWSS) Policy Framework and Strategy" by and often destroyed villages or resettled into new means of the Planning and Capacity Building Project habitations, often in areas where the land was arid and (PCBP). One of the aims of this strategy is for 32 per cent vegetation sparse. Political instability and violence was of rural families to have access to family latrines and still rife. It was not until after 1997 that the communities practice good hygiene behaviors by the year 2011. could settle down to a more peaceful existence and start investing in their land and homes. From a baseline coverage rate of 9 per cent and no clear behavioral baselines available in 2000, ways of reaching Hygiene and sanitation activities have not yet received such a strategy goal are far from clearly visible. Much much attention in Cambodia. 91 per cent of the rural learning remains to be done and assimilated about what population today does not have access to a household works in the Cambodian rural context, what does not latrine.1The rural population has traditionally used local and why, from small successes available for study, since rice fields, banana groves and water sources for large-scale sanitation programs do not exist. It was 1 General Population Census of Cambodia 1998, National institute of Statistics, Ministry of Planning, Phnom Penh, Cambodia. July 1999. 4  therefore considered worthwhile to consult rural country study carried out by WSP-EAP with country communities in Cambodia which had experienced partners in Cambodia, Indonesia and Vietnam. The sanitation interventions and where these interventions had studies are integral to sector policy and strategy been relatively more successful than average. The development initiatives ongoing in the three countries rationale was that such communities could provide clues which are led by country governments, technically assisted as to what strategies may be most successful in promoting by WSP-EAP and involve all major stakeholders i.e. various sanitation and hygiene in Cambodia. government ministries, NGOs, donor partners, the private The Cambodian Sanitation Study was part of a three- sector and community organizations. Figure 1 Access to sanitation services in districts of Cambodia Percentage of households with Toilets 0 - 2.5 20 - 30 0 20 40 60 80 100 Kilometers 2.5 - 5 30 - 50 5 - 7.5 50 - 75 7.5 - 10 >75 10 - 15 no data Source: General Population Census of Cambodia 1998, National institute of Statistics, 15 - 20 Ministry of Planning, Phnom Penh, Cambodia. July 1999. 5  Figure 2 Provinces identified for selecting sample communities for the sanitation study in Cambodia Battambang Kompong Spue Sample Selection and Methodology The 1998 Census mapped population access to sanitation The first water-seal toilets were constructed in rural facilities and found communities having higher than Cambodia by World Vision in 1993 and UNICEF in 1996. average coverage concentrated in certain parts of the Since then, population coverage for family toilets has country (Figure 1). Two such provinces, Battambang and grown, gradually at first, and somewhat faster during Kompong Spue were selected from geographically diverse the last few years of the millennium. Other agencies such locations. Battambang province is located in the northwest as SEILA/CARERE have added further sanitation and borders on Thailand. Kompong Spue is in the south- interventions. All sanitation projects to date have been central part of the country, 48 kilometers west of Phnom offered with subsidies by agencies building the toilets. As Penh, the capital of Cambodia (Figure 2). In consultation access to building materials was difficult due to poor road with provincial government departments, a short list of conditions, agencies' subsidies included bringing about 20 communities was identified, which had received materials to the village. sanitation assistance from UNICEF, SEILA/CARERE and 6  World Vision International, and had achieved unusually and the non-poor categories of households. For topics high sanitation coverage rates (i.e. around 30 per cent considered sensitive to gender issues, assessment was of community households with sanitation access as done in gender-segregated groups. compared to the national average of only 9 per cent). The communities were contacted by the research team The decision to explore patterns associated with "success to verify the coverage situation, explain the purpose of stories" rather than using classic comparative studies of the study and ascertain the community's interest in successful and unsuccessful examples was based on three participating in the study. A final selection of 10 considerations: communities was thus made, 5 in each province, which Substantial global research evidence already exists met the required criteria and where people were willing about why sanitation programs fail, but little to participate in assessing their sanitation situation. documented evidence is available about why some sanitation interventions succeed. Two gender-balanced field teams were formed which included local NGO personnel (SAWAC) with social A Cambodia-specific exploration of what works is the research experience, personnel from the Ministry of Rural aim. What works or has worked in another country Development and the Provincial Departments of Rural may not apply to Cambodia, as sanitation is a Development. They were trained together by WSP-EAP in behavioral issue embedded in local culture and the use of a specially designed sequence of PHAST2 and practices. MPA3 participatory tools and a discussion guide to consult men's and women's groups in the villages. In each village For identifying the range of possibly diverse and not they also used observation checklists to assess fully predictable factors associated with "successful environmental and household hygiene conditions and sanitation" in Cambodia, it is more efficient and cost- reviewed secondary data (see Annexure A for tools). effective to study known high coverage cases (in the absence of other indicators for success), instead of In each community the researchers met with key studying a sample representing good, bad and individuals and groups of men and women at times and average cases in the country. places of their convenience, over a period of 3-5 days. The assessment process involved 95 - 244 people in The Study Communities different communities.4 Considering that the populations of the communities visited ranged between 50 and 389 Theparticipatingcommunitiesinthetwoprovincesconsisted households, this meant that the process covered at least of between 50 and 389 households, the Battambang 50 per cent or more of the adult populations of the villages being somewhat larger on average. The primary communities. Poverty targeting methods were employed livelihood activity in all villages was agriculture. A small to ensure that the groups met represented both the poor minority (3-5 per cent of the households) was engaged in 2 Participatory Hygiene and Sanitation Transformation: Step-by-Step Guide, WHO, Sida and UNDP-World Bank Water and Sanitation Program, 1998. 3 Methodology for Participatory Assessments: Linking Sustainability with Demand, Gender and Poverty, R. Dayal, C. van Wijk, and N. Mukherjee, Water and Sanitation Program and IRC International Water and Sanitation Centre, 2000. 4 In each community the researchers held 6-8 group assessment sessions, of which at least 4-6 were gender-desegregated. Groups varied in size between 10-30 people for different assessment activities. 7  small business, government service or other service wells in 3 other villages out of the 10. Almost all villages employment, and they were mostly in Battambang, which had a large number of privately owned ponds. hasbetterdevelopedroadsandtransportationinfrastructure. In Kompong Spue secondary sources of livelihoods were The Poor within the Communities more rural, area-specific and natural resource based, such as making palm sugar, producing charcoal from forests, Using their own criteria for well being, community groups river and stream fishing and small livestock breeding. identified an average 8 per cent of households as "rich/ better off/prosperous", 54 per cent as "poor/very poor" All 10 communities had access to 2-4 common property and 38 per cent as "in-between/middle income group/ natural water sources such as lakes, large ponds, streams neither poor nor rich". Within each community these or man-made irrigation canals. Improved public water percentages varied considerably, but the largest majority supply facilities included between 1-7 hand pump wells being classified as "poor" was a common feature across in 9 villages and 6 hand-dug wells in the remaining the sample. The table on the following page provides an village. Privately owned water supply facilities included a idea of the nature and level of well-being and poverty in rare private hand pump in 1 village and household dug villages of the two provinces. Province District Commune Village Project Battambang Thmor Kol Ta Moeun Kok Trop CASD/UNICEF Thmor Kol Boeng Phring O-Nhor CASD/UNICEF SEILA/CARERE Thmor Kol Rong Chrey Balang Krom CASD/UNICEF Thmor Kol Rong Chrey Kok Khpos CASD/UNICEF Sang Ker Rang Kasey Rang Krol SEILA/CARERE Kompong Spue O-Dong Preah Sre Srei-Chenda World Vision International O-Dong Preah Sre Praveuk Pong World Vision International Samrong Tong Tang Kroch Samrith CASD/UNICEF Samrong Tong Tang Kroch Pech Sang Va CASD/UNICEF Samrong Tong Tang Kroch Aundong Sla CASD/UNICEF 8  Criteria for categories of well-being, as defined by community groups Province Rich/Well-off In Between/Middle Poor/Very Poor Battambang - Rice field >10-30 Ha - Rice field 2-10 Ha - Rice field only 5 rai5 - Orange trees >50-200 - Orange trees 10-50 No rice field - Have tractor - Zinc roofed house - Thatch roofed house - Drainage pump - 2-5 pigs/10-20 chickens - Chickens/Ducks 2-5 - Concrete house - Black and White TV - Old bicycle - >10 pigs - Secondary school - Many children/7-10 - Chickens 30-100 education children - Rice mill/Harvesting - Physical labor for food machine - Have loans/In debt - Motor bike/Car/Truck - Primary school education - Color TV - University education Kompong Spue - Have irrigated rice - Rice field 1 Ha - No rice field ----already land 2-5 Ha - Tile roof/thatch roof pawned or sold off - NEVER short of food, - 1-2 cows, or 1 bull - No capital have rice for selling - Old motorcycle/bicycle - No cow - Generator/Battery/ - Shortage of food for - Many children Electric pump/Rice mill 1-4 months a year - Bad clothes/Second - Zinc or tile roof house, - Sometimes borrow hand clothes brick walls money and rice - Thatch roof house - Household latrine - Children don't go to - Can't buy seeds/ - Cows >2 college feed for animals - Chickens/Pigs/Ducks - Either ox cart or cow - Children go to primary - Bicycle/Motor bike/ - Black and White TV school only Ox Cart or Radio - Often sick - Black and White TV - No agricultural tools - Good clothes - No chicken, pig - Few children/all - Many loans children go to school - Clever person - Gives loans - High education 5 Measure of land, less than a hectare. 9  1. Who has Access to Sanitation? T he study team began by requesting the village men and women's groups to classify households into various well-being classes using locally relevant criteria and culturally acceptable terminology. They then helped villagers to draw a map of their community, mark all households as rich, poor, middle etc. and mark the households that have their own sanitary latrines, or household that could access and use one. In the 10 communities 33 per cent of the households had access to household latrines, as compared to the national average of only 9 per cent. However, as Figure 3 shows, the benefits of sanitation interventions had been disproportionately shared within the communities. The rich/ better-off households comprise only 8 per cent of the population but typically 77-100 per cent of them have sanitation access. The middle-income group makes up 38 per cent of the sample households, but 22-73 per cent of them have access. The poor households, on the other hand, comprise 54 per cent of the population, but only 3- 26 per cent of them have access to sanitation. The poor in Kompong Spue are far worse off than the poor in Battambang in this respect, with 4 out of 5 Kompong Spue villages showing 5 per cent or less of poor households having access. Photo : Bruce Gross 10  Figure 3 Percentage of Rich, Middle-income, and Poor households that own/have access to household latrines in the 10 selected communities In Battambang province, known for its large rice the total population in the sample villages, and probably production, the groups stated that is was because there comprise similar proportions of total households in was "less assistance" and villagers "lack enough money". Cambodian villages countrywide. Together these findings In Kompong Spue, both men and women said "no money" suggest that increasing overall population access to was the main constraint, suggesting that the absolute extent sanitation to 32 per cent (the RWSS Strategy goal) by of poverty was higher in Kompong Spue. As can be seen 2011 will only be possible if special poverty targeting in Figure 3, all well-being categories in Battambang villages methods and locally relevant enabling strategies are had higher levels of sanitation access than in Kompong employed in sanitation interventions for the rural poor. Spue. The poorest in Battambang had access levels similar to those of the middle-income group in Kompong Spue. Discussions with the community groups yielded the following ideas about what might make it easier for the In these 10 villages, which represent high coverage cases poor to acquire sanitation facilities: in the Cambodian context, after 6-7 years of sanitation project intervention only 3-20 per cent of the poor Poor households find it almost impossible to pay their households have gained access to sanitation. It is share of the cost in cash, and at one time. In many of important to note that the poor constituted well over half the study villages a cash contribution of 30,000 riel6 6 3800 Riels = US $1 at year 2000-01 prices. 11  had been necessary to get the subsidized latrine construction materials from projects. This was at a time when the daily wages of an agricultural laborer amounted to 3000 riel a day. Project rules need to have more flexibility in the modes and schedules of payment. Making it possible for poor households to pay in labor and kind rather than cash, letting them pay in installments, linking payments to times of harvest (when they can get more work and rice prices are lower) are some ways in which the poor can be better empowered to gain sanitation access. Two or more poor households often decide to contribute and share ownership of sanitation facilities. Revolving micro-credit schemes for household sanitation could allow several households to jointly take loans, provided they stand guarantee for each other in getting repayments made on time. Photo : Nilanjana Mukherjee Photo : Nilanjana Mukherjee 12  2. What Factors Influenced Demand for Household Latrines? families started to settle down in the villages and take initiatives to improve their dwellings. The first flush toilets were brought to the villages by World Vision International during 1992 and 1993 and by CASD/UNICEF or SEILA/CARERE in 1998. It is interesting to compare how sanitation coverage grew in the two provinces. The Kompong Spue villages were served only by sanitation projects. In comparison, the Battambang villages V illages in Cambodia are not large and experienced project interventions together with population densities in rural areas are low. infrastructure development, which linked villages to Availability of land to build household latrines urban markets. Timeline explorations with men's and is not a problem. Discussion groups in 3 villages reported women's groups found that it took only 4 years in that they had first dug their own pit latrines in 1979, Battambang villages for coverage to grow from 0-40 without any outside assistance but encouraged by the per cent, as compared to 8 years in the Kompong Spue new government after the Pol Pot regime had fallen. After villages. Presently, 16 per cent of all latrines in the the national elections and the return of the population Battambang villages are self-financed. None in the from the Thai/Cambodian border camps in 1991-92, Kompong Spue villages are. 13  What catalyzed demand for In 3 out of 10 villages the motivating factor was the lack household latrines? of forest cover and rice fields getting farther from the village. Both men's and women's groups said that it was The groups discussed reasons why they had decided to getting increasingly difficult to reach the fields or woods build household toilets. Two reasons were mentioned to defecate as villages grew bigger or as more land was in several villages and seem to be more common cleared and women especially wanted the privacy the motivators of demand as shown in Table 1. The most household toilet allowed. Women's groups in 3 villages common motivating factor seemed to be prior exposure also mentioned that latrines were easier and more to and positive experience of using a latrine. These convenient for their children to use. experiences came from visits to an urban area or having lived in a camp on the Thai-Cambodian border where In 2 out of 10 villages it was mentioned that having an there were latrines. 3 of the men's and 4 of the women's awareness of hygiene and being already accustomed to groups out of 10 also said that people in the community pit latrines influenced people's motivation to build the were influenced and encouraged to own a household newer flush latrines when they became available from toilet by seeing their neighbors' practice. projects or otherwise. 2 villages also identified affordability due to greater overall prosperity in the village However, the desire to own latrines translates into as the motivator. reality only when it is easy to act on the desire. In 4 out of 10 villages people mentioned the ease of At the same time, in 2 villages out of the 10 people said getting sanitation materials and construction skills that there really was no demand for toilets, but they were from nearby towns and availability of transport built because the project provided sanitation materials services as the next most important motivating factor. free of cost. Elsewhere projects had promoted latrines Table 1 What motivated people to build household latrines? Frequency Major influencing factors according to village groups of mention in 10 villages Previous exposure to sanitation facilities through visits to urban areas, from family members working in the city, from living in camps on the Thai-Cambodian border 5 where there were latrines, seeing/using neighbors' latrines Nearness/easy access to towns for getting sanitation supplies and skills for latrine 4 construction Diminishing forest cover/forests far from villages/rice fields unavailable 3 Awareness of good hygiene, being already accustomed to using pit latrines 2 Well-off village, can afford latrines because of 4 harvests per year 2 14  with subsidized latrine construction materials, which Beyond the point of project intervention, lack of supply required cost sharing by user households. In addition, in options emerged as the most important factor obstructing Battambang villages many latrines were also built through the growth of demand for household latrines (see Table complete self-financing, through private initiative. Water 2). When water-seal latrines were introduced by projects, access was crucial because the only project-promoted concrete rings and bowls were brought in from long design option was a water-flush toilet. All sanitation distances and in limited quantities. There was no projects had been in villages that had reasonable access encouragement for local production of sanitation supplies to water either from streams, ponds, reservoirs or pump or for local business enterprise to supply materials. People wells. who did not receive project-supplied materials could not readily access them from anywhere else. In Kompong Spue At any given time a number of influencing factors are particularly, bad roads and lack of transport facilities made likely to be operating, singly or in combination. The it difficult to buy materials and skills from outside the results seem to suggest that there was no single, strongly community. motivating factor for sanitation improvements in all the communities, and that certain situation-specific In general, people felt that sanitation projects did not facilitating conditions tend to interact with existing communicate adequately with the villagers about project motivating factors to produce a resultant level of benefits and rules. When initial project-supplied latrines demand. The implication is that generating demand got built, more interested households requested latrine for sanitation and scaling it up will call for careful packages but projects had pre-allocated quotas for supply exploratory research and strategic promotion. in each village and did not adjust the supply to emerging demand. In 6 discussion groups out of 20, men and What discouraged people from women said that they had either not been informed of getting their household toilets? meetings to discuss family sanitation or that their request for a household toilet was put in too late and was therefore Discussions with men's and women's groups revealed not considered. those users' demands and preferences had nothing to do with the way sanitation projects were implemented in In 3 villages water scarcity or water sources being far the sample communities. from homes was mentioned as an inhibiting factor. Since all projects were promoting only the water-flushed latrine The villagers did not make decisions about which design, this discouraged households who would have to communities would get sanitation assistance and which haul the water for flushing from distant sources everyday. household would participate in the sanitation project. 10 out of 20 discussion groups7 said that the international In 2 villages, which were flood-prone, people mentioned project agencies made that decision. In 8 villages people unpleasant experiences with initially built latrines being said that the International agency had decided with the flooded or pits collapsing, which put many people off local provincial government. In 2 villages the village household latrines. People felt that projects should have development committee (VDC) was also consulted. provided technical advice about ways to prevent flooding 7 These were 10 groups of women and 10 of men, formed out of the gatherings of villagers at the discussions over the community map, which they had drawn at a public meeting place in each village. 15  of latrines, e.g. by building raised platforms for latrine negative experiences with sanitation can kill demand. pans and better protected pits that withstand flooding. Projects need to invest in ensuring that people's first However, such measures also increased costs of experiences are positive. To do this, local motivating construction and no advice was available from projects factors, which are diverse and not always predictable, on ways to cut costs safely. There was no technical advice need to be considered and catered to. Providing available from projects about special problem areas. sanitation choices and relevant information about choices can be one way of ensuring better matches The cash cost of getting sanitation facilities was mentioned between what people want and what projects can as an important factor even when there were external offer. subsidies, but only in 2 villages. In 1999 32.4 per cent of the Cambodian rural population were below a poverty By the time demand emerges, supply options need line of 54,050 riel (approximately US$14) per head per to be in place to respond to demand. Sanitation month.8 For them the expected contribution of $9-12 per projects have to help develop self-sustaining local family for a latrine was considered too large an amount. alternatives for supply of sanitation materials and The rate of cash contribution however had not been skills, instead of being service provision monopolies. uniform across different projects. A few villages had even got latrines for free. Single-option sanitation projects tend not to benefit the poor within communities. Affordable options for Implications arising out of the above findings are sanitation facilities and modes of payment need to that: be offered to the poor, in order to generate the extent Demand for sanitation grows when people can see of community demand needed for achieving national and experience its benefits before investing in it. Initial RWSS Strategy goals. Table 2 What hindered demand for household latrines? Frequency Major inhibiting factors, according to village groups of mention in 10 villages Difficult to access sanitation supplies 7 Agency had a limited number of toilets to build/project does not supply as many 6 latrines as requested/no option except from projects Water is scarce/water source too far from household 3 People can not pay 30,000-50,000 riel in cash 2 Lack of technical skills in village for construction, especially in flood-prone areas 2 8 The Second Five Year Socioeconomic Development Plan, 20001-2005, Part 1, Ministry of Planning, Cambodia. 16  3. Was There a Change in Sanitation Behavior? B ehavior change does not happen until people realize or experience the benefits resulting from the change. When behavior change is dependent on external factors such as supplies of materials and skills for sanitation facilities, the process takes still longer. Behavior can be said to have changed only when newer behavior patterns replace older ones consistently and are sustained thereafter. The present study used pocket voting9 to identify defecation sites used by different age-sex groups in the village. In view of multiple possibilities for preferred sites, pocket voting was done twice in each community, once to find out the most frequently/regularly used site and a second time to identify alternative sites that people continue to use occasionally. When community groups analyzed their defecation behavior before and after sanitation project interventions, the result showed a significant reduction in people's regular use of rice fields, orange and banana groves and water sources for defecation purposes, along with a large increase in the use of flush latrines (Figure 4). As compared to men, women seemed to have made a 9 Participatory analysis tool from the SARAR methodology, adapted by the PHAST methodology for use in sanitation, supplemented with procedures for quantification of results from the MPA. 17  greater shift away from open defecation after getting Sanitation programs thus need to focus on assessing household latrines. They had stopped using water bodies sanitation behavior at the start and thereafter for defecation altogether. Older women seemed to have periodically, with tools that go beyond superficial made the greatest shift towards using latrines after the yes/no answers. Programs need to understand project. Babies' feces were however still being thrown in people's rationale underlying their behavior, in banana groves instead of into latrines. And, despite the order to identify what will trigger consistent behavior overall change towards use of latrines, a large proportion change, and use that information in sanitation of people continued to use the rice fields and fruit groves promotion strategies. for "occasional" defecation, signaling the fact there had not been a real change of behavior (Figure 5). Functionality, Maintenance and Use of Latrines Hence, people use whatever site is most convenient, regardless of the fact that they have household latrines. From the community map prepared in each village, If they need to defecate when they are in rice fields, which approximately 10 household latrines were selected for tend to be far from homes, it is impractical to try to return observation, taking care to distribute them evenly across home for defecation. Also, there is a prevailing belief the community and representing latrines in poor, middle- that feces would add to the fertility of the crop fields. income and rich households. A total of 95 latrines were Orange and banana groves likewise provide vegetation observed in the 10 communities, using an observation cover and privacy outdoors when one needs to defecate. checklist during transect walks through the villages.10 Water bodies are convenient for cleaning purposes after defecation. Banana groves behind the house may be Functionality, maintenance and use scores were higher convenient in case the latrine is out of stored water for for communities in Battambang as compared to flushing and one is not willing to carry more water in at Kompong Spue, as shown in Table 5. All family latrines that time. observed in the Battambang province communities were found to be functional, in regular use and most were This suggests that the construction of household maintained in a hygienic condition. In contrast, one-third latrines in large numbers and high coverage levels of the observed latrines in the Kompong Spue villages are no reasons for complacence, if the goal is public were broken up and no longer in use. These were mainly health improvement. Places where people earn their in 2 villages where latrines had been provided by the livelihoods in the rural environment are rarely earliest sanitation projects, in 1992-93. These 2 equipped with sanitation facilities. Continued use communities present a classic illustration of the pitfalls of places other than latrines for defecation is highly of not using a demand-responsive approach for likely to continue even after people acquire sanitation. The 2 communities had poor access to water household toilets, unless they make conscious sources (public dug wells far from most homes, the ponds decisions to change their sanitation behavior, dry up in summer), and it was only in these two villages requiring not just investing in construction but also that projects had provided many latrines completely free adjustments to their lifestyles and time-use patterns. of cost to villagers. Moreover, while the projects provided 10 Each latrine observed was scored between 0-10 using a 10-item dichotomous checklist. It included 3 items on functionality, 3 items on design and construction quality, 4 items on hygienic quality of use and maintenance. Scores from all latrines observed were averaged and converted to a percentage, taking the sum of maximum possible scores (10 per latrine) as 100 per cent. 18 18  Figure 4 Percentage of total responses about defecation sites "Always" used by different age-sex groups in 10 Cambodian villages Figure 5 Percentage of total responses about defecation sites "Occasionally" used by different age-sex groups in 10 Cambodian villages 19 19  all toilet construction materials, they had no hygiene or just outside 30 per cent of the observed latrines in education components, thus indicating that there was the Battambang communities, and 15 per cent of those little communication between the villagers and project observed in Kompong Spue. personnel about the benefits, operation and maintenance requirements of pour-flush latrines that Sanitation projects came more recently (late 1990s) to were being provided. the Battambang communities. They provided subsidized family toilet construction materials and included Only in 4 out of the 10 villages (2 in each province), technical instruction and hygiene education. In addition, feces were not visible on the floors or walls of all latrines better roads and transport facility to nearby towns observed. In the rest of the villages up to 30 per cent of allowed families to self-finance their latrines by buying the latrines showed some fecal pollution. In Battambang necessary technical skills and sanitation materials of communities almost all latrines observed had walls, their choice from non-project sources. Latrines that screens and shutters to provide adequate privacy, which people can choose from several possible options, after is often an indication of regular use. In Kompong Spue making a conscious decision to invest their own only 61 per cent of latrines observed provided enough resources, are evidently better valued and maintained privacy. Water for cleaning purposes was available in by them. Table 5 Average functionality, use and maintenance scores for latrines in 10 communities # of latrines Latrines Latrines Average score Community observed functioning in use* Total score for community out of max. 10 Battambang Province Rang Krol 10 10 10 75 7.5 Kok Trop 10 10 10 94 9.4 O-Nhor 10 10 10 92 9.2 Balang Krom 10 10 10 73 7.3 Kok Khpos 10 10 10 83 8.3 Kompong Spue Province Samrith 10 10 10 88 8.8 Pech Sangva 9 6 6 67 7.4 Aundong Sla 9 9 7 58 6.4 Praveuk Pong 7 7 5 57 8.1 Srei Chenda 10 8 5 58 5.8 Battambang communities average use and maintenance score: 417/500 = 83% Kompong Spue communities average use and maintenance score: 328/450 = 73% * Latrines can be functional (capable of being used) without being in regular use, i.e. when water for flushing is not available near homes because the household pond has dried up. Households may devise ways of obstructing access to the latrine seasonally in such cases. 20  4. What Benefits Matter Most to Users? G roups of women and men from latrine- owning households were met separately in the 10 communities for discussions regarding their perceptions of the benefits experienced from having household latrines. MPA tools were used to help them assess the extent to which they were experiencing specific benefits, the value of these benefits to them as compared to the cost of getting a latrine, and their user satisfaction. Having a clean and smell-free house and village environment was the leading benefit of having household latrines, according to both men and women groups. The next most important benefit was "safety", followed by "convenience" and "disease prevention". "Privacy" was next, and equally felt by both men and women. This was mentioned especially by participants in more populous villages where houses were close together and it was getting more difficult to find secluded places to defecate. "Time saving" and "reduction of flies" were almost as important. Economic benefits were mentioned in more than half the groups, implying the availability of manure and savings from fewer working days lost to diarrheal diseases. Benefits such as prestige and comfort were mentioned by very few groups (Figure 6). 21  Women in most groups voiced their main benefit as protect themselves against them by acquiring household privacy and safety that their household toilets afforded latrines, among other things. them. The two benefits are related. The need for privacy requires seclusion, which on the other hand invites risks Since both women and men in rural Cambodian to personal security. For reasons of privacy, outdoor communities seem to highly value benefits from defecation is usually practiced under cover of darkness, latrines such as safety, cleanliness of homes and at pre-dawn or at night, and darkness spells danger. A surroundings, convenience and privacy in addition household latrine provides privacy without the danger. to disease reduction, rural sanitation programs are Both sexes valued the safety from the culturally accepted likely to be a lot more effective if they use demand- dark spirits of the night, and snake and insect bites, creating and promotional strategies based on a particularly during the rainy season. For women, going combination of these motivations. As seen in many out alone at night in rural Cambodia poses risks of other countries, health benefits are included among the criminal attack from bandits and robbers who still roam benefits perceived by users, but they are not necessarily the countryside. Also, forests and fields in many parts of the ones most readily perceived, nor the ones ranked the country are still unsafe due to mines, which continue highest in importance. A promotional strategy based on to kill and maim farmers as they clear and prepare the a researched combination of local motivating factors is land. Safety from these risks are important to all families likely to be more successful in creating demand for yet it is the wealthy families who can better afford to sanitation facilities, which would allow sanitation services Figure 6 Frequency of mention of perceived benefits of a household latrine in 20 discussion groups of men and women 22  to be provided exclusively through demand-responsive and women's average value-for-cost score from 10 approaches, thus leading to better sustained services for villages was also 15 per cent higher than men's average all. value-for-cost score. This meant that while both sexes experienced similar benefits, women valued their Cost-Benefit Perceptions benefits somewhat more than the men did. Women felt that the costs incurred in getting household latrines had Men's and women's groups used a MPA tool to quantify been more worthwhile, as compared to men. When the extent to which they felt their expectations of benefits discussing cost, 6 men's groups out of 10 and 5 women's from their latrines were being met, and how worthwhile groups out of 10 felt they had saved money by building they considered their latrines to be, considering the cost a household toilet, that is, they felt the benefits incurred in getting and using them. outweighed the costs of construction. As Figure 7 shows, average benefit scores given by men According to 11 out of 20 discussion groups, the husband and women were comparable in 7 out of 10 and wife jointly decided to acquire a household toilet. communities. However, women's value-for-cost scores Women in the family initiated the decision according to were higher than men's scores in 6 out of 10 villages, 6 other groups and 3 groups said that the whole family Figure 7 Men's and Women's average scores for Benefit Expectations Met and Value-for-Cost perceptions for household latrines in the 10 study communities 23  decided together to get a household toilet. This reflects per cent) or something very close (95 per cent). Half the how the husband and wife, both of whom work the farm men's groups were fully satisfied. Results from all and bring in any income, discuss use of their financial communities are shown in Figure 8. resources. Any sanitation promotion needs to target both men and women equally well if it expects to achieve Men do not like to carry water to their toilets. Their successful outcomes. principal reason for lower satisfaction scores was a lack of water close to the toilets. Men found carrying water to User Satisfaction latrines to be more of a chore than women did. In three villages where the women were fully satisfied, the men User satisfaction with household toilets was measured were only 55-80 per cent satisfied because they had to using a visual rating scale11 with groups of women and carry water to the toilets. In Praveuk Prong men are fully men separately. Generally, women were marginally more satisfied, but women are not, because women have to satisfied than men with their pour-flush household bear the burden of carrying all the water needed for latrines, the only kind constructed and assessed. 7 out of flushing the toilets and cleaning it periodically, while men 10 women's groups gave a score of full satisfaction (100 do not share the tasks. Thus ease of cleaning is another factor that adds to women's satisfaction. Women's satisfaction had more to do with privacy. In Srei Chenda village, Kompong Spue, women were only 75 per cent satisfied, because the walls of the toilet were never finished and thus provide less than total privacy. Men of this village gave 100 per cent user satisfaction score, which indicates the greater importance of total privacy to women. Other reasons included ease of use, especially for children, good hygiene and fly reduction. Sustained use and maintenance of household sanitation facilities are functions of continued satisfaction of their users. As seen in the study, men and women can have different reasons to be satisfied or dissatisfied. Sanitation programs that consult men and women about their expectations and offer and discuss service options with them are likely to be more successful because they allow the most satisfying and sustainable solutions to be identified and implemented. 11 The two ends of the scale represented "Full Satisfaction" (100 per cent) and "No Satisfaction" (0 per cent) respectively. The groups indicated their satisfaction by marking a point anywhere between the two ends, or the ends themselves. 24  Figure 8 Satisfaction with sanitary latrines, as perceived by men and women user groups Village Rating Explainatory Remarks 0 % 100 % Rang Krol Easy to use, to have good hygiene, get compost. Kuok Trop Easy to use, prevent some diseases, easy for guests. Onhor Flies reduction, safety, good hygiene but lack of water for using pour flush latrine. Balang Krom Sanitary household, good health in family, smell reduction but men dislike carrying water for flushing latrine. Kuok Khpos Men lazy to cary water for flushing latrine, easy for child, smell reduction, disease reduction, clean household. Easy for child, smell reduction, disease reduction, clean Samrith household, easy to use, (especially at night and raining time) and has prestige. Women find that it is difficult to clean. Pech Sangva Men satified. Reduces diseases saves time, women bear the burden to carry water for cleaning latrine. Andong Sla Easy to use, water sources near. Women more satified because flies and smell reduced and make it easy for the guests. Men less satisfied. Don't like to Praveuk Pong carry water for flushing. The water sources are far. Many latrines have not constructed the wall/enclosure for privacy. Easy, especially to children. Compost/fertilizer. Reduces flies. Srer Chenda Women prefer to defecate in the rice field. They feel that it make the rice field fertile. Many latrines have no wall for privacy. 0 = Not satisfied at all Women's rating 100 = Fully satisfied Men's rating NB: These ratings are from visual scales 2 meters long drawn on the ground. Men and women's groups marked their positions by group consensus on the scale. 25  5. Was Sanitation Coverage Linked to Hygiene Awareness and Practices? major gaps in awareness of both men and women, leading to inconsistent hygiene behaviors. It is always risky to assume that high awareness levels correlate with extent of hygiene practice. It is possible to spread awareness of certain standard hygiene education messages without making any difference to actual practice, some examples of which were seen in this study. Table 5 presents an analysis of the 20 flow diagrams prepared by men and women, which reveals the following range of awareness: Very high awareness (mentioned by 80-100 per cent of A participatory flow diagramming exercise groups) of: (PHAST) was used to explore men and women's Need to boil drinking water (all groups). awareness of how fecal-oral transmission Need to keep food covered and protected from happens and possible hygiene practices that can block flies (all groups). transmission routes and prevent diseases borne by food, Sanitary toilet use as a way to prevent disease water and vectors. transmission (all groups). The 3 major routes of transmission of fecal Results from the 10 communities showed that women contamination being food, water and hands. were somewhat more aware of good hygiene practices. Moderate awareness (mentioned by 45 per cent of There was universal awareness of a few key hygiene groups) of: practices among men and women, which is a good Need to wash hands before feeding a child. foundation to build upon. However, there were also Need to wash hands after cleaning babies' feces. 26  Low awareness (mentioned by 30-35 per cent of important after cleaning up babies' feces or working in groups) of: the field, and before feeding a child or eating. Both men's Need to wash hands after working in the fields. and women's groups were either little aware or generally Need to wash hands before eating. unconvinced that hand washing was an important way Need to wash hands with soap and water after to reduce or prevent the transmission of disease, defecating. particularly after defecating and cleaning up babies' Very low awareness (only 15 per cent of groups, only feces, before eating and feeding the children. No hand women) of: washing facilities were observed near household latrines Need to dispose of babies' feces in the latrine. in 80 per cent of cases. Soap or soap substitutes were generally absent even where water was available for hand All men and women were aware that the use of a sanitary washing. toilet can block disease transmission, that boiling water makes it safer to drink and that it is important to keep Observed Household and food covered so that flies cannot access it, thereby Environmental Hygiene acknowledging that flies spread diseases. On further examination, however, several discrepancies in hygiene The field team used an environmental and household awareness become evident. observation checklist to assess overall hygiene conditions as they undertook transect walks with community Even though all groups identified the use of sanitary members. They discussed what was observed with latrines as a means to block disease transmission, only community members and sought their opinions about 3 women's groups and none of the men's groups why conditions were good or bad. identified the need to dispose of babies' feces into latrines. When probed, the other groups said that the common Households that had latrines usually built them inside practice was to scrape infants' feces to the edge of a their yards, but not attached to or inside the main dwelling path or into a bush. Some villagers explained their belief unit. This was in keeping with people's preference to have that babies' feces are "harmless" and "safe" (when, in a facility that was close enough to be convenient but not reality they contain higher concentrations of disease- too close in case it smelled bad. The availability of land causing microorganisms than adult feces). The results of around homes made it possible. However, there was no this misconception are reflected Figures 4 and 5, which hand washing facility near the latrine in 80 per cent of show babies' feces still being thrown into corners of yards cases. Most households reported cleaning their latrines and banana groves behind homes even when people 2-3 times a week. The rest did not have a regular schedule have household latrines. and cleaned when they considered it necessary. Animal pens were usually adjoining dwelling units or in a corner Although 16 out of 20 discussion groups identified hands of the yard. as one of the three principal routes for fecal-oral transmission, for both men and women hand washing Garbage was generally disposed of into a hole in the was neither a high priority nor a common practice. Less yard for composting, or accumulated for a few days and than half the groups considered hand washing with soap burnt off. Wastewater from the house was let out into the and water necessary after defecation. In fact, more than yard to flow into banana groves or led through small half the groups did not consider washing even with water drainage channels to ponds at the back of homes. People 27  Table 5 Hygiene awareness assessed from contamination route diagrams prepared by men and women in 10 communities Awareness of Identified by Men in Identified by Women in 1 Using sanitary toilet a way to block disease 10/10 villages 10/10 villages transmission 2 Need to keep food covered 10/10 villages 10/10 villages 3 Need to boil drinking water 10/10 villages 10/10 villages 4 3 major routes of transmission of fecal 7/10 villages 9/10 villages contamination (food, water hands) 5 Need for hand washing after cleaning 5/10 villages 4/10 villages babies' feces 6 Need to hand wash before feeding a child 5/10 villages 4/10 villages 7 Need for hand washing before eating 2/10 villages 5/10 villages 8 Need for hand washing after working in 3/10 villages 4/10 villages the field 9 Need to hand wash with soap and water after 4/10 villages 2/10 villages defecating 10 Need to dispose of babies' feces in the toilet 0/10 villages 3/10 villages confirmed that these become stagnant pools in the rainy The findings suggest that improving community season and breed mosquitoes. Kitchens were not always understanding of the locally operating routes of fecal shuttered, allowing access by domestic animals such as contamination could be the key to popularizing chickens, cats and dogs, which carries substantial risks preventive hygiene practices, crucial among which would of contaminating food. The villagers said that cooked be effective hand washing and safe handling of infant food is rarely stored in the kitchen as it is consumed or carried away soon after cooking. excreta. This implies using hygiene promotion approaches that work with community groups to: The areas with the greatest contamination with animal a) identify local practices representing the greatest dung were along village roads and footpaths, as well as health hazards; b) identify locally developed the yards outside dwelling units. Villagers feel that animal strategies to eliminate or replace them with safer feces are not as polluting as human feces, and that people practices; and c) build a community movement for clean their households periodically but care less about promoting the same few key behavior changes, cleaning common property such as roads and footpaths clean. through local groups and institutions. 28  6. What Factors Influence Behavior Change? T he researchers consulted men's and women's groups about what strategies worked best in changing people's sanitation behaviors in their communities. The villagers' views are summarized below. Behavior-changing communication Focus on what is already achieved. According to women, hearing stories about the benefits of sanitation as experienced by other villagers is a potent catalyzer of thinking about changing one's own behavior. In several benefits already achieved elsewhere, such as "children villages women said that project functionaries generally are not getting diarrhea every month, after the sanitation talk about the benefits that will come in the future if people project" or "people in 8 out of every 10 villages are not acquire sanitary latrines. People are skeptical because losing so many working days any more because last year no one can predict the future. They said that it would be they built household latrines and they get sick less often more convincing if project personnel told stories of now." 29  Communication can be more effective if it focuses communication, particularly from people who are known on benefits that are important to local people.12 and credible to villagers, with whom they can also have Men's groups illustrated this by suggesting messages a dialogue for further information and clarification of highlighting various benefits, e.g. the safety provided by doubts. latrines from criminals, snakebites, etc. "if you have a latrine, you are safe forever." About the convenience and Seeing others experiencing benefits is a powerful laborsaving benefits, it could be "families that have motivator. Many discussion groups mentioned that latrines do not have to dig and bury their stools everyday." observing the practice and benefit that neighbors with About economic benefits they suggested "families that household toilets received caused them to want the same have latrines can save 100,000 to 150,000 riel in medical for themselves and their families. Even a small number costs every year because they do not get diarrheal of successful installations of household toilets can have diseases." a positive influencing effect among the families without toilets. Local people make more convincing motivators. Both men and women in many villages said that people are convinced to change their behaviors only when someone Other facilitators of behavior change they know well and trust tells them that it would be beneficial to make the change. Therefore, they suggested Prioritize villages that are more ready for sanitation. that owners of the first few latrines in a village could be In some villages people suggested that there is greater the best carriers of messages for further behavior change readiness for sanitation behavior change in certain types in the community, because they can talk credibly about of villages. They suggested that villages which are far the benefits that they experience from their latrines. Village from forests, are crowded, where it is difficult to find chiefs, Village Development Committee members, Village secluded spots for outdoor defecation, and prosperous Development Volunteers all can fit this role well, villages that have several rice harvests a year, are those particularly if they own a sanitary latrine. Also, they said most likely to ready for change. Sanitation projects could that "telling or reminding each other regularly" about be more successful if they prioritized such villages for practices to change such as washing hands after intervention, and later used them as good examples to defecation, using latrines, not throwing babies' feces in promote change in other villages. However, easy the yard, etc. can gradually lead to change in behavior household access to water sources must also be for the whole community. They felt that hearing these considered if the project promotes water-flushed latrines. messages a few times from external authorities such as the mass media may create some awareness, but really Within prioritized villages, target the poorest with has no effect on community behavior.13 For behavior to special provisions. Several women's groups and one change, communication from sources external to the men's group recommended special strategies to make it community must be followed up with interpersonal possible for the poorest households to acquire latrines. 12 This confirms conclusions drawn in Chapter 4. 13 Same recommendation is made in Chapter 5, i.e. identifying key behaviors to change and building a community movement around those behaviors, through schools, men's and women's groups, village leaders, community organizations. 30  They said, "Everyone wants to be healthy and clean, even Link with earning opportunities. Several women's the poorest. But they cannot pay cash like the better off. groups suggested linking sanitation services with earning They can pay in labor or materials, particularly if given a opportunities for villagers, e.g. providing them training longer period to pay." Some recommended that projects for production of sanitation materials and construction should provide free spare parts for latrine repair and and repair skills. They said that would provide them maintenance, once people have invested their own funds with incentives to promote sanitation coverage in their to get one. own village, as well as in others nearby. Three-pronged promotion strategy advice from a group of Cambodian villagers: o Provide information about sanitation benefits and facilities through radio and television (mass media for information). o Government or NGO to introduce sanitation activity in community (supplies and skills for trying things out). o Use neighbors to convince people to change behavior (interpersonal media for influencing). - Men's discussion group in Pech Sang Va, Kompong Spue province 31  Key Lessons Learned of locally motivating factors to develop culturally appropriate promotional strategies is likely to be more effective than standard health-education based promotion. Promoting a set of design, cost and payment options for household toilets is important for scaling up sanitation coverage. In a situation where only one design is offered and that design is relatively expensive or has an inflexible mode of For accelerating demand for and payment, poorer village families are unable to afford access to sanitation: to buy a household toilet. High proportions of rural Cambodian families still fall in this category. Sanitation promotion strategies need to be based on researched understanding of local motivation Until poverty in the rural areas is reduced, special to acquire household toilets, which could be as poverty-targeted strategies must be found to diverse as convenience, safety, privacy, health assist the poorest families and/or communities to improvement or money saving. Using a combination build household latrines. This does not have to mean 32  highly subsidized or free toilets, which tend not to local supply capacity to respond to projected have good sustainability records. Developing very low household sanitation demand. The next few years cost toilet designs, allowing poor households to pay could then be used for sanitation and hygiene in non-cash form and over long periods of time, behavior promotion, latrine construction and follow micro-credit schemes to finance toilets, and promoting up monitoring of sanitation interventions including shared toilets between several household are some technical support to the families with newly installed innovative solutions that are possible. latrines. Sanitation promotion needs to be gender- Promoting local technical and building skills sensitive and gender-inclusive. Sanitation services may be key to sustainable rural sanitation can mean different types and extent of benefits and services. Particularly in remote rural areas isolated costs for women and men. Unless these differences from urban markets, local ability to make concrete are considered and catered to (gender-sensitive bowls and platforms made of locally appropriate approach), sanitation interventions may even end up materials would help develop a local market adding to women's existing burdens. Moreover, it was enterprise for sanitation as well as other concrete found that in most cases the husband and wife jointly building products. decided to acquire a household toilet. Therefore, to awaken potential population demand and to make Developing behavior change strategies in the greatest possible positive impact on the lives of consultation with communities can pay off in poor rural communities, both women and men must terms of their effectiveness. Communities know be reached and consulted adequately (gender- best how to bring about behavior change amongst inclusive approach) by sanitation programs. their people. They need information support about hygiene, and the freedom to plan how change will For sustaining sanitation be effected. Projects can help village groups to select improvements and impact on their own sanitation and hygiene promotion community lives: strategies and monitoring indicators. Community members are the best influencers and Sanitation projects need to plan for longer communicators for change. Indigenous potential contact periods with communities. The first 1.5-2 change agents can be supported by projects through years may be necessary to devote to the exploration training and incentives for the time and energy they of the local hygiene awareness, assessment of devote to promoting sanitation, e.g. by linking sanitation demand and its underlying causes, incentives to every new adopter of sanitation/home developing demand-generating interventions and hygiene services or facilities. 33  Annex A Participatory Tools used for investigation The following participatory tools supplemented open-ended focus group discussions. They did not necessitate literacy skills. Where illiteracy was a problem, symbols and visuals replaced writing. Locally available drawing and marking materials in the communities were used optimally. Well Being Classification (MPA tool)