Assessing the Sustainability of an Integrated Rural Sanitation and Hygiene Approach
Introduction
Achieving universal access to adequate and equitable sanitation and hygiene is a key Sustainable Development Goal (SDG 6.2). However, ensuring the sustainability of sanitation and hygiene interventions has proven to be a significant challenge. Many rural sanitation programs have struggled with slippage or backsliding in coverage after the completion of implementation activities.
The Sustainable Sanitation and Hygiene for All (SSH4A) approach, developed by SNV and its partners, aims to address this challenge through a multi-dimensional framework focused on strengthening capacity in four key areas: demand creation, sanitation supply chain and finance, hygiene behavior change communication (BCC), and water, sanitation, and hygiene (WASH) governance. The approach is designed to work closely with local governments to ensure that the improvements in sanitation and hygiene service delivery are sustained even after the program’s implementation period.
Between 2014 and 2018, the SSH4A approach was implemented across 15 countries in sub-Saharan Africa and Asia. A previous evaluation of the program found significant gains in sanitation and hygiene coverage across these countries. However, a critical question remained: Were these gains sustained over time, or did slippage occur once the program’s direct implementation activities ceased?
To answer this question, the authors conducted a post-implementation evaluation, surveying over 22,000 households across 12 program areas in 10 countries to assess the sustainability of the SSH4A approach. This article shares the key findings from this sustainability assessment, providing important insights for policymakers, program managers, and funders working to achieve lasting improvements in rural sanitation and hygiene.
Assessing Sustainability Across 10 Countries
The post-implementation evaluation surveyed households in Bhutan, Ethiopia, Ghana, Indonesia, Kenya, Mozambique, Nepal, Tanzania, Uganda, and Zambia – comprising 12 distinct program areas – approximately 1-2 years after the completion of the SSH4A intervention. This allowed the authors to compare coverage levels at the end of the program’s implementation period to the situation after the program had concluded.
Sustained Gains in Basic Sanitation Coverage
The results were mixed, with half of the program areas (6 out of 12) showing sustained similar levels of basic sanitation coverage 1-2 years post-implementation. In these areas, the percentage of households with access to a basic sanitation facility remained statistically unchanged compared to the final year of the program.
However, the other half of the program areas experienced varying degrees of slippage. Declines in basic sanitation coverage ranged from a 63 percentage point drop in one of the Ethiopia sites to a more modest 4 percentage point decline in Indonesia.
Notably, even in the program areas that saw decreases in sanitation coverage, the final coverage levels were still higher than the baseline before the SSH4A intervention began. This suggests the program was able to achieve lasting improvements, even if full sustainability proved elusive in all contexts.
Shifts in Sanitation Technologies
The authors also examined changes in the specific types of sanitation technologies used by households over time. Many of the areas with larger drops in overall sanitation coverage, such as Ethiopia, Mozambique, Uganda, and Zambia, had been relying heavily on pit latrines with slabs.
In contrast, the decline in flush/pour-flush toilets was more pronounced in Nepal, where this technology had been more common. The authors’ sensitivity analysis found that while flush/pour-flush toilets were more likely to be sustained than other improved latrine types, there was still some slippage in their coverage over time.
Hygiene Outcomes and Open Defecation
The sustainability assessment also looked at key hygiene behaviors and outcomes. In 3-4 program areas, the prevalence of handwashing stations with soap and safe disposal of child feces remained unchanged 1-2 years post-implementation. However, the other program areas saw declines in these indicators, though they still ended with higher coverage than at baseline.
Additionally, in areas that experienced drops in sanitation coverage, the authors generally did not observe an increase in sanitation sharing among neighbors. Instead, open defecation tended to rise in these contexts.
Factors Associated with Sustained Coverage
To understand what might drive sustainability, the authors examined several community, household, and structural factors that could influence sanitation and hygiene outcomes over time. Their analysis revealed several key insights:
Community Factors:
– Higher baseline sanitation coverage (before the SSH4A program began) was associated with better sustainability.
– Dramatic improvements in sanitation during the implementation period were linked to higher slippage post-intervention.
Household Factors:
– Households in the lowest wealth quintiles were more likely to experience slippage compared to wealthier households.
– Households with members who have disabilities were less likely to see declines in sanitation coverage.
Structural Factors:
– Toilets with underground tank pits were more likely to be sustained compared to those with above-ground tanks.
– Contrary to expectations, areas with deeper water tables were more prone to sanitation coverage declines, though this finding was driven by a few specific program areas.
These findings suggest that the maturity of sanitation markets, supply chains, and governance systems prior to the intervention may play a key role in determining sustainability. Households facing greater socioeconomic barriers also appear to be more vulnerable to coverage losses over time.
Lessons and Implications
This study represents one of the first rigorous assessments of the sustainability of an integrated rural sanitation and hygiene approach implemented across multiple countries. The mixed results, with some areas sustaining coverage gains while others experienced slippage, offer important lessons:
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Sustainability Remains a Challenge: Even a multidimensional approach like SSH4A, designed to address a range of barriers to sustained service delivery, did not guarantee that coverage improvements would be fully maintained in all contexts. Policymakers and program managers must continue to prioritize sustainability as a key objective, not just initial coverage gains.
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Context Matters: The factors associated with sustained coverage suggest that the local context, including the maturity of sanitation systems and the socioeconomic status of target populations, can significantly influence whether gains are maintained over time. Tailoring interventions to these contextual realities is crucial.
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Equity Concerns Persist: While the SSH4A approach was able to reach vulnerable groups like low-income households and those with members who have disabilities, the sustainability of gains was lower for these groups in some cases. Ensuring equitable and lasting access to sanitation and hygiene remains an ongoing challenge.
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Longer-Term Commitment Needed: The findings on steep coverage increases being linked to higher slippage imply that building sustainable systems may require more gradual, long-term engagement from stakeholders. Quick wins may come at the expense of durable change.
Going forward, the authors emphasize the need for more rigorous implementation research to unpack the programmatic and contextual factors that enable or hinder the sustainability of rural sanitation and hygiene interventions. Benchmarking sustainability across different approaches will be critical to achieving the SDG vision of universal access to adequate and equitable sanitation and hygiene services.
As policymakers, program managers, and funders continue their efforts, the insights from this multi-country evaluation of the SSH4A approach can serve as an important reference point. Sustaining coverage gains remains an elusive but essential goal in the quest for lasting improvements in community health and environmental sustainability.
