The Impact of Pro-Poor Sanitation Subsidies in Open Defecation-Free Communities: A Randomized, Controlled Trial in Rural Ghana.

BACKGROUND: According to the World Health Organization/United Nations International Children's Fund Joint Monitoring Program, 494 million people practice open defecation globally. After achieving open defecation-free (ODF) status through efforts such as Community-Led Total Sanitation (CLTS), communities (particularly vulnerable households) may revert to open defecation, especially when toilet collapse is common and durable toilets are unaffordable. Accordingly, there is increasing interest in pro-poor sanitation subsidies. OBJECTIVES: This study determined the impacts of a pro-poor sanitation subsidy program on sanitation conditions among the most vulnerable households and others in the community. METHODS: In 109 post-ODF communities in Northern Ghana, we conducted a cluster randomized controlled trial to evaluate a pro-poor subsidy program that identified the most vulnerable households through community consultation to receive vouchers for durable toilet substructures. We surveyed households to assess toilet coverage, quality, and use before and after the intervention and tracked program costs. RESULTS: Overall, sanitation conditions deteriorated substantially from baseline to endline (average of 21 months). In control communities (not receiving the pro-poor subsidy), open defecation increased from 25% (baseline) to 69% (endline). The subsidy intervention attenuated this deterioration (open defecation increased from 25% to only 54% in subsidy communities), with the greatest impacts among voucher-eligible households. Noneligible households in compounds with subsidized toilets also exhibited lower open defecation levels owing to in-compound sharing (common in this context). CLTS followed by the subsidy program would benefit more households than CLTS alone but would cost 21-37% more per household that no longer practiced open defecation or upgraded to a durable toilet. DISCUSSION: Sanitation declines, often due to toilet collapse, suggest a need for approaches beyond CLTS alone. This subsidy program attenuated declines, but durable toilets likely remained unaffordable for noneligible households. Targeting criteria more closely aligned with sanitation inequities, such as household heads who are female or did not complete primary education, may help to generate greater and more sustainable impacts in Northern Ghana and, potentially, other contexts facing toilet collapse and limited market access. https://doi.org/10.1289/EHP10443.

Can open-defecation free (ODF) communities be sustained? A cross-sectional study in rural Ghana.

Community-led total sanitation (CLTS) is a widely used approach to reduce open defecation in rural areas of low-income countries. Following CLTS programs, communities are designated as open defecation free (ODF) when household-level toilet coverage reaches the threshold specified by national guidelines (e.g., 80% in Ghana). However, because sanitation conditions are rarely monitored after communities are declared ODF, the ability of CLTS to generate lasting reductions in open defecation is poorly understood. In this study, we examined the extent to which levels of toilet ownership and use were sustained in 109 communities in rural Northern Ghana up to two and a half years after they had obtained ODF status. We found that the majority of communities (75%) did not meet Ghana's ODF requirements. Over a third of households had either never owned (16%) or no longer owned (24%) a functional toilet, and 25% reported practicing open defecation regularly. Toilet pit and superstructure collapse were the primary causes of reversion to open defecation. Multivariate regression analysis indicated that communities had higher toilet coverage when they were located further from major roads, were not located on rocky soil, reported having a system of fines to punish open defecation, and when less time had elapsed since ODF status achievement. Households were more likely to own a functional toilet if they were larger, wealthier, had a male household head who had not completed primary education, had no children under the age of five, and benefitted from the national Livelihood Empowerment Against Poverty (LEAP) program. Wealthier households were also more likely to use a toilet for defecation and to rebuild their toilet when it collapsed. Our findings suggest that interventions that address toilet collapse and the difficulty of rebuilding, particularly among the poorest and most vulnerable households, will improve the longevity of CLTS-driven sanitation improvements in rural Ghana.

How Much Will Safe Sanitation for all Cost? Evidence from Five Cities.

Global sustainable development goals call for universal access to safely managed sanitation by 2030. Here, we demonstrate methods to estimate the financial requirements for meeting this commitment in urban settings of low-income countries. Our methods considered two financial requirements: (i) the subsidies needed to bridge the gap between the willingness-to-pay of low-income households and actual market prices of toilets and emptying services and (ii) the amounts needed to expand the municipal waste management infrastructure for unserved populations. We applied our methods in five cities- Kisumu, Malindi, Nakuru in Kenya; Kumasi in Ghana; and Rangpur in Bangladesh and compared three to five sanitation approaches in each city. We collected detailed cost data on the sanitation infrastructure, products, and services from 76 key informants across the five cities, and we surveyed a total of 2381 low-income households to estimate willingness-to-pay. We found that the total financial requirements for achieving universal sanitation in the next 10 years and their breakdown between household subsidies and municipal infrastructure varied greatly between sanitation approaches. Across our study cities, sewerage was the costliest approach (total financial requirements of 16-24 USD/person/year), followed by container-based sanitation (10-17 USD/person/year), onsite sanitation (2-14 USD/person/year), and mini-sewers connecting several toilets to communal septic tanks (3-5 USD/person/year). Further applications of our methods can guide sanitation planning in other cities.

Assessing the Demand for Plastic Latrine Slabs in Rural Kenya.

Improving access to safe and affordable sanitation facilities is a global health priority that is essential for meeting the United Nation's Sustainable Development Goals. To promote the use of improved sanitation in rural and low-income settings, plastic latrine slabs provide a simple option for upgrading traditional pit latrines. The International Finance Corporation/World Bank Selling Sanitation program estimated that plastic slabs would have a 34% annual growth, with a market size of US$2.53 million in Kenya by 2017. In this study, we examined the commercial viability of these plastic latrine slabs in rural Kenya by evaluating a financing and distribution model intervention, documenting household slab sales to date, and assessing consumer exposure and perceptions. We also determined household willingness to pay through a real-money auction with 322 households. We found that no households in our study area had purchased the plastic slabs. The primary barriers to slab sales were limited marketing activities and low demand compared with the sales price: households were willing to pay an average of US$5 compared with a market price of US$16. Therefore, current household demand for the plastic latrine slabs in rural Kenya is too low to support commercial distribution. Further efforts are required to align the price of plastic latrine slabs with consumer demand in this setting, such as additional demand creation, product financing, and public sector investment.

Measuring the Impacts of Water Safety Plans in the Asia-Pacific Region.

This study investigated the effectiveness of Water Safety Plans (WSP) implemented in 99 water supply systems across 12 countries in the Asia-Pacific region. An impact assessment methodology including 36 indicators was developed based on a conceptual framework proposed by the Center for Disease Control (CDC) and before/after data were collected between November 2014 and June 2016. WSPs were associated with infrastructure improvements at the vast majority (82) of participating sites and to increased financial support at 37 sites. In addition, significant changes were observed in operations and management practices, number of water safety-related meetings, unaccounted-for water, water quality testing activities, and monitoring of consumer satisfaction. However, the study also revealed challenges in the implementation of WSPs, including financial constraints and insufficient capacity. Finally, this study provided an opportunity to test the impact assessment methodology itself, and a series of recommendations are made to improve the approach (indicators, study design, data collection methods) for evaluating WSPs.

Why do water quality monitoring programs succeed or fail? A qualitative comparative analysis of regulated testing systems in sub-Saharan Africa.

BACKGROUND: Water quality testing is critical for guiding water safety management and ensuring public health. In many settings, however, water suppliers and surveillance agencies do not meet regulatory requirements for testing frequencies. This study examines the conditions that promote successful water quality monitoring in Africa, with the goal of providing evidence for strengthening regulated water quality testing programs. METHODS AND FINDINGS: We compared monitoring programs among 26 regulated water suppliers and surveillance agencies across six African countries. These institutions submitted monthly water quality testing results over 18 months. We also collected qualitative data on the conditions that influenced testing performance via approximately 821 h of semi-structured interviews and observations. Based on our qualitative data, we developed the Water Capacity Rating Diagnostic (WaterCaRD) to establish a scoring framework for evaluating the effects of the following conditions on testing performance: accountability, staffing, program structure, finances, and equipment & services. We summarized the qualitative data into case studies for each of the 26 institutions and then used the case studies to score the institutions against the conditions captured in WaterCaRD. Subsequently, we applied fuzzy-set Qualitative Comparative Analysis (fsQCA) to compare these scores against performance outcomes for water quality testing. We defined the performance outcomes as the proportion of testing Targets Achieved (outcome 1) and Testing Consistency (outcome 2) based on the monthly number of microbial water quality tests conducted by each institution. Our analysis identified motivation & leadership, knowledge, staff retention, and transport as institutional conditions that were necessary for achieving monitoring targets. In addition, equipment, procurement, infrastructure, and enforcement contributed to the pathways that resulted in strong monitoring performance. CONCLUSIONS: Our identification of institutional commitment, comprising motivation & leadership, knowledge, and staff retention, as a key driver of monitoring performance was not surprising: in weak regulatory environments, individuals and their motivations take-on greater importance in determining institutional and programmatic outcomes. Nevertheless, efforts to build data collection capacity in low-resource settings largely focus on supply-side interventions: the provision of infrastructure, equipment, and training sessions. Our results indicate that these interventions will continue to have limited long-term impacts and sustainability without complementary strategies for motivating or incentivizing water supply and surveillance agency managers to achieve testing goals. More broadly, our research demonstrates both an experimental approach for diagnosing the systems that underlie service provision and an analytical strategy for identifying appropriate interventions.

Determinants of breast cancer early detection for cues to expanded control and care: the lived experiences among women from Western Kenya.

BACKGROUND: Estimately, 70-80% of cancer cases are diagnosed in late stages in Kenya with breast cancer being a common cause of mortality among women where late diagnosis is the major ubiquitous concern. Numerous studies have focused on epidemiological and health policy dynamics essentially underestimating the determining factors that shape people's choices and cues to health care service uptake. The study sought to evaluate the knowledge, attitude and health seeking behavior towards breast cancer and its screening in a quest to explain why women present for prognosis and treatment when symptomatic pointers are in advanced stages, impeding primary prevention strategies. METHODS: Eight focus groups (6-10 members per group) and four key informant interviews were conducted among adult participants from rural and urban settings. Sessions were audio-recorded and transcribed. A thematic analysis of the data was based on the concepts of the health belief model. Data analysis was conducted using NVIVO10. RESULTS: Most women perceived breast cancer as a fatal disease and conveyed fear of having early screening. Rural women preferred self-prescribed medications and the use of alternative medicine for long periods before presenting for professional care on suspicion that the lump is cancerous. Accessibility to equipped health facilities, lack of information to establish effective follow-up treatment and low-income status were underscored as their major health seeking behavior barriers whereas, urban women identified marital status as their main barrier. Key informant interviews revealed that health communication programs emphasized more on communicable diseases. This could in part explain why there is a high rate of misconception and suspicion about breast cancer among rural and urban women in the study setting. CONCLUSIONS: Creating breast cancer awareness alongside clear guidelines on accessing screening and treatment infrastructure is critical. It was evident, a diagnosis of breast cancer or lump brings unexpected confrontation with mortality; fear, pain, cultural barriers, emotional and financial distress. Without clear referral channels to enable those with suspicious lumps or early stage disease to get prompt diagnosis and treatment, then well-meaning awareness will not necessarily contribute to reducing morbidity and mortality.

How Much Will It Cost To Monitor Microbial Drinking Water Quality in Sub-Saharan Africa?

Microbial water quality monitoring is crucial for managing water resources and protecting public health. However, institutional testing activities in sub-Saharan Africa are currently limited. Because the economics of water quality testing are poorly understood, the extent to which cost may be a barrier to monitoring in different settings is unclear. This study used cost data from 18 African monitoring institutions (piped water suppliers and health surveillance agencies in six countries) and estimates of water supply type coverage from 15 countries to assess the annual financial requirements for microbial water testing at both national and regional levels, using World Health Organization recommendations for sampling frequency. We found that a microbial water quality test costs 21.0 ± 11.3 USD, on average, including consumables, equipment, labor, and logistics, which is higher than previously calculated. Our annual cost estimates for microbial monitoring of piped supplies and improved point sources ranged between 8 000 USD for Equatorial Guinea and 1.9 million USD for Ethiopia, depending primarily on the population served but also on the distribution of piped water system sizes. A comparison with current national water and sanitation budgets showed that the cost of implementing prescribed testing levels represents a relatively modest proportion of existing budgets (<2%). At the regional level, we estimated that monitoring the microbial quality of all improved water sources in sub-Saharan Africa would cost 16.0 million USD per year, which is minimal in comparison to the projected annual capital costs of achieving Sustainable Development Goal 6.1 of safe water for all (14.8 billion USD).