Assessing the Impact and Equity of an Integrated Rural Sanitation Approach: A Longitudinal Evaluation in 11 Sub-Saharan Africa and Asian Countries

Abstract

Few rural sanitation programs have documented large increases in sanitation coverage or have assessed if interventions equitably increase sanitation coverage for vulnerable groups. We characterize the impact of the Sustainable Sanitation and Hygiene for All (SSH4A) approach on key program WASH (water, sanitation, and hygiene) indicators, and also assess if these increases in WASH coverage are equitably reaching vulnerable groups. The SSH4A approach was administered in 12 program areas in 11 countries, including Bhutan, Ethiopia, Ghana, Indonesia, Kenya, Mozambique, Nepal, South Sudan, Tanzania, Uganda, and Zambia. Repeated cross-sectional household surveys were administered over four rounds at annual follow-up rounds from 2014 to 2018. Surveys were conducted in an average of 21,411 households at each round of data collection. Overall, sanitation coverage increased by 53 percentage points between baseline and the final round of data collection (95% CI: 52%, 54%). We estimate that 4.8 million people gained access to basic sanitation in these areas during the project period. Most countries also demonstrated movement up the sanitation ladder, in addition to increases in handwashing stations and safe disposal of child feces. When assessing equity—if sanitation coverage levels were similar comparing vulnerable and non-vulnerable groups—we observed that increases in coverage over time were generally comparable between vulnerable groups and non-vulnerable groups. However, the increase in sanitation coverage was slightly higher for higher wealth households compared to lower wealth households. Results from this study revealed a successful model of rural sanitation service delivery. However, further work should be done to explore the specific mechanisms that led to success of the intervention.

The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: a cluster-randomized trial

“…Changes were much lower than with approaches found by Crocker et al elsewhere in Ethiopia [34,37]. Similarly, Apanga et al found that implementation of the Rural Sustainable Sanitation and Hygiene for All (SSH4A) approach that employs a multidimensional intervention led to a large increase of 77 percentage points in sanitation coverage in Ethiopia and also coverage gains in many other countries under study [60], although slippage did occur after conclusion of program activities, whereas many other countries sustained their previous sanitation coverage gains [61].…”

Sources and routes of SARS-CoV-2 transmission in water systems in Africa: Are there any sustainable remedies?

“…Water, Sanitation and Hygiene, commonly known as WASH have been the focus of many researchers in Africa in recent times ( Sanou et al, 2015 ; Elisante and Muzuka, 2016 ; Metwally et al, 2007 ; Adams, 2018 ; Back et al, 2018 ; Nhamo et al, 2019 ; Sunkari and Abu, 2019 ; Zango et al, 2019 ; Abanyie et al, 2020 ; Apanga et al, 2020 ; Mutono et al, 2020 ; Sunkari et al, 2020 ). Globally, it is well established that poor sanitation, unhygienic conditions and lack of quality water supply have been the cause of many illnesses and deaths.…”

Geography Matters for Sanitation! Spatial Heterogeneity of the District-level Correlates of Open Defecation in India

“…The available sanitation research overwhelmingly comprises of case studies that most commonly draw on household-level micro-data. A few studies have investigated international and sub-national geographical inequalities in sanitation conditions [50,51,52,53], while some have also analyzed the various sanitation determinants [54,20,49]. The research focusing on the meso-and macro-level patterns of OD practices is generally scanty and rather descriptive, being often limited to simply monitoring basic sanitation indicators [55].…”