WATER AND SANITATION PROGRAM: TECHNICAL PAPER 56934 Global Scaling Up Sanitation Project Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Christine Sijbesma, Truong Xuan Truong, and Jacqueline Devine April 2010 The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. Christine Sijbesma, IRC effort to meet the basic sanitation needs of the rural poor who Truong Xuan Truong, ADCOM do not currently have access to safe and hygienic sanitation. Jacqueline Devine, WSP The project is being implemented by local and national governments with technical support from WSP. For more The task manager for the study was Jacqueline Devine of information, please visit www.wsp.org/scalingupsanitation. the Water and Sanitation Program (WSP), who also reviewed This Technical Paper is one in a series of knowledge products this report. The study was executed by IRC International designed to showcase project findings, assessments, and Water and Sanitation Centre, The Hague, the Netherlands, lessons learned in the Global Scaling Up Sanitation Project. and ADCOM Consultants in Hanoi, Vietnam. The respective This paper is conceived as a work in progress to encourage international and national team were Dr. Christine Sijbesma the exchange of ideas about development issues. For of IRC and Dr. Truong Xuan Truong of ADCOM. ADCOM more information please email Christine Sijbesma, Truong team members were Dinh Ngoc Bich, Dr. Ha Viet Hung, Le Xuan Truong, and Jacqueline Devine at wsp@worldbank.org Duc Hanh, Nguyen Thi Hong Sam, Nguyen Kim Thai, Ho or visit our website at www.wsp.org. Thi Kim Uyen, Nguyen Nhu Trang, and Nguyen Tuan Minh. Joanna Rhodes of IRC edited the case study report and WSP is a multi-donor partnership created in 1978 and administered by Amy Grossman of WSP edited the study for publication, with the World Bank to support poor people in obtaining affordable, safe, and assistance from Kara Watkins. sustainable access to water and sanitation services. WSP's donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, The authors wish to thank Nguyen Danh Soan, Coordinator Switzerland, United Kingdom, United States, and the World Bank. of the Rural Water Supply and Sanitation Partnership (RWSSP) in the Ministry of Agriculture and Rural WSP reports are published to communicate the results of WSP's work to the development community. Some sources cited may be informal Development (MARD), and Pham Bich Ngoc, also of the documents that are not readily available. RWSSP, for their continued guidance. Nghiem Thi Duc, IDE's manager of the pilot project, provided valuable documents The findings, interpretations, and conclusions expressed herein are and clarifications. Support from Vinh Thanh Nguyen of WSP entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of is also gratefully acknowledged. Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data Peer-reviewers for this report included Eduardo A. Perez, included in this work. Craig Kullmann, and Christopher Trethewey of WSP, and Pete The map was produced by the Map Design Unit of the World Bank. Kolsky of the World Bank. Their comments were invaluable. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the All photographs used by permission of team members. World Bank Group concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Global Scaling Up Sanitation is a WSP project focused The material in this publication is copyrighted. Requests for permission on learning how to combine the promising approaches of to reproduce portions of it should be sent to wsp@worldbank.org. Community-Led Total Sanitation and Sanitation Marketing WSP encourages the dissemination of its work and will normally grant to generate sanitation demand and strengthen the supply permission promptly. For more information, please visit www.wsp.org. of sanitation products and services at scale, leading to © 2010 Water and Sanitation Program improved health for people in rural areas. It is a large-scale R W S SP Executive Summary Background with the promoters, providers, and some local government From 2003 to 2006, a rural pilot project was conducted in authorities. Interviews were held with district and provin- Vietnam with technical support from the non-governmental cial authorities and at a national level with the NGOs, organization (NGO) International Development Enter- national authorities, and donors involved in rural sanita- prises (IDE) and funding from Danish International Devel- tion. With the help of participatory tools, focus group dis- opment Assistance (DANIDA). The project tested whether cussions were held with sixty-one householders who had a sanitation marketing approach could improve rural access built sanitary toilets or upgraded their unsanitary ones, and to sanitary toilets in 30 communes in six districts of the sixty householders who had either no toilet or a still unsani- coastal provinces of Thanh Hoa and Quang Nam. tary one. Finally, the study team visited a very small and non-random sample of installed toilets to observe the qual- The project trained promotion teams consisting of local ity of construction and hygiene as per the national stan- health workers, Vietnam Women's Union leaders, and village dards of the Ministry of Health. heads, as well as small providers (shopkeepers, producers, and masons). These teams, in turn, promoted sanitary Case Study Findings toilets and helped households to build the type of toilets The trend of increased access to sanitary toilets was sus- they wanted and could afford. The pilot project trained over tained. Average access which in the study sample was 15% 2,000 government staff, Women's Union leaders, small in 2003 (one percentage point lower than in the pilot area entrepreneurs, and trainers. After 3.5 years, over 15,000 as a whole) and grew to 44% in 2006 and to 59% by 2008. households had gained access to a sanitary toilet in the pilot The average annual growth rate of 7.5% equaled that of the area out of 32,000 households targeted. This number was pilot project as a whole, and in the study villages was even 2.5 times the increase achieved under a conventional one percentage point higher. sanitation program conducted in the three preceding years. Average access grew from 16% to 46%. Growth in three of the comparative communes was much lower. In one it was even negative, as the population grew Three years after the end of the pilot program, WSP con- more rapidly than sanitation access. In the fourth no statis- tracted IRC/ADCOM to design and carry out a case study tics could be obtained. to investigate the sustainability of the rural sanitation marketing approach. The main research question was At the end of the pilot project, 16% of the poor households whether the outputs and outcomes had been sustained had built a sanitary toilet, while their proportion in the after the external support had ended. Other research ques- pilot population was 19%. However, the poor-specific tions were used to determine if the approach had spread to monitoring was not sustained. In the case study it was neighboring communes ("spill-over effect"), if the districts impossible to get commune statistics specified for poor and had extended the approach district-wide ("scaling-up non-poor households. It was only possible to note that effect"), and if there were signs of spontaneous marketing overall, access to sanitary toilets increased steadily while the developments ( "parallel development"). The case study percentage of poor households remained the same or varied was conducted in a purposively selected sample of eight over time. communes in four districts of the two provinces. Four matched communes that did not participate in the pilot All but one promoter had continued to promote sanitation but were located in other parts of the same districts served along with their job duties, albeit at a lower intensity and as a comparative group. with fewer methods. The promoters had not received new promotional materials and two-thirds said they had run out Research for the case study took place between June and of pilot project brochures. Interest in toilets had reportedly August 2009. Local sanitation statistics were collected in all remained high, especially among women. However, the sus- study communes. Semi-structured interviews were held tainability of promotion may drop in the future because www.wsp.org iii Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Executive Summary local women leaders and village heads change after three or They reported sharing a toilet with relatives or neighbors or four years and training for their successors was not practicing open defecation. However, many said that in the institutionalized. latter case they used the "cat method" (i.e., defecate in a small hole and then cover the excreta with soil). Local providers had continued to develop their services and customer base and other entrepreneurs had joined when Local authorities in the study communes, districts, and they saw the growing sanitation demand. All but one provinces varied in their willingness and actions to sustain provider had continued to expand their range of goods and rural sanitation marketing after the pilot. In some com- services. Septic tanks were the most popular option with munes, the authorities continued the sanitation steering both customers and providers, raising a concern for the committees, annual sanitation plans, toilet loans, etc. with- future as it is common practice for villagers to empty full out going back to subsidizing toilets. Other communes tanks directly into the environment. had accepted NGO projects with toilet subsidies since the pilot, but said that this was not a real solution as project Virtually all entrepreneurs gave some form of credit to cus- duration was short and the number of households that tomers and some shops also gave credit to masons. On aver- could be assisted was small. The supportive commune gov- age, one-third of the customers bought on credit. There ernments had been convinced by the good results of the were no agreements or collateral; the decision was based on pilot. The less supportive authorities were doubtful about acquaintance and trust. being able to convert the poor and hard-core open defeca- tors, or faced other more urgent constraints--no land Three-quarters of the providers said that they now had more title deeds, industrial solid waste problems, and absence of customers and over half reported a greater business volume. a proper cemetery. Two-thirds said that they made more profit and had higher incomes in the last three years. However, all also provided In three of the four study districts (no interview could be other goods and services and worked seasonally and often conducted in the fourth) the district authorities had sus- part-time in sanitation: the toilet business alone was not tained their positive attitudes. They praised the project enough to live on. strategy; the demand for district commitment; the organ- ization of the program; the professionalization of the Although trained in marketing as part of the pilot, only half communication approach; the increase in awareness, of the providers had continued this practice. None had knowledge and skills of promoters, providers, and con- developed their own leaflets or catalogs. To attract new sumers; the capacities developed in the private sector; the business, they relied on local relationships, networks, and lower cost and better cost-awareness; and the greater their reputation. As part of the pilot, IDE had encouraged access at higher speed that had resulted in less open defe- the formation of provider networks to cooperate on cation and better living environments. Nevertheless, the production, procurement, sales, transport, construction, districts had not continued their support to the study and after-sales services. These networks were sustained and communes after the pilot. They mentioned in particular new ones had been formed. the absence of funding for new promotion materials and training. However, as discussed below, two study districts Satisfaction with services and toilets had remained high had supported scaling up. among householders. The few dissatisfied householders reported clogging, allegedly due to using regular paper While provincial authorities had not been directly involved in instead of toilet paper, and poor quality construction. The the pilot, they praised the project and its good results in a small number of toilets observed and built either during or coastal environment, where poverty and open defecation hab- since the pilot all met the standards of Ministry of Health. its are serious constraints to improving sanitation. They saw two problems for strategy adoption and support province- Those householders without a toilet cited financial concerns wide. The first was paying an incentive for sanitation as the primary reasons they had not installed or upgraded. iv Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Executive Summary promotion to three promoters in all communes. The second similar coverage as the pilot study commune in a little over was promoting no-subsidy toilets and training local masons two years. The highest coverage achieved was 96%; the and shops in the mountainous areas with high rates of district-wide average was 49%. The two other study ethnic minorities. districts did not scale up. At the national level, authorities reported that Vietnam is Conclusions, Lessons, and currently not reaching its rural sanitation targets and that Recommendations adoption of sanitation marketing could help. The Vietnam The case study report includes a series of conclusions, les- Women's Union and donors cooperating in rural sanitation sons learned for replication of the approach in Vietnam and were ready to support with capacity development and fur- elsewhere, and recommendations. Some highlights: ther piloting. They also recommended the development of · Although sanitary toilet promotion by community improved monitoring of access for the poor, and combining health workers, women's leaders, and village heads sanitation marketing with Community-Led Total Sanita- had continued, the lack of budgeting for ongoing tion (CLTS) as piloted in other parts of the country. supply of promotional materials, the lack of training of new promoters and providers, the lack of market The providers reported that households in neighboring research, and the lack of development of a more spe- communes had begun to seek services from them and their cific marketing strategy for the poor may jeopardize networks after the pilot project. They also said that new future sustainability. providers and networks had emerged, which copied their · Service providers and demand for sanitary toilets example and now offered the same services and goods. continued to develop after the pilot project. As long However, without proper user information, training of pro- as this growth was limited, peer learning, instruc- viders and promoters, and toilet follow-up, the same quality tion manuals, and ongoing consumer information of service as in the studied pilot communes was not assured. could ensure an acceptable construction quality and In Nghi Son Economic Development Zone, for example, user satisfaction. An explosion in demand combined which included some of the pilot projects, the quality of with unguided and controlled supply meant that the construction of sanitary models and user satisfaction had good results from private sector involvement were both decreased. Reasons for the decline included: the rapid not sustained. demand increase, the absence of organization and training · The strategy to target especially women through the of the promoters and providers, and monitoring of con- women leaders and the heath workers has worked struction quality by the community health workers that was well in the two provinces. From the interviews with too little and too late without support from trained women the promoters, the providers, and the FGDs, it be- leaders and village heads. came clear that women were the most interested, but that the couple, and sometimes their children, The research of sustainability at institutional levels also re- made decisions jointly and harmoniously. However, vealed that after the pilot project, two of the four study dis- this may be different for other regions in Vietnam tricts had encouraged all other communes in their districts and elsewhere, where agreement on a toilet or bath- to adopt sanitation marketing. In Hau Loc district in Thanh room as an investment priority in rural households Hoa province, the District Steering Committee advocated is lower. the approach to the other communes through exposure · Sanitation marketing has enabled men who visits, but without providing training. The district of Nui worked part-time in sanitation to move out of Thanh in Quang Nam actually scaled up sanitation market- the agriculture and fishery sectors and obtain bet- ing to all 17 communes. The district encouraged the com- ter jobs with more career prospects in small-scale mune staff to promote sanitation and each commune was enterprise. Thus, rural sanitation marketing has able to send some providers for training to the district head- contributed to Vietnam's policy and strategy of quarters. As a result, the other 12 communes achieved rural poverty reduction, albeit without a specific www.wsp.org v Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Executive Summary strategy for gender equity in capacity develop- environment, institutionalized capacity building for ment of the providers. promoters and providers, more regular consumer · Since there is not a formal recognition from the na- studies, further development of promotional mate- tional government and its integration in rural sanita- rials and communication channels, and the design tion strategies and programs is not institutionalized, and testing of a specific strategy enabling the poor to not all commune, district, and provincial govern- install unsubsidized sanitary toilets. ments were ready to replicate the approach and scale · A key lesson was the lack of a good, but sim- it up. Provincial governments, which are the imple- ple sanitation monitoring system. Missing were: menters of the national rural sanitation program, (i) poverty-specific monitoring of toilet access; were especially not ready to shift funds now used for (ii) the combination of data from all the local toilet subsidies in poor regions to building longer- sanitation projects of different government term local toilet promotion and supply capacities. departments and NGOs; (iii) the participation of · A financing strategy for the poor is missing. A more the people in assessing and monitoring the sanitation refined and comprehensive strategy than promoting coverage in their own locations to raise awareness, loans and savings--especially in light of the high motivate change, and enhance validity of the data inflation level, estimated at 8% for 2009--is needed. and transparency of program performance; and · In the long term, the approach used in the pilot study (iv) data aggregation and integration into a single, may not be sustained and expanded without further easy to use computerized and comparative database advocacy for a supportive political and administrative at commune, district, and provincial level. vi Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Abbreviations and Acronyms Abbreviations and Acronyms AusAID Australian Government Overseas Aid Program CERWASS Centre for Rural Water Supply and Rural Environmental Sanitation CHW Community Health Worker CLTS Community-Led Total Sanitation DANIDA Danish International Development Assistance DFID Department for International Development (United Kingdom) FGD Focus Group Discussion GoI Government of India GoVN Government of Vietnam HAPI Hanoi Authority for Planning and Investment IDE International Development Enterprises IEC Information-Education-Communication IPC Inter Personal Communication MARD Ministry of Agriculture and Rural Development MDG Millennium Development Goals MOHA Ministry of Home Affairs MOH Ministry of Health MOLISA Ministry of Labor, Invalids and Social Affairs NCERWASS National Centre for Rural Water Supply and Rural Environmental Sanitation NGO Non-governmental Organization NTP National Target Program ODF Open Defecation Free O&M Operation and Maintenance PDR People's Democratic Republic PRA Participatory Rural Appraisal RC Resource Center RSM Rural Sanitation Marketing RWSSP Rural Water Supply and Sanitation Partnership SAWAP Sanitation and Water Partnership SME Small and Medium Enterprises SNV Netherlands Development Organization ToT Training of Trainers TSSM Total Sanitation and Sanitation Marketing U3SAP Unified Sanitation Sector Strategy and Action Plan UNICEF United Nations Children's Fund VH Village Head (of the hamlet, not the commune) VIP Ventilated Improved Pit VND Viet Nam Dong (national currency) VPD Vietnam Partnership for Development VUFO Vietnam Union of Friendship Organizations VWU Vietnam Women's Union WSMB Water and Sanitation Management Board WSP Water and Sanitation Program www.wsp.org vii Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Table of Contents Table of Contents Executive Summary................................................................... iii Abbreviations and Acronyms ................................................... vii I. Introduction ............................................................................... 1 1.1 Background, Focus, and Objectives .............................. 1 1.2 Rural Sanitation Development in Vietnam ...................... 2 1.3 The Rural Sanitation Marketing Pilot Project .................. 5 1.4 Case Study on the Sustainability of Sanitation Marketing....................................................... 7 II. Design of the Case Study ......................................................... 8 2.1 Case Study Design Process ........................................... 8 2.2 Sample and Methods of Data Collection........................ 8 2.3 Study Limitations ............................................................ 9 III. Sustainability of Increase in Access to Rural Sanitation ....... 11 3.1 Toilet Construction in the Case Study Area .................. 11 3.2 Coverage in the Individual Study Communes .............. 12 3.3 Comparison with Non-Project Communes................... 12 3.4 Installation by Poor Households ................................... 14 IV. Continuation of Sanitary Toilet Promotion ............................. 16 4.1 Promotion During the Pilot Project ............................... 16 4.2 Continuation of Sanitation Promotion After the Pilot ... 17 4.3 Availability of Promotion Materials After the Pilot ........ 20 4.4 Future Sustainability of Sanitation Promotion .............. 20 4.5 Sustainability of Constructed Toilets ............................ 20 4.6 Replicability of Promotion in Other Parts of Vietnam ... 21 V. Sustainability of Sanitation Supply Services.......................... 22 5.1 Existing and New Providers.......................................... 22 5.2 Range and Development of Services ........................... 22 5.3 Types of Toilets Sold and Installed ............................... 24 5.4 Gender Roles ................................................................ 25 5.5 Sanitation Promotion by the Providers ......................... 25 5.6 Sales, Income, and Types of Customers ...................... 26 5.7 Provider Networks ........................................................ 26 5.8 Types of Credit.............................................................. 27 5.9 Providers' Origins and New Career Opportunities ....... 28 VI. Household Perspectives on Sanitary Toilets .......................... 29 6.1 Households Who Built a Toilet During and After the Pilot .......................................................... 29 6.2 Households Without a Sanitary Toilet ........................... 31 viii Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Table of Contents 6.3 Observed Quality of Toilet Construction and Hygiene .... 34 6.4 Views of the Toilet Owners ........................................... 35 VII. Support from the Stakeholder Institutions ............................. 36 7.1 Support of Sanitation Marketing by Communes .......... 36 7.2 Sustainability of No Subsidy Approach ........................ 38 7.3 District Views on Effectiveness and Sustainability ....... 39 7.4 Perceptions of the Provincial Sector Authorities .......... 40 7.5 Environmental Sustainability of the Approach .............. 42 7.6 Perceptions at Country Level ....................................... 43 VIII. Scaling Up the Approach ........................................................ 47 8.1 Spill-Over and Parallel Development ............................ 47 8.2 Scaling Up District-Wide .............................................. 47 8.3 Impacts from Parallel Development and Scaling Up ..... 48 IX. Conclusions, Lessons, and Recommendations..................... 51 9.1 Conclusions on Sustainability of Results and Approach ............................................................... 51 9.2 Lessons Learned for Vietnam ....................................... 53 9.3 Recommendations for Further Development in Vietnam ..................................................................... 54 9.4 Lessons for Wider Application and in Other Countries ...................................................................... 56 Annexes 1: Terms of Reference....................................................... 63 2: Composition of the Study Team ................................... 68 3: Participants and Feedback, First Consultative Meeting ......................................................................... 69 4: Participants, Second Consultative Meeting ................. 71 5: Functionaries Interviewed............................................. 73 6: Quality Standards for Sanitary Toilets, Ministry of Health Vietnam ............................................................. 74 References ............................................................................................ 76 Figures 1: Access to Clean Water and Sanitary Toilets in Rural Areas Before and After NTP I ................................ 4 2: Location of Pilot Area ..................................................... 5 3: Number of Sanitary Toilets Built Per Year Before and During Pilot .............................................................. 7 4: Interview with Provider ................................................... 9 5: Sanitation Statistics Were Not Always Available .......... 10 6: Increase in Sanitation Coverage in the Study Sample During and After Pilot ...................................... 11 7: Difference in Sanitation Coverage in Study Communes in Thanh Hoa and Quang Nam ................ 11 www.wsp.org ix Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Table of Contents 8: Evolution of Sanitation Coverage in Individual Study Communes Over Time ....................................... 12 9: Incremental Sanitation Coverage in Study Communes During and After Pilot ................................ 12 10: Evolution of Sanitation Coverage in the Study Sample and Three Comparative Communes ............... 14 11: Changes in Poverty Levels and Sanitation Access in Study Communes During and After Pilot in Thanh Hoa Province ..................................................... 15 12: Changes in Poverty Levels and Sanitation Access in Study Communes During and After Pilot in Quang Nam Province ............................................................... 15 13: Sanitation Leaflet .......................................................... 16 14: Handwashing Leaflet .................................................... 18 15: Number of Promoters Mentioning Activities Carried Out During and After Pilot ............................................ 19 16: Pre-Cast Rings for (Semi) Septic Tanks........................ 20 17: Observed Toilet Hygiene and Hygiene Implements...... 21 18: Owner Shows Large, Shiny Toilet ................................. 21 19: Providers Adjusted to New Demands, Such as Seat-Type Toilets .......................................................... 23 20: Demand Increased for Septic Tanks and Full Bathrooms ............................................................. 24 21: Interview of Female Provider ........................................ 25 22: Number of Providers Who Reported Promoting Sanitation, by Methods Used ....................................... 25 23: Number of Providers Who Reported Providing Different Types of Credit to Customers ........................ 27 24: FGD Participants Who Built Toilets During and After Pilot, by Information Source ......................................... 29 25: Grandfather Helps Grandson Use the Toilet................. 35 26: Interview with Commune Leader .................................. 36 27: Coastal Communes Not Effectively Mobilized in the Past. .................................................................... 41 28: In Thanh Hoa, the Health Department Had Concerns about Excreta Disposal and Reuse .............................. 43 29: Tinh Gia Coastal Area with Nghi Son Economic Zone.... 47 30: Interview of District Leader ........................................... 48 31: Effects of Scaling Up District-Wide in Nui Thanh District ............................................................... 48 Tables 1: Estimated Amounts and Sources of Funding for RWSS Under NTP I (in Million VND) ............................... 2 2: Access to Clean Water and Sanitation in Rural Regions in December 2005 ............................................ 5 x Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Table of Contents 3: Cost Reduction of Toilet Models Offered Under Pilot, by Household (in USD) ................................................... 6 4: Indicators Used to Select the Case Study Sample ........ 8 5: Composition of the Case Study, by Type of Performance During Pilot ............................................... 9 6: Comparison of the Study and Comparative Sample .... 13 7: Most Cited Sources of Information about Toilets ......... 29 8: Arrangements of FGD Participants for Toilet Construction During and After Pilot.............................. 30 9: Reasons Households Gave for Building a Toilet During and After Pilot ....................................... 31 10: Sources of Information on Toilets Given by Those Who Had Not Yet Built a Toilet...................... 32 11: Places of Defecation Given by FGD Participants Without Sanitary Toilet .................................................. 32 12: Preferred Financing Options for Households With a Toilet .................................................................. 33 13: Topics on Which FGD Participants Without Sanitary Toilet Wanted More Information.................................... 34 14: Number of Toilets with Observed Quality Built During and After Pilot, and Mason Training ............................. 34 15: Observed Meeting of MOH Standards for Toilets Built During and After Pilot ................................................... 35 16: Commune Activities to Support Sanitation Marketing ..................................................................... 37 Boxes 1: Opportunities and Limitations of Rural Credit for Sanitation in Vietnam................................................. 3 2: Sanitation Leaflet, English Translation .......................... 17 3: Handwashing Leaflet, English Translation .................... 18 4: Open Defecation and "Treasured Possession" ............ 21 5: Rural Sanitation Marketing Provides Career Opportunity: From Farmer to Entrepreneur .................. 28 6: Cultural Household, Village, Commune, Communal Health Station, and District........................................... 37 7: A District Leader's Vision to Improve Sanitation in Nui Thanh District ............................................................... 49 8: Transparent, Accountable, and Locally-Specific Toilet Subsidy for the Very Poor ............................................. 55 www.wsp.org xi I. Introduction 1.1 Background, Focus, and Objectives during the three years after the completion of the pilot proj- This case study of the sustainability of rural sanitation mar- ect. Other objectives were: keting is part of a wider activity entitled "Total Sanitation · To investigate whether the approach had spread to and Sanitation Marketing (TSSM): New Approaches to neighboring communes ("spill-over effects") and if Stimulate and Scale Up Sanitation Demand and Supply any spontaneous sanitation marketing development Project," also known as the Global Scaling Up Sanitation ("parallel development") had occurred in other areas; Project. The long-term vision for this effort is to help a · To capture lessons on sustainability, replicability, and number of developing countries meet the basic sanitation scaling up about the approach under the national needs of the rural poor who do not currently have access to rural sanitation program in Vietnam; and safe and hygienic sanitation. TSSM tests proven and promising · To learn lessons for sanitation programs in India, approaches to create demand for sanitation and improve the Indonesia and Tanzania (the TSSM focus countries) supply of sanitation-related products and services to increase and in Cambodia, Lao PDR, and Southern China household access to safe and sustainable sanitation; create under the Sanitation and Water Partnership for the open-defecation free communities; and promote improved Mekong Region (SAWAP), taking into account the hygiene practices. Though not one of the TSSM focus coun- socio-cultural, economic and political differences tries, Vietnam is one of the countries where a piloted ap- with rural Vietnam. proach to enhance and meet rural sanitation demands has had promising results. After reporting on the case study design and the methods of data collection in Chapter 2, subsequent chapters (3­8) The piloting of a new approach to creating and meeting address the following research questions: rural sanitation demands took place in the context of a · Have the pilot communes sustained the increase in changing national rural sanitation policy and program. In access to sanitary toilets that they achieved during 1998, the Socialistic Republic of Vietnam had formulated the pilot projects? (Chapter 3) a new policy, strategy, and program to meet the Millen- · Have differences in results between individual com- nium Development Goals (MDG) and national targets in munes increased, decreased, or remained the same, relation to access to improved water supply and sanitation and why? (Chapter 3) in rural areas. However, while the access to improved · Have the underlying sanitation promotion activities rural water supply increased rapidly, progress in rural san- been sustained after the end of the pilot project or itation lagged behind, making national target achieve- not, and for which reasons? Which changes have ment less likely. A three-year pilot project was therefore occurred and why and to which effects? (Chapter 4) undertaken in 2003 to test if the use of sanitation market- · Has the local private sector sustained its service de- ing could improve of rural households' access to sanitary livery after the end of the pilot project or not, and toilets. for which reasons? Which changes have occurred, why and to which effects? (Chapter 5) Three years after the completion of this pilot project, a case · How satisfied are the users with the rural sanitation study was undertaken to determine to what degree the ap- marketing approach, the services and the products, proaches and results of the pilot project had been sustained. and what, if any, are the user problems? (Chapter 6) The overall purpose of the study was to assess and docu- · Have some households not yet installed sanitary toi- ment how well the approach and results have been sustained lets or upgraded unsanitary ones, and if so, why not? www.wsp.org 1 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Introduction What could be done better to achieve sanitary toilet programs, the National Target Program I (NTP I) from use and freedom from open defecation for all? How 1999 to 2005 (GoVN 1998) and NTP II from 2006 to sustainable and sustained are the installed toilets 2010 (GoVN 2006, MARD 2005). The rural sanitation themselves? (Chapter 6) targets for 2010 are: · To what extent have the authorities in the institu- · 70% of rural households use sanitary toilets and tions, from commune to national level, continued have good sanitary practices; to support the rural sanitation marketing approach? · 70% of the farmers and animal raising households What is their willingness to support this approach in in rural areas use sanitary animal husbandry facilities future? (Chapter 7) and practices; · And finally, have the marketing approach and results · All kindergartens, schools, health stations, markets, spread to other communes and districts? Has there district head offices and other public offices in rural been a natural "spill-over effect" to neighboring areas have enough clean water and sanitary toilets; communes? And have similar processes developed · Environmental pollution from rural industries, espe- independently from the pilot project ("parallel cially related to food and food processing is reduced. development")? Have the pilot districts themselves scaled up the approach to a district-wide approach or By 2020, all rural households are to have sanitary toilets not, and why? Are there any observed impacts from and good sanitary practices and keep the surrounding envi- this scaling up? (Chapter 8) ronment clean (MARD 2000, emphasis added). Before presenting the study design in Chapter 2 and at- Under the new policy, rural water supply and sanitation ser- tempting to answer these research questions in detail in vices are community-managed and will be planned and Chapters 3­8 and arrive at the conclusions, lessons, and implemented with participatory methods. The strategy fol- recommendations in Chapter 9, the remainder of this lows a demand-based approach, in which the users: (i) de- chapter briefly summarizes the rural sanitation context in cide on the type of rural water supply and sanitation Vietnam and the history and achievements of the pilot facilities they want and will pay for; (ii) finance the con- project. struction costs and either hire the contractors themselves or do their own construction; (iii) are fully responsible for the 1.2 Rural Sanitation Development operation and management of the facilities. Behavior in Vietnam change will be promoted through awareness raising and According to the National Bureau of Statistics, the rural capacity building. Information-Education-Communication population of Vietnam numbered 61.7 million people in (IEC) programs must also be added to introduce the tech- 2007, 73% of the total population. In 1998 only 24% had nology and design options, the operation, management and sanitary toilets. The government of Vietnam (GoVN) financing mechanisms, and opportunities for credit to help therefore adopted a new sector strategy (GoVN 2000), users make the right decisions. Table 1 gives the financing financing policy (Ministry of Agriculture and Rural of NTP I. Unfortunately there is no separate data on Development (MARD) 2003) and two new national sanitation. TABLE 1: ESTIMATED AMOUNTS AND SOURCES OF FUNDING FOR RWSS UNDER NTP I (IN MILLION VND) Sources of International People's Credit by Funding Central Budget Other Budgets Assistance Self-Investments Households Total Amount 1,420,000 1,221,585 1,008,600 2,518,702 323,863 6,492,750 % of total 22 19 16 38 5 100 Source: CERWASS 2006. 2 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Introduction The table does show that the largest share of financing of As part of the donor cooperation program, the Department water and sanitation facilities (43%) comes from the users, for International Development, United Kingdom (DFID) through direct investments (38%) and loans (5%). For in- commissioned a study (Folkard 2009a,b) as part of a plan ternational assistance, MARD has signed an agreement to target rural loans for improved water and sanitation to with a group of 16 donors (MARD 2006). poor communities and households. Financially, user households must, in principle, pay all costs Other characteristics of the new sanitation sector policy and of construction, operation and maintenance. However, the program are the mobilization and organization of the com- Government will help households and organizations that munes for participation, the possibility of private sector need loans to build or upgrade water and sanitation facili- participation and the adoption of three toilet models. They ties. Very poor households, families with harsh living condi- are the double vault composting toilet, the septic tank tions and other special cases, can get 25% of their investment toilet, and single vault pour-flush water-seal toilet. costs through government finance. Free material or cash subsidies have been abolished, except when targeted at the The promotion of sanitary toilets and toilet hygiene and the above-mentioned categories. The use of credit is common control of their quality are the responsibility of the Depart- in rural Vietnam, but the social loans programs have a low ment of Preventive Health in the Ministry of Health. The sustainability and the main program does not reach the national women's movement, the Vietnam Women's Union ultra poor (Box 1). (VWU), also promotes sanitary toilets and good hygiene BOX 1: OPPORTUNITIES AND LIMITATIONS OF RURAL CREDIT FOR SANITATION IN VIETNAM Credit to finance sanitation with a favorable interest rate (0.5%/month) is available for rural populations under Decision No.62/2004QÐ-TTg by the Prime Minister. The portfolio of sanitation and water loans of the Viet- nam Bank for Social Policy is 7% (Folkard 2009a). Beside bank loans, people take loans from relatives and friends, buy on credit, and borrow from moneylenders. Moneylenders charge very high interest rates. How- ever, the monthly interest from various social banks (0.5­2%) is too low to cover the costs. As a result, the loan funds are not self-sustainable and services cannot be expanded to new clients without extra capital injections. Other restricting factors are high bureaucratic requirements and transaction costs, loan management problems in the institutions, and preference of users to take loans for productive, rather than consumptive use (Tran undated). In a study on water and sanitation loans taken by 12 rural communes in each of three provinces from the Vietnam Bank for Social Policy, about half of the loan takers had an income below the national poverty line. However, those in the lowest income bracket (<200,000 VND per capita/month) were underrepresented. Furthermore, the researchers found that the willingness to take a latrine loan at an interest rate covering the real costs fell with increasing loan size. Based on extrapolation, over 7.4 million rural households were estimated to be interested in a loan of one million VND (56 USD) and 78% were ready to pay the real interest costs of 2.9%. This dropped to 2.7 million households and a 28% willingness to pay a real interest rate when the loan value increased to four million VND (225 USD). Many households also took a combined loan for sanitation and water supply up to the maximum of 8 million VND. The average amount of such a loan was 6 million VND. This amount and the duration of the loans were twice what was planned and budgeted, which further decreased the sustainability of the loan fund. It was also fairly common that households diverted part of their toilet loan to other uses (Folkard 2009a). www.wsp.org 3 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Introduction practices. In 1998, the VWU organized a Training of Trainers (ToT) to make this promotion more effective (Bolt FIGURE 1: ACCESS TO CLEAN WATER AND SANITARY TOILETS IN RURAL AREAS BEFORE AND AFTER NTP I 1998). In 2002, one of the developers of the PHAST meth- odology1, Ron Sawyer advised the MOH on using more 70 participatory methods and visual stimuli to enhance sanita- 60 tion and hygiene knowledge, practices and demand and organized community action. As a result, the MOH in co- 50 operation with the Vietnam Partnership for Development 40 decided to encourage the water and sanitation sector to in- 30 troduce participatory hygiene promotion in their programs 20 (VDP 2003). 10 In 2003, Vietnam adopted new guidelines for Informa- 0 tion-Education-Communication (IEC) on clean water 1998 2005 supply and safe sanitation and hygiene. The guidelines Water Sanitation included training at all levels, but especially for local civil servants, on diversification of messages and channels, the Source: GoVN 2006 use of participatory methods, dissemination of good models and practices, and resource allocation. A pilot NTP I greatly increased rural access to improved water sup- program conducted in four provinces from 2001 to 2006 ply and sanitation. Access to improved water supplies grew showed that the program made most communes and 28% in 1998 to 62% in 2005, an increase of 34% or almost leaders adopt participatory and demand-responsive proj- 5% per year (Figure 1). Reaching the target in 2020 is fea- ects (Nguyen and Stoltz undated). However, as of 2003, sible (GoVN et al. 2006). application at larger scale had not yet started (CERWASS 2003). Access to sanitary toilets also increased, but less rapidly. Out of a total of 12.8 million rural households, around 6.4 mil- External support to rural sanitation has so far come lion households had a sanitary toilet by the end of 2005. The mainly from Danish International Development Assis- total increase was 26 percentage points, from 24% in 1998 to tance (DANIDA). The agency finances a senior advisor to 50% in 2005. However, compared with the 4.9 percentage NTP II in the Ministry of Health and supports piloting of point annual growth in access to an improved water supply, new approaches, including the pilot project that is the the 3.7 percentage point annual growth in access to sanitary subject of this study. Many NGOs also support rural sani- toilets has been more modest. tation. Most have partnered with local government (the People's Committees) at provincial, district, and commune However, actual access varies considerably across the coun- level (Vietnam Union of Friendship Organizations try. Table 2 shows that out of seven regions, access to an (VUFO) and NGO-Resource Center (RC) 2005). So far, improved water supply is below the national average of the different approaches and results have not been 67% in four regions, while access to improved sanitation is compared. A unification of approaches on national policy below the national average of 50% in three regions. has therefore been proposed, especially with regard to subsidies for poor households, which may be as high as Furthermore, access was still worse amongst the poor: "The 50%, twice as much as adopted under the new policy poorest 20% are 35 times less likely to have hygienic latrines (GoVN et al. 2006: Annex p. 74). than the richest 20%" (GoVN et al. 2006: 10). 1 Participatory Hygiene and Sanitation Transformation 4 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Introduction TABLE 2: ACCESS TO CLEAN WATER AND SANITATION IN RURAL REGIONS IN DECEMBER 2005 FIGURE 2: LOCATION OF PILOT AREA % Access % Access to Clean to Sanitary Region Water Toilets CHINA Nine Dragons River Delta Region 66 35 Red River Delta Region 66 65 South East Region 68 62 HANOI Highlands Region 52 39 LAO Northern Mountains 56 38 PEOPLE'S Thanh Hoa Middle and South Sea Coast Region 57 50 DEM. REP. East North Region/Middle North 61 56 National Average 62 50 Source: GoVN 2006 Quang Nam THAILAND Because of the slower increase in rural sanitation, a pilot project was therefore started in two provinces to test if a rural sanitation marketing approach could enhance access to sanitary toilets. The approach and results of this project CAMBODIA are summarized in the next section. 1.3 The Rural Sanitation Marketing Pilot Project IDE, or International Development Enterprises, is a non- profit organization, which uses business principles and un- subsidized markets to help poor rural households sell their products and services better, and so reduce their poverty. IDE has been active in Vietnam since 1991. The Vietnam branch has six offices and 30 staff members. IDE undertook four major activities: · Assessment of the rural toilet market. IDE studied: From January 2003 to December 2006, with a six-month where rural households bought toilets, materials, and gap in 2005, IDE carried out a pilot project on rural sanita- services and for which reasons; who in the household tion marketing in 30 communes in six districts of two prov- decided on sanitary toilets; which types of toilets inces, Thanh Hoa and Quang Nam (Figure 2). Both are customers wanted and could afford and which types coastal and have above-average poverty levels, but no ethnic were available at which costs; when the demand was minorities. The pilot communes had a total population of highest, and which gaps, constraints, and opportuni- 270,000 or almost 54,000 families. Of these, 16% had san- ties existed in the rural sanitation market. itary toilets, 24% unsanitary toilets and 60% no toilet be- · Offering households a greater toilet choice at lower fore the pilot project began. Poor households constituted costs. Before NTP I, the Vietnamese standard models 19% of the population at that time (IDE 2006). The aim of for sanitary toilets were the double vault composting the pilot project was to test if it were possible to increase toilet and the septic tank toilet. Construction costs and accelerate the growth of sanitation coverage without were high (Table 3) and masons were not trained providing household subsidies by enlarging the demand for quality construction at lower overall costs. Under and improving the supply for sanitary toilets. the pilot project, households got a choice of four www.wsp.org 5 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Introduction TABLE 3: COST REDUCTION OF TOILET MODELS OFFERED UNDER PILOT, BY HOUSEHOLD (IN USD) Average Cost Under Pilot Project Type of Toilet Pre-Pilot Cost (Dec '02) (adjusted to Dec '02) (Adjusted)2 June '06 (Actual) Double vault composting toilet $ 52.20 $ 58 Single vault pour-flush toilet $ 65 $ 58.50 $ 65 Semi-septic tank toilet $ 63.90 $ 71 Septic tank toilet $ 150­200 $ 87.30 $ 97 Source: Frias and Mukherjee 2005, IDE 2006. 2 USD1 in 2006 was equivalent to USD0.90 in 2002 models: single-vault, pour-flush toilets, semi-septic included direct single vault pour-flush toilets, ven- tank and septic tank. IDE also modified designs and tilated improved pit (VIP) toilets, semi-septic tank material options to reduce the indicative costs of toilets, and toilet upgrading. these models (Table 3). · Construction of a local model to determine con- · Training local sanitation providers. In each pilot struction costs when using as many local and lower- commune, IDE selected shops and masons to par- cost materials as possible. ticipate in the project. They learned how to procure · Users' choice of the toilet model. Households make stock and sell all materials for the new models and an informed choice of the type of toilet they will build the new toilets. The latter included making ad- build, the design of the superstructure, the speed of justments to materials and designs that lowered costs, construction, the amount they will spend, and the but left essential technical specifications unchanged. method of financing. · Training local toilet promoters. IDE trained three · Emphasis beyond toilet construction. The local pro- promoters in each pilot commune to promote sani- moters also promoted good hygiene practices: no tary toilets: the local women's leader from the Viet- more open defecation, hygienic toilet use, and hand- nam Women's Union (VWU), the Village Head washing with soap at critical times. (VH) and the Community Health Worker (CHW). · Diversification of local services. The private sector They promoted the toilets through village meetings, was trained on local production, goods supply, con- group meetings, home visits, the local media (such struction, and networking to meet locally-specific as messages over the commune loudspeaker system service demands (IDE 2005). and articles in the local press), and distribution of informational materials (leaflets). IDE prepared and The results of the pilot project can be summarized as follows: distributed the materials to the communes, but the · As shown in Table 3, the estimated cost of the toilet CHW, VWU leader and VH prepared the scripts models is reduced substantially, although the actual for the loudspeaker messages (IDE 2003, 2006). cost is locally specific and contingent on negotia- tions between customer and provider; There were several major differences from the existing toilet · Some 2,000 persons were trained, including the programs: members of the district and commune steering · No toilet subsidies to individual households. All pro- committees and project-related civil servants and gram financing went to market development, train- authorities at provincial level, 120 district trainers, ing and monitoring, and project support services by 723 village promoters, and 750 local masons and the NGO. The participating households paid the full shopkeepers; direct construction costs of their toilet. Staff costs · Between January 2003 and June 2006, households were borne by the respective departments/union. in the 30 pilot communes constructed or upgraded · An even wider range of toilet options. Besides the 15,149 toilets, an average of 3,787 toilets per year. three options mentioned in Section 1.3, these also This was 2.5 times the average number of 1,522 6 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Introduction pilot project was over 16.000 toilets. When based on the FIGURE 3: NUMBER OF SANITARY TOILETS BUILT PER YEAR BEFORE AND DURING PILOT actual number of months of support from IDE (34), the average monthly construction was almost four times the 8,000 comparative output of the government program during the 7,000 7,029 preceding three years. 6,000 Poor households installed sanitary toilets less easily than the Number Built 5,000 4,257 3,869 intermediate-level and better-off households. While 19% of 4,000 the households in the pilot communes were poor, their rep- 3,000 resentation among the total of those building toilets was 2,000 1,522 1,574 16% (Nghiem 2009). 1,000 0 Average 2003 2004 Jan.­Jun. Jan.­Jun. The above results were achieved with an investment of 2000­2002 2005 2006 USD33 (546,249 VND) per toilet for project support Period costs, excluding the initial research and development and Before Pilot Project During Pilot Project start-up costs. Households themselves spent on average the equivalent of USD65 (1,075,945 VND), an investment Source: MARD 2004 and data adjusted from IDE statistics and interview with ratio of 2:1. However, their actual investments depended IDE Pilot Project Coordinator greatly on the type of toilet built. toilets constructed per year in 2000­2002 under the 1.4 Case Study on the Sustainability existing conventional program. of Sanitation Marketing Three after the completion of the pilot project, the World Figure 3 shows the construction progress over time. The out- Bank's Water and Sanitation Program (WSP) commis- put was still limited in 2003, because until August of that sioned a case study to investigate the sustainability of the year the focus was on research, organization, and training. approach and its effects. Actual construction only covered four months from Septem- ber to December 2003. Outputs increased rapidly in 2004. The overall purpose was to assess and document how well As Figure 3 illustrates, they were four times the average out- the approach and results have been sustained during the put of the conventional program in the preceding three three years following completion of the pilot project. Other years. The lower outputs in 2005 reflect the gap between objectives were: Phase I and Phase II, when support from IDE stopped tem- · To investigate whether any spontaneous sanitation porarily. In 2006, the outputs are also lower than in 2004, marketing development ("parallel development") because they are for the first six months only, after which have occurred in other areas; IDE ended the monitoring support. · To capture lessons on sustainability, replicability and scaling up of the approach under the national rural After the interval between Phase I and II, toilet construc- sanitation program in Vietnam; and tion accelerated again in the second half of 2005 and the · To learn lessons for sanitation programs in India, first half of 2006, until it reached a peak of 1,999 toilets in Indonesia and Tanzania and in Cambodia, Lao PDR the last quarter of 2006 (not shown in Figure 3). By the and Southern China under the Sanitation and Water time that the pilot project ended, construction was almost Partnership for the Mekong Region (SAWAP), tak- back at the previous rate, with 1,902 households financing ing into account the socio-cultural, economic and and building sanitary toilets in the second quarter of 2006 political differences with rural Vietnam. (data not in the figure above). Overall, and including the number of upgraded toilets, the recorded output of the Annex 1 contains the Terms of Reference for the study. www.wsp.org 7 II. Design of the Case Study Before going into the findings of the case study on the sus- agencies involved in rural sanitation. At this meeting, on tainability of rural sanitation marketing, this chapter de- the 6th March 2009, the team presented the draft design scribes the case study design process, the design itself and and methodology of the study in English and Vietnamese. the limitations of the study. The major results of the case Annex 3 contains the list of participants. This generated study are given in the next chapter. valuable comments and suggestions from the participants, which have been summarized in Annex 4. Annex 5 contains 2.1 Case Study Design Process the list of participants of the second meeting with the na- A team of four specialists in sanitation, community devel- tional and provincial stakeholders to present and discuss the opment and communication, marketing and economics, findings of the field study and the preliminary conclusions and engineering prepared the design of the case study and and recommendations. collected and analyzed the data. Six other social specialists assisted in the field implementation. The composition of 2.2 Sample and Methods of Data Collection the team is given in Annex 2. The case study was carried out in eight pilot project com- munes in four of the six districts in Than Hoa and Quang After review by WSP, the draft design was presented for a Nam province (Figure 2) and in two non-project com- wider review to a Consultative Meeting organized by the munes in each province. A two-step purposive sampling ap- Coordination Unit of the Rural Water and Sanitation Part- proach was followed to get a good cross-section of study nership (RWSSP) of the Ministry of Agriculture. Other locations. To look also at other performance criteria than participants besides the members of the RWSSP (a partner- just output, the team used seven indicators to identify a ship of the Government of Vietnam and 14 donor agencies) cross-section of communes which had performed better were representatives of relevant Vietnamese departments and less well on these indicators during the pilot period. and organizations and of international NGOs and other They are listed in Table 4. TABLE 4: INDICATORS USED TO SELECT THE CASE STUDY SAMPLE # Indicator Description 1 Performance prior to the pilot Degree of progress in % access to sanitary toilets during the three years preceding project the pilot project (2000­2002) 2 Performance during the pilot Degree of progress in % access to sanitary toilets during the four years of the pilot project project (2003­2006) 3 Comparative growth The relative growth in % access to sanitary toilets under the pilot project as compared to that under the preceding program 4 Upkeep of growth during the pilot Degree to which the districts and communes continued their progress in % access project hiatus to sanitary toilets in the six months between Phase I and Phase II of the pilot project, when support from IDE had stopped 5 Speed in recovery of their growth The speed in which the communes had recovered their growth in % access from after the pilot project hiatus before the hiatus 6 The relative increase in % toilet The degree to which communes have sustained their growth in % access to sanitary coverage over time toilets during these five years (lowest performance = 100) 7 Access for the poor % poor households in each commune which have installed a sanitary toilet 8 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Design of the Case Study TABLE 5: COMPOSITION OF THE CASE STUDY, BY TYPE OF PERFORMANCE DURING PILOT Province Thanh Hoa Quang Nam Hau Loc District: Hai Loc: "better" Nui Thanh Tam Anh Nam: "better" Project "better" My Loc: "less" "better" Tam Hoa: "less" Districts Tinh Gia District: Hai Thanh: "better" Thang Binh Binh Trieu: "better" "less" Tinh Hai: "less" "less" Binh Hai: "less" Non-Project Hau Loc Minh Loc Nui Thanh Tam Hiep Districts Tinh Gia Binh Minh Thang Binh Binh Tu The list of study districts and communes that emerged from FIGURE 4: INTERVIEW WITH PROVIDER this selection process is given in Table 5. They have been labeled "better" and "less," because none did best or worst on all seven indicators. For example, those with the highest score on % access did not necessarily also have the highest increase in % access or the highest % access for poor house- holds. The table also contains the non-project villages, which were visited to find out more about sanitation perfor- mance without the support of rural sanitation marketing. Information on the sustainability of the approaches and results was collected through the following research meth- ods (see Annex 5 for the list of functionaries interviewed): · Qualitative information collection from providers · Review of project documents, records and project- and district authorities on "natural spill-over" of related literature the approach to neighboring communes and on any · Collection and review of commune statistics from vari- similar processes that have developed independently ous sources on the population, number of households, from the pilot project ("parallel development"). and number of households with sanitary, unsanitary, and no toilets in the pilot and control communes The study began in the last week of February 2009 with the · Semi-structured interviews with IDE and other desk study and the design of the field study. Interviews at stakeholders at national level national level began in May 2009. They were followed by · Semi-structured interviews with the promoters and the fieldwork in June and the first part of July. Data analysis providers in the eight study communes (Figure 4) and the remaining interviews at the national level were car- · Semi-structured interviews with district officials ried out in the second half of July. This allowed sharing in relevant positions (local government, Vietnam preliminary information from the field study when discuss- Women's Union, and Preventive Health Department) ing potentials for replication and scaling up. · Eight focus group discussions with householders who had built a sanitary toilet either during or after 2.3 Study Limitations the pilot project, and eight with householders who As with all research studies, this case study has some limita- had no, or unsanitary, toilets and had not yet built a tions. They are highlighted here. sanitary toilet · Structured observations of 28 household toilets on Representativeness. Both the size and composition of the their quality of construction, use and hygiene, and pilot project--30 communes in six out of 553 districts and questions about patterns of use and disposal of two out of 63 provinces (Government of Vietnam 2009)-- children's stools and of the study--eight communes, four districts, and two www.wsp.org 9 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Design of the Case Study provinces--are not representative of the whole of rural FIGURE 5: SANITATION STATISTICS WERE NOT Vietnam. The findings from the study can therefore not be ALWAYS AVAILABLE generalized for the whole country. At the same time, the study sample can be taken as a cross-section for the whole pilot project area because of the balance between com- munes and districts with better and less good sanitation program indicators. Thus, while the findings are not repre- sentative for the country, they can be considered representa- tive for the pilot project. Another factor with a potential effect on the representative- ness of the findings was that the study did not include in- terviews with providers who had taken part in the pilot project, but had stopped working in sanitation since the project ended. However, no evidence of such dropping out was found. Both promoters and providers were asked if they knew about any people who had stopped. This was not the case in any commune, and 14 of the 23 promoters said that only new providers had come. Reliability. It should be taken into account that when asking the participants about their experiences and motivations, a period of between three and six years has passed between their participation in pilot project and the time of the inter- view. This passage of time may have influenced the accuracy of the information and the reliability of the findings. A fur- ther shortcoming was that the interview and FGD sched- ules were not pre-tested. With hindsight, the pre-tests, but it has been explained in the text. A final limitation was the especially the analysis of their results, could have led to lack of data on % access to toilets in the two comparative adjustments that would have increased recall and the reli- communes in Quang Nam province. In Tan Hiep, no data ability of the data. was available at all. In Binh Tu only for 2008. Data availability. A major limitation to the study was the Before the study could start, the local authorities had to be limited availability of project records: due to a computer informed about the purpose and nature of the study. This crash IDE had lost part of its financial and field data. It also was also necessary to dispel any notions that a new sanita- proved to be very difficult to collect reliable statistics on tion project was about to be implemented. This informa- toilet coverage for all 30 pilot project communes and three tion may have influenced some to present a rosier picture, non-project communes (Figure 5). Data was obtained from so as to appear in a good light, and others a gloomier one different sources, such as the commune vice chairmen, in the hope of getting support once again. The experiences commune statistical officer, and the head of the Health in the interviews and FGDs do not support this, however. Post, but they were frequently incomplete or internally con- For example, many households who had not yet built a flicting and much effort was needed to resolve these prob- sanitary toilet suggested other solutions to financing than a lems to the best extent possible. Where this was not possible, program subsidy. 10 Global Scaling Up Sanitation III. Sustainability of Increase in Access to Rural Sanitation In this chapter, the main results of the case study are pre- 2006) to 59% (at the end of 2008). This is an increase of sented. First, it is reported to what extent the results of the 15 percentage points in two years or 7.5 percentage points pilot project have been sustained in the sample as a whole. per year. This means that the local stakeholders in the study This is followed by the results in the individual case study sample have sustained the average annual growth rate in villages and the differences between them. The develop- sanitation coverage of 7.5 percentage points from the pilot ment in the case study sample is then compared with what project in all 30 communes, and have surpassed by 1.1 per- happened in the comparative communes without pilot. centage point the average growth in their own group. As And finally, the chapter discusses the topic of sustained ac- mentioned in the paragraph above, this growth averaged cess increase for the poor. 6.4 percentage points per year and after the pilot increased to an average growth of 7.5 percentage points per year. 3.1 Toilet Construction in the Case Study Area Province-wise, the rate of growth has been higher in the The statistics on population and toilet ownership collected in study communes in Thanh Hoa province than Quang Nam the study communes during the case study showed that in province. This is shown Figure 7 and Figure 8. However, the two full years after the pilot project ended, the increase in the 62% coverage in 2008 in the rural sanitation marketing sanitary toilet coverage in the study area has been sustained. study communes in Thanh Hoa province is still below the Figure 6 gives the overall picture for the eight case study com- 75% coverage given in the national statistics (RWSSP munes. During the pilot project, coverage in this sample in- unpublished data). creased from 18% to 44%, an increase of 26 percentage points in four years, or 6.4 percentage points per year. For Quang Nam province, the coverage in the study com- munes in 2008 (38%) is slightly above the provincial aver- Review of the study commune statistics showed that after age of 37% (RWSSP unpublished data). IDE's support had ended, the average sanitary toilet cover- age in the study sample continued to grow from 44% (in FIGURE 7: DIFFERENCE IN SANITATION COVERAGE IN STUDY COMMUNES IN THANH HOA AND QUANG NAM FIGURE 6: INCREASE IN SANITATION COVERAGE IN THE STUDY SAMPLE DURING AND AFTER PILOT 70 60 % Access to Sanitary Toilets 70 % Access (Averages) to Sanitary Toilets 50 60 40 50 30 40 20 30 10 20 10 0 2003 2004 2005 2006 2007 2008 0 During Pilot (2003­06) and After Pilot (2007­08) 2003 2004 2005 2006 2007 2008 During Pilot (2003­06) and After Pilot (2007­08) Than Hoa Quang Nam Source: Commune statistics for eight study communes, this study Source: Commune statistics, this study www.wsp.org 11 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Increase in Access to Rural Sanitation FIGURE 8: EVOLUTION OF SANITATION COVERAGE IN FIGURE 9: INCREMENTAL SANITATION COVERAGE IN INDIVIDUAL STUDY COMMUNES OVER TIME STUDY COMMUNES DURING AND AFTER PILOT 90 100 80 90 % Access to Sanitary Toilets % Access to Sanitary Toilets 70 80 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 nh oc ai c am u ai oa c c oa Lo ie h am u H H ai ai Lo Lo ha L H an ie Tr N H H H nh nh Tr ai y N m T Th An nh M ai y nh nh m H Ti Bi Ta h M nh ai H Bi Ta An ai Bi Ti H m Bi H Ta m Ta Baseline Increase Under Pilot Increase After Pilot 2002 2006 2008 Source: Commune statistics, this study Source: Commune statistics, this study 3.2 Coverage in the Individual were able to catch up a lot of their gap during 2007 and Study Communes 2008. They also achieved this in almost half the time. While Figure 8 shows the individual performance of the eight case the pilot took almost four years, they caught up in sanita- study communes in sanitation coverage between 2003 and tion coverage in two years. 2008. The data shows a sustained growth in sanitation cov- erage in all communes. All increased their toilet coverage In the interviews, the local authorities of the communes further, including after the support from the pilot project concerned gave different explanations for these jumps for- had ended. As the data is in percentage of population cov- ward. In My Loc, the People's Committee chairman said ered, the sanitation coverage growth amply surpasses the that the Commune Steering Committee had been very ac- average annual population growth of 1.02% during the tive in supporting sanitation promotion after the end of the pilot project and of 1.06% in the two years afterwards. pilot project (see also Table 18). In Tinh Hai, the local health and commune authorities indicated that the main The figure also shows that under the pilot project, Hai Loc, reason for their progress was the fact that the commune had Hai Thanh and Tam Anh Nam in particular made great become part of the new industrial zone of Nghi Son and progress in their sanitary toilet coverage. At the end of the many households used the government's compensation for pilot project in 2006, they had achieved coverage figures of their farmland to build a new house with a sanitary toilet. 71%, 59% and 65% respectively. They also sustained these top positions after the pilot project, with coverage reaching 3.3 Comparison with Non-Project Communes 80%, 65%, and 72% respectively, by 2008. Is there any difference between the growth of sanitation coverage in the pilot sample and in a group of comparative Two communes, My Loc and Tinh Hai, made their greatest communes without a pilot project intervention? The case progress in % access to sanitary projects after the pilot proj- study looked at this question in four non-project villages. ect. This is illustrated more clearly in Figure 9. While their They were different, however, from the comparative villages progress during the pilot project was relatively slow, they that had been included in the pilot project. 12 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Increase in Access to Rural Sanitation In 2003, IDE also collected baseline data in three non-proj- and 4.7 respectively; statistics not shown in Table 6). How- ect communes in Quang Nam province (Tam Phuoc, Binh ever, the table also shows that the both the variation in aver- Dinh and Duy Hai) in order to compare progress in the age individual income and income growth over time are pilot communes with developments in non-project com- greater in the study sample than in the comparative group. munes. In Thanh Hoa province, no comparative data was collected. In contrast, the study sample has 6% more poor households on average. On the second indicator of poverty, the per- Because these comparative communes were quite far from centage of children under five with nutritional deficiencies, the study area, visiting them would have increased the time both groups scored the same, but the variation is lower in and budget of the case study. Moreover, the database had no the study group than in the comparative group. Finally, data on the characteristics of these communes with the pilot Table 6 has statistics on the annual income of the com- communes. Hence, it was decided to select four other com- munes themselves. These do not give a clear picture. Al- parative communes, which would belong to the study dis- though the average income of the communes is higher in tricts and be comparable to the study communes, but would the comparative group than in the study group, the varia- be located at sufficient distance to reduce the chances that tion is too large to show any true differences. they were influenced by the pilot project. For these logistical, financial, and methodological reasons, the study team From the above it can be concluded that with regard to the therefore chose four other non-project communes, two in household characteristics, the two groups are quite compa- Thanh Hoa province (Minh Loc and Binh Minh), and two rable except for economic status. However, because the two in Quang Nam province (Binh Tu and Tam Hiep). trends (income and % poor) are in opposite directions, the confounding influence of economic status on the match be- Comparison of the study communes and comparative com- tween study sample and comparative group can be consid- munes on location showed that agriculture was the main ered negligent. Thus, the results in two groups--with and source of income in both groups. The only exceptions were without pilot--can be considered comparable. However, the study communes of Hai Loc, a fishing commune, and because the design of the study is not a randomized control Tinh Hai, a former agricultural commune, but now part of trial, no statistical conclusions can be drawn about the the industrial area of Nghi Son. Other characteristics of the attribution of the effects to the pilot approach. two groups are presented in Table 6. As the table shows, both groups are comparable in population size, number of The results on the increase of sanitation coverage in the two households and average annual income per person. The lat- groups are shown in Figure 10. For the reasons already ter implies that incomes per household are also comparable, given, the figure covers only three of the four non-project because the average household size is almost the same (4.5 communes, and in Binh Tu has only the access for 2008. TABLE 6: COMPARISON OF THE STUDY AND COMPARATIVE SAMPLE Annual Annual Income Income of Per Person % Increase in % Nutrition Commune Population Per Year Annual Income Per % Poor Deficient (X 000.000 Samples Size # Households (X 000 VND) Person Per Year Households Children < 5 VND) Av. Range Av. Range Av. Range Av. Range Av. Range Av. Range Av. Range Study 9,032 4,449­ 1,999 1,071­ 4,932 3,264­ 174 126­ 27 22­27 25 22­27 1,420 750­2,000 Communes 11,549 3,397 9,200 263 Comparative 8,664 2,368 1,277­ 5,236 5,400­ 149 146­ 21 11­30 25 11­30 2,077 1,700­ Communes 2,779­ 3,291 6,500 151 4,600 13,286 Source: Commune statistics, this study www.wsp.org 13 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Increase in Access to Rural Sanitation month in rural delta areas (Socialist Republic of Vietnam FIGURE 10: EVOLUTION OF SANITATION COVERAGE 2002). For 2006­2010, this was raised to less than VND IN THE STUDY SAMPLE AND THREE COMPARATIVE COMMUNES 200,000 (USD11.23 per person in rural areas (Ministry of Labor, Invalids and Social Affairs [MOLISA] 2005). 70 60 The communes keep statistics on the percentage of poor % Access to Sanitary Toilets households. They also keep statistics on the numbers 50 of households without toilets and with unsanitary and 40 sanitary toilets, according to the national toilet standards. 30 However, none of the communes collect combined annual statistics: the percentage of poor households with sanitary, 20 unsanitary, and no toilets. Data on income quintiles (num- 10 ber of poor, poor-to-average, average, above-average and 0 well-off households) are also not available, except for three 2003 2004 2005 2006 2007 2008 of the eight study communes in 2008. Minh Loc Binh Tu Binh Minh Average in Study Sample During the pilot project, the local promoters monitored the increase in sanitary toilets in households above and below Source: Commune statistics, this study the poverty line. IDE then aggregated the data into the project's database. This made it possible to show, as reported in Section 1.3, that 16% of the households who built a The figure shows that average sanitation coverage in the study toilet under the pilot were poor, while poor households in sample, as indicated by the squares, climbed steeply. In con- the pilot communes averaged 19%. trast, the comparative commune of Minh Loc, which had a much higher sanitary toilet coverage at start in 2003, was not After the pilot project, none of the study communes have able to keep up its sanitation coverage with its population continued to monitor toilet installation by poor house- growth. By the year 2008, the group of the eight study com- holds. It has therefore been impossible for the study team to munes had almost closed the gap in coverage difference. find out if, after the pilot project, the access of the poor has remained the same, has increased or has dropped. The only Sanitary toilet coverage in the comparative commune of findings that can be reported are the unrelated trends on Binh Minh increased, but at a much slower pace than that poverty and sanitary toilet ownership in the study com- of the study sample. For Binh Tu, the only sanitation figure munes in Thanh Hoa province) and Quang Nam province available was for 2008. This is also lower than the average (Figures 11 and 12). for that year in the project communes. Looking at the changes in Thanh Hoa (Figure 11), toilet cov- 3.4 Installation by Poor Households erage increased over time irrespective of whether poverty was After reporting the results on the sustainability of the increase relatively high, as in Hai Loc and Tinh Hai, or low, as in My in toilet access after the pilot, this section looks into statistics Loc and Hai Thanh. Toilet coverage in Hai Loc even contin- on toilet access for poor households. More qualitative data ued to grow when the poverty level soared temporarily. on poverty and sanitary toilet construction can be found in the chapter on Focus Group Discussion in Section 6.2. In Quang Nam (Figure 12), the same contradictory changes can be seen. Toilet coverage increased over time while pov- Vietnam has set national criteria to define poverty and clas- erty levels remained the same (in Binh Trieu), or periodi- sify households as poor. From 2002 to 2005, poor house- cally increased (in Tam Anh Nam, Tam Hoa, Binh Hai). holds were those that had an average income of less than Furthermore, in Tam Anh Nam and Tam Hoa, sanitation 100,000 VND (USD60 in December 2005) per person per coverage increased more rapidly than poverty levels fell. 14 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Increase in Access to Rural Sanitation FIGURE 11: CHANGES IN POVERTY LEVELS AND SANITATION ACCESS IN STUDY COMMUNES DURING AND AFTER PILOT IN THANH HOA PROVINCE 90 % Poor and % Access to Sanitary Toilets 80 70 60 50 40 30 20 10 0 03 04 05 06 07 08 03 04 05 06 07 08 03 04 05 06 07 08 03 04 05 06 07 08 08 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Hai Loc My Loc Hai Thanh Tinh Hai Binh Tu (non- % Poor hhs % Sanitary Toilets project) Source: Commune statistics, this study FIGURE 12: CHANGES IN POVERTY LEVELS AND SANITATION ACCESS IN STUDY COMMUNES DURING AND AFTER PILOT IN QUANG NAM PROVINCE 80 % Poor and % Access to Sanitary Toilets 70 60 50 40 30 20 10 0 03 04 05 06 07 08 03 04 05 06 07 08 03 04 05 06 07 08 03 04 05 06 07 08 03 04 05 06 07 08 03 04 05 06 07 08 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Binh Trieu Tam Anh Nam Tam Hoa Binh Hai Minh Loc Bin Minh (non-project) (non-project) % Poor hhs % Sanitary Toilets Source: Commune statistics, this study However, it should be cautioned that these trends do not better-off. Because the current commune records do not necessarily mean that toilet ownership in the study areas give data on toilet ownership by economic level, it was has increased irrespective of local poverty levels. Many of not possible to identify if the poor have continued to the households who have built toilets since the pilot may install sanitary toilets as often, more, or less than during well belong to the less poor, the middle class, and the the pilot project. www.wsp.org 15 IV. Continuation of Sanitary Toilet Promotion This chapter explores the promotion efforts with which the Each promoter had also a handbook on what to promote pilot project results were achieved and sustained. (The role and how to do it. of the providers in sanitation marketing is covered in Chap- ter 5). For this purpose, semi-structured interviews were The promoters further encouraged the acquisition of sani- held with 23 promoters (eight VWU leaders, eight VHs and tary toilets through door-to-door visits and home visits to seven CHW), in total 11 women and 12 men. All had families with or without unsanitary toilets. They also in- worked as promoters during the pilot project. vited commune masons to come to the meetings to present the toilet models, answer questions and get into contact 4.1 Promotion During the Pilot Project with potential customers. During the interviews, the promoters reported that dur- ing the pilot project, they had encouraged households Messages that the promoters said they spread included with no or provisional toilets to build sanitary ones, and "Have sanitary toilets to protect your family," "Be civilized had informed people about the types and costs of models and have a modern toilet," and "Have a sanitary toilet to available at general commune assemblies. They had also protect community health." They also told the villagers that organized special meetings on sanitation and distributed a high number of households with sanitary toilets was a sign the material provided by IDE. This included a leaflet of a "cultural" or modern village. The "cultural village com- with the four toilet models (Figure 13) and a leaflet with petition" is an annual event and many standards must be handwashing instructions (Figure 14) and wooden mod- met to obtain the title, for example, percentage of poor els of the four types of toilets. The translation of the leaf- households, percentage of households with sanitary toilets lets is given in Box 2 and Box 3. The promoted benefits and no social evils such as drugs and family violence. If the were based on IDE's consumer research. Most com- percentage of households with sanitary toilets decreases, the munes also placed a signboard in the centre of the com- VHs concerned lose the title of "cultural village" for their mune and used banners at special sanitation meetings. community (see also Section 7.1.1). FIGURE 13: SANITATION LEAFLET Source: IDE material, this study 16 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Continuation of Sanitary Toilet Promotion BOX 2: SANITATION LEAFLET, ENGLISH TRANSLATION First side: Second side: Under symbol (boy with toilet): Toilets are sanitary only when you know how to · Sanitation maintain them: · Civilization · Clean the toilet often · Health · Put water and soap near toilets for hand washing · Build or upgrade toilets to protect health and Central heading: Sanitary toilet: fellow traveler of happiness for you and the people families' future happiness SANITATION/HEALTH For further information, please contact the following address: · Save time and money from buying medicines ........................................ · Children's feces are as dangerous as adults' feces ........................................ CIVILIZATION/PRIVACY Left side: · Convenience when guests are coming over Choose for your family one prototype of these toilets: · No smell for your family and neighbor Double vault composting toilet: CONVENIENCE/SAFETY without water · Can use at any time · feces can be used · Safe fertilizer storage · low construction costs · No pollution to water sources and environment Single vault pour flush toilet: BE A MODEL FAMILY IN A CULTURED VILLAGE · can be constructed close to or inside the house The diagram on the left: · needs a sufficient supply of water People's feces contain very dangerous germs · reasonable construction costs Diarrhea, dysentery, typhoid, hepatitis, parasitic worms Septic tank toilet: Sickness, labor force reduction · can be constructed close to or inside the house Money wasted to buy medicine and for health · needs a sufficient supply of water treatment · high construction costs Poverty While all three types of promoters--VHs, VWU leaders the toilets in their own meetings. People's Committees and and CHWs--said they had been equally active in terms of Party officials were said to be more rarely involved. time spent on promotion, the VHs have reportedly partici- pated in the widest range of promotion activities. As one 4.2 Continuation of Sanitation Promotion promoter said: "The head of the village must participate in After the Pilot everything." (Promoter #6) IDE paid the village promoters an incentive of 20,000 VND/month (USD1.20 at the end of 2006) during the The promoters said that other commune mass organiza- pilot project. This incentive stopped after the pilot project. tions, such as the Farmers' Union, the Soldier's Union Nevertheless, of the 24 promoters, only one VH said that ("Fatherland Front"), the Communist Youth Union, and he had stopped sanitation promotion because the pilot the Students' Club supported their efforts by promoting project had ended. The other 23 said that they continued www.wsp.org 17 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Continuation of Sanitary Toilet Promotion FIGURE 14: HANDWASHING LEAFLET Source: IDE material, this study BOX 3: HANDWASHING LEAFLET, ENGLISH TRANSLATION Front page: Sanitation, Civilization, Health Back page: Handwashing is an effective way of disease Health: the assurance for your children's bright prevention future · How to wash hands? Wash hands with clean water · Toilets need to be maintained and cleaned and soap · Always keep toilets locked, dry and clean · Rub hands firmly at least three times · Collect and put feces of children into toilets · Dry hands on a clean cloth Put water close to toilets for easy hand washing When to wash hands? Feces need to be composted at least 6 months · Before eating and feeding before disposal · Before processing food · After going to the toilet and cleaning children's bottoms Unclean hands contain lots of dangerous germs Diagram: Human stool and unclean water source Hand Child suffering from stomach pain · Diarrhea, dysentery, typhoid, polio, hepatitis, parasitic worms · Hands are one of the ways of spreading the above diseases · When the hands of the mother are not clean, there is a risk of spreading the above diseases to other members of the family The future happiness of the family is in your hands 18 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Continuation of Sanitary Toilet Promotion Vietnamese New Year, when no toilets are built. Only in FIGURE 15: NUMBER OF PROMOTERS MENTIONING Thang Binh district did the promoters continue their toilet ACTIVITIES CARRIED OUT DURING AND AFTER PILOT promotion year-round, because there was a mutual agree- ment that the district would compete on sanitation cover- 25 age throughout the year. After the pilot project was over, 20 this year-round toilet promotion has continued, but with a Number of Promoters lower intensity for the reasons given above. 15 Most promoters said that they had continued the work be- 10 cause it is part of their job. Other motivating factors were that the toilets improved their village and village health. A 5 smaller number mentioned the future of the children and the training from IDE. Several also said that they hoped 0 that their village would be awarded the title of "cultured er s ia e ee e in s ts gs ial gs om n er ut s et isi st so village" mentioned above. tin ec ls tin at ib t rg v rm o cu a m istr ee p he om d km ta e m ld s to hom D ot Pr an Lin o H y Pa Intensity of continuation was reportedly also influenced by During Pilot After Pilot the presence of specific programs, plans and funds: "Only when there is a plan, will there be financing. Source: Promoters' interviews, this study Financial support is one of the prerequisites for action." (Promoter #5) Most promoters said that in spite of high construction rates the through the present time, albeit with a lower intensity the interest in sanitary toilets among those without toilets had and range of activities. The type of activities that they re- not dropped and had sometimes even increased. (Note: This is ported is given in Figure 15. As illustrated here, they said borne out by the FGDs with householders without toilets. that they had especially continued promotion during local Most participants wanted more and different information, see meetings and through home visits. Section 6.2.4 below). Furthermore, they said that both during the pilot and at pres- About half of the promoters said that they also still made ent, women were the most interested target group. If men par- follow-up visits to check the construction quality and the ticipated, it was together with their wives. hygiene of the installed toilets. In most study communes, the promoters further said that they carry out these activi- The promoters also said that there was no class factor in access ties once a month, particularly on "green day." This day, to information on sanitary toilets. People from all classes-- which individual communes give different names, is for upper, middle and lower class--attended the meetings equally promoting cleanliness "from the door to the alley." well. Nevertheless, half of the promoters had noted an increase in toilet construction by the poor: The reasons that the promoters gave for their reduction of "Now, people are building many toilets. Even house- promotion activities was that after the end of the pilot proj- holds near the river build toilets, too. Some families ect there was no more money for printing new promotional have the rings cast already and complete their toilets materials and their promotion allowance had stopped. later." (Promoter #5 and Figure 16) The promoters explained that during the pilot period their Of the 23 promoters still working, ten said that the number of work was subject to seasonal variation, and that this was poor households that build toilets now is the same as under still the case. Promotion stopped during the wet season, the the pilot project. Ten others say that more poor households planting and harvesting time, and during Tet, the now build a sanitary toilet, two say fewer, because of a lack of www.wsp.org 19 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Continuation of Sanitary Toilet Promotion promotional materials, but several reported having made new FIGURE 16: PRE-CAST RINGS FOR (SEMI) SEPTIC TANKS messages for the local radio and loudspeaker programs. 4.4 Future Sustainability of Sanitation Promotion The promoters expected that their work would continue as it is now and that in due course, and in spite of the challenges for the poorest, their communes would achieve 100% toilet cov- erage, with all households having sanitary toilets according to the Vietnamese standards. Target setting will help: "If we continuously increase coverage as planned, we shall have achieved 70­80% after 10 years." (Promoter #5) However, the continuity of the promotion may decrease because VHs and VWU leaders are transferred every three to four years. None of the promoters knew of any budget- money and one did not know. The promoters who said that ary provisions for new promotional materials, training of now more poor people build a sanitary toilet gave the follow- the replacement staff or further development of the promo- ing reasons: tion work. Of the interviewed promoters, the CHWs could · People are more aware of the different models, costs best recall the pilot project's strategy and results. However, and prices. (Promoter #9) neither they nor the VHs or VWU made annual sanitation · Some have no money, but they get the tank cast and and hygiene promotion plans or monitored sanitation installed first. (Promoter #1) progress in their communes. · They save money to build a toilet. (Promoter #9) · They are supported by low-interest government loans. 4.5 Sustainability of Constructed Toilets (Promoters #18 and 19) On the sustainability of the toilets themselves, the promoters · Poor households have saving clubs. Each pays e.g., said that people generally maintained their toilets well (Fig- VND 200,000 per round and the money for the toilet ures 17 and 18; compare also Section 6.3 on toilet observa- goes to the group member who draws the "lucky num- tions). They either knew no case of broken toilets constructed ber." (Promoter #21) during or since the pilot project, or only one or two cases. · Poor households can get money to improve their water Larger numbers mentioned by three promoters referred to a supply or sanitation under the "Clean Water Program." wider working area than the study communes and to toilets (Promoter #2) that had not been built to a satisfactory standard. The most Those promoters who had observed increased toilet construc- common problems reported were the use of cheap materials tion by the poor said that this was due to the better economic and bad design or construction. situation, the greater awareness of the benefits of a sanitary toilet so that people are more willing to save or take out a loan for Regarding sustained use by all, most promoters said that some construction, the reduced availability of waste land for open def- people with toilets still occasionally used the fields for open ecation, and the greater choice of differently priced toilet types. defecation and that open defecation also still occurred among children. However, in the FGDs reported in Section 6.2.2, 4.3 Availability of Promotion Materials many participants said that in the field they used the "cat After the Pilot method." They made a small hole for defecation and covered About one-fifth of the promoters still had some promotional the excreta with sand/soil afterwards. The FGD participants materials left from the pilot project to share with new house- also said that families with a toilet and young children gener- holds. Nowhere had promoters produced or obtained any new ally threw the stools of infants in the toilet, but that infants in 20 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Continuation of Sanitary Toilet Promotion households without toilets would defecate outside, in one case FIGURE 17: OBSERVED TOILET HYGIENE AND HYGIENE with immediate bodily harm (Box 4). IMPLEMENTS On environmental sustainability, half of the promoters thought that when the pits and tanks of the sanitary toilets have filled up, the owners will deposit the sludge directly onto the vegetable crops. 4.6 Replicability of Promotion in Other Parts of Vietnam Virtually all promoters said that the same three types of staff could do the sanitation promotion in other parts of Vietnam. They were almost equally divided in their opinion whether the best expansion strategy would be that they train the staff in neighboring communes and districts themselves, or that IDE should do this. A small sub-group said that they favored "rov- ing teams of master trainers" organized by the Department of Preventive Health and the VWU. Many promoters also said that a good financing strategy for poor households would be a major necessity for any new program. FIGURE 18: OWNER SHOWS LARGE, SHINY TOILET BOX 4: OPEN DEFECATION AND "TREASURED POSSESSION" In one of the FGDs, the group told a tragic case of a child's excreta disposal in their village. A mother had told her son to defecate outside. Immediately, a dog came to scavenge the stool and unfortunately he bit the "treasured possession" of the son. The boy had to be hospitalized. www.wsp.org 21 V. Sustainability of Sanitation Supply Services As mentioned in the section on methods, the field study · The increasing demand for sanitary toilets; team carried out semi-structured interviews with sanita- · The opportunity to expand their business and tion providers who participated in the pilot program. They increase their income; were one producer, five contractors, five shopkeepers and · The availability of resources (time and money) to ten masons, 21 providers in all. All masons but one, as well expand their business; as the producer, were middle-class entrepreneurs. The one · The opportunity to gain new experiences and skills; mason who was an exception belonged to the locally bet- · The wish to serve the people; ter-off. Of the shopkeepers and contractors, one was mid- · The opportunity to fill a gap in the market. dle-class, the others belonged to the locally better-off. The classification has been based on observed indicators such as "Until now, nobody sells this product, so if I sell [it], it is type of building and size of business and stock, in compari- promising." (Provider #21) son with neighboring enterprises and on information from the interviews themselves (e.g., on turnover and income). 5.2 Range and Development of Services Asked about their service activities, 17 of the 21 providers 5.1 Existing and New Providers said that they provided a range of services for the house- Of the 21 providers, 13 said that they were already in business holds to choose from. Sixteen of them also said they had before the pilot project had started the others had started their increased their range of services since the pilot project. This sanitation business during the pilot. Two mentioned explicitly is detailed further below. One of the contractors, for exam- that they had started their business because of the training ple, also had a large shop. Not only did he sell sanitation they had had from IDE. Most providers had already been materials and goods and construct toilets, but he also pro- working in the construction industry for at least five years and vided a full sanitation package if so desired: locally adjusted some as long as 15 years. Three people had started in 2005/6. design, costing, materials procurement and supply, trans- Some had had different jobs before: two were farmers, others port, and construction. However, he did not distribute occupations included the transport business, selling agricul- information materials nor did he participate in meetings for tural supplies, electrician and community health worker. toilet promotion or pay home visits. The other contractors said that they made no specific designs, but otherwise pro- Half of the providers (two contractors, one producer, one vided the same services as their colleague. Three shopkeepers shopkeeper, and seven masons) said that they had been said that they also carried out toilet design and costing, and trained by IDE. Those trained said that they had been cho- another three said that they also transported materials. sen because of their experience in the construction busi- ness and had mainly been selected by the village authorities, The ten masons also said that they provided different ranges of such as the VH or the CHW. The others had not received services. Only one, who was also the community health training. They had been working as masons in the pilot worker, did toilet construction as an additional job and did communes and did not know why they had not been cho- not provide any extra service. The others also did design and sen. The contractor said that his foreman had been trained costing, and/or provided transport. None of the providers said and that he had trained the others. All providers used the that they gave any specific after-sales services, but a number new models, designs, materials, and construction meth- provided a product guarantee as detailed in Section 5.2.3. ods. They had learned about them from other masons and shops, and from the mason manual produced by IDE. 5.2.1 Adjustments to Materials, Designs, and Products As mentioned, 16 of 21 providers had developed their ser- The providers mentioned several reasons why they had vices since the end of the pilot project. Most said that they started or expanded their toilet business: had done so to meet changing market requirements and 22 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Sanitation Supply Services As mentioned in Section 1.1, Vietnam's rural sanitation targets FIGURE 19: PROVIDERS ADJUSTED TO NEW DEMANDS, for 2010 include that all kindergartens, schools, health sta- SUCH AS SEAT-TYPE TOILETS tions, markets, district head offices, and other public offices in rural areas have sanitary toilets. In the study communes, an observed gap in service expansion were the buildings of the People's Committees. Recently constructed buildings did not have inside toilets, and there were no handwashing provisions alongside the toilets. Water supply, toilet maintenance and pri- vacy at existing facilities needed improvement. 5.2.2 New Construction vs. Upgrading Unsanitary to Sanitary Models Of the 12 providers that upgrade toilets from unsanitary to sanitary models, eight said that the upgrading business had increased, three said that it was the same as before and two that it had dropped. Upgrading is especially relevant to sep- tic tanks. There were indications that upgrading unsanitary better satisfy their customers. Reported changes were ad- toilets into sanitary types rather than building new ones was justment to rural sanitation materials, designs and prod- not popular among masons: "I am afraid because doing the ucts, services (financing and desludging), and network upgrading work is unhygienic, moreover, the income is not development. They are detailed in the next sections. high." (Provider #17) Sixteen providers reported that they had made adjustments 5.2.3 Product Guarantee since the end of the pilot (Figure 19). Changes concerned Two-thirds of the providers currently guaranteed the quality the types and nature of the materials ("more ready-made"), of their product or service. From the data it was not clear, the toilet design, and the range of products: however, if they had done so during the pilot project. Usu- · Provider # 24 said that he now designed with more ally, the period was one year, but this also depended on the expensive materials. product. One mason said that he did not give a guarantee: · Provider #4 now installs septic tanks with ventilation. "But if there is any breakdown, I will still come to fix it for · Provider #18 said that he had adjusted the dimensions the customer." (Provider # 17) and interior design of the toilet building, "arranging the interior more reasonably to reduce the amount of 5.2.4 Other Services land needed and make toilet use more comfortable." The other most common service was providing some kind of financing to masons and households. As one supplier for- Two masons also reported using higher quality materials as mulated it: "If one wants to sell goods, one must sell on well as more ready-made devices (platform, plastic pipe, basin, credit." (Provider #24) etc., Provider #20). Mason #20 also said that he "followed the septic tank design more precisely and also builds toilets closer This was already common during the pilot project, but half to people's house." Two of the three shopkeepers now also of the providers said that they now gave credit more fre- stocked more expensive types of toilet parts and the third one quently than during the pilot project. More detail on who reported having more plastic pipes and selling more sitting provided this service, how, and to whom can be found in type toilets (Provider #16). All providers except one (the the section below. CHW/mason) had further expanded their range of products: all also sold/installed bathrooms, 15 installed handwashing The other additional service was the emptying of full toilet basins, and four built toilets in schools and hospitals. pits and tanks and the final disposal of the sludge. At www.wsp.org 23 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Sanitation Supply Services present, only one provider in the study sample said that she · "Double vault toilets cost garden land and are less also provided emptying and end-disposal services for full hygienic." (Provider #20) toilet pit/septic tanks (Provider #24). According to the pro- · "They don't want a cheap type." (Provider #5) moters and the FGD participants, most households emp- · "If they can, they build septic tanks; if not, they tied, or will empty, the contents from full pits and tanks don't want to build." (Provider #17) themselves and spread the contents on their own land or The providers said that households now know about this obtained the service from a local farmer. option through the pilot project and that the different de- signs, construction materials, and skills were now available. 5.2.5 Pricing Strategy, Market Research, and Physical Other reasons mentioned were that people now had more Environment money and could afford this more expensive model and Other ways in which providers said that they had adjusted that they had a lower economic need for excreta as a fertil- to the needs and demands of their customers--households, izer. They also said that the septic tank is seen as more mod- masons, schools--since the end of the pilot project were: (i) ern and hygienic, that it looks tidier when installed in the adjustments of stocks and prices to demand, (ii) providing yard and is more suitable for bathrooms (Figure 20). The a good balance between price and quality, and (iii) giving providers themselves said that they too preferred septic price discounts during sales: tanks over the other models, giving the following reasons: · "I buy many suitable goods." (Provider #24) · Greater cleanliness (11 providers) · "I look for hand basins with prices and colors that · Higher demand (nine providers) local people like." (Provider #21) · Greater profit margin (four providers) · "I buy innovative bathtubs, stainless steel hand wash- ing basin instead of porcelain." (Provider #5) Provider #23 worded this preference this way, "It [the septic · "I ensure quality with a price suitable to their tank toilet] can be put under the bathroom, so it is tidier pocket." (Provider #28) and it does not affect the environment" [sic]. Two-thirds of the providers said that two years after the All interviewed providers said that they installed the pit pilot they continued to follow market developments, espe- models or sold the materials for them mainly because of the cially through their contacts with producers. poverty or the customers' lack of space and that this was · "I learn through others/producers who know what also the type that such people built themselves: types of goods people like." (Providers #7 and #9) · "They build it due to poverty, they don't have the re- · "I depend on the producers to know what to supply sources and they need the excreta to fertilize their fields to the customers." (Provider # 22) after keeping them for six months." (Provider #24) · "I go to the city to search for service providers." (Provider # 38) FIGURE 20: DEMAND INCREASED FOR SEPTIC TANKS · "I depend on my diplomatic relations for new AND FULL BATHROOMS products and services." (Provider # 18) 5.3 Types of Toilets Sold and Installed Of the four types of sanitary toilets promoted and installed under the pilot project, the providers said that the septic-tank model was sold and installed still more frequently today: · "At present, people only choose this type." (Provider #27) · "Households with resources want to build sep- tic toilets, few now build a double vault toilet." (Provider #7) 24 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Sanitation Supply Services · "When the land is narrow and crowded, there are no FIGURE 21: INTERVIEW OF FEMALE PROVIDER other choices." (Provider # 17) · "They build the dry kind themselves." (Provider #24) · "When they build [it], they build according to stan- dard, the only problem is how big or small to reduce expenses." (Provider #21) Two shopkeepers (Providers #16 and #28) further reported a trend towards the sitting-type toilet. This type is especially preferred by the better-off customers. 5.4 Gender Roles All providers stressed that in sales and construction they followed the wishes of the customers. According to their experiences, men generally wanted to build bigger: "They build big, nice, and monumental [toilets]." (Provider # 22) FIGURE 22: NUMBER OF PROVIDERS WHO REPORTED Women were more economic, wanted to build simpler PROMOTING SANITATION, BY METHODS USED models and preferred squatting toilets, which are cheaper. The FGDs (reported in Chapter 6), the interviews with the 18 promoters reported in Chapter 4.4, and the interview with 16 one of the commune leaders confirmed that women played 14 Number of Providers a leading role in the market, but that couples made the de- 12 cisions jointly. As the interviewed head of a Board of 10 Culture and Communication said: 8 "In families here, the wife and the husband discuss 6 with each other about construction of toilets. The 4 wife is the one who manages the money, but the hus- 2 band manages the construction. After selling some 0 pigs, the wife will keep the money. They estimate the Do not Promote Promote when Promote promote by talks customers by costs for bricks, stone, cement, then call masons to toilets in meetings come and ask home visits do the construction." Source: Provider interviews, this study (N=21) In reference to gender roles in the sanitation business, sev- eral providers said that they did this together with their wife or husband. Five providers (two suppliers, one contractor, they promoted sanitation mostly by home visits. They were who also makes ferro-cement rings for septic tanks, one a mix of masons, contractors, and providers with a com- mason/supplier of building materials, and the CHW/ mon characteristic of a relatively low education level: all but mason) said that they ran their business together with their one had primary school with, at most, some years of sec- spouses (four wives and one husband) (Figure 21). One ondary education. supplier also mentioned help from his grandchildren. Eight providers gave information and promotion materials when potential customers came to their business and four 5.5 Sanitation Promotion by the Providers still went and talked about sanitary toilets at meetings (Fig- Although marketing through promotion activities was part ure 22). None of those promoting sanitation had developed of the providers' training developed by IDE, half of the in- new promotion materials. Only six providers mentioned that terviewed providers said that currently they did not do any others (VWU leaders, VH, CHW) also did toilet promotion toilet promotion activities (Figure 22). The others said that www.wsp.org 25 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Sanitation Supply Services activities. Instead of using marketing instruments such as project. On average, they had multiplied their profit almost leaflets, the providers said that they relied on their relation- 2.5 times, but with large individual differences (a range in ships, network, and reputation in the commune to get new growth from 2% to 300%). For three providers, their profit assignments. had remained the same, two reported a drop, and two did not know. About half of the providers (10) said their profit on all toilet types was the same, while five said that they made more 5.6 Sales, Income, and Types of Customers profit on the expensive models (semi-septic and septic tanks). The providers interviewed said that toilet construction now ranged from one toilet per two months to 20 toilets per However, not all could make a living from their businesses, month, with an average of seven per month. Sales of con- although all but one sold other goods and did other con- struction materials ranged in value from 4 to 61 million struction work than for sanitation purposes alone. Out of 21 VND (USD226­3,424) with an average of 20 million providers, five did other work to add to their income, 15 VND (USD1,130). Four providers had average sales were able to make a living from their business and one did of VND 4 million per month, two sold to a value of some not answer. VND 10 million, one sold VND 40 million per month, and one VND 61 million (USD3,424). Only three provid- Exactly what proportion of their businesses was specifically ers had a steady business throughout the year, however; for related to sanitation and how this has changed relative to the others the dry season at the end of the year was the overall change was not asked, but from the conversations and busiest. the display of goods, the study team estimated that about 10% of the income of providers comes from sales of toilets. Overall, 16 providers said that they had more sanitation customers now than during the pilot project; while 13 said Asked about the type of customers, 12 of the 20 providers their volume of sales had increased since 2006. Two provid- who answered this question said that they had all kinds of ers said that the number of customers was the same and customers: better-off, middle class, and poor families. Seven three said that they had fewer customers. Of these, one said said that they had mainly middle-class and better-off house- that the commune was becoming saturated with toilets and holds, and one said that his customers were mainly poor. the other blamed the recent drop on the economic crisis. Asked if they undertook any action to assist the poor in Asked how their business had changed, 19 of the 21 provid- acquiring sanitary toilets, 12 providers said that they gave ers said that they now carried out more new construction easier terms of payment, seven said they accepted a lower than under the pilot. Nine also did more upgrading, four profit, and one said people bought their own materials, had seen their material sales to masons increase, three sold transported the materials themselves, and/or carried out more materials to households for self-construction, and their own construction. One other provider said that he three did more repairs. adjusted the design. More details on credit to customers is given in Section 5.8. Profits and income had also increased according to 14 pro- viders. The reasons given by those who had seen their busi- ness increase were the growing demand for good toilets due 5.7 Provider Networks to economic growth, the reduction of land for open defe- During the pilot project, IDE had encouraged the provid- cation, and the local availability of materials and services: ers to form provider networks, whose members cooperate "In the past, they [the customers] had to go to the in sanitation production, procurement, sales, transport, city to buy sanitary goods, now they can buy them construction, and other sanitation services. here." (Provider #24) From the providers' interviews it was learned that in the As a result of the increase in business, 14 of the 21 providers study sample these networks have been sustained. This was said that their profit had increased since the end of the pilot the case in two-thirds of the study communes in Thanh Hoa 26 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Sanitation Supply Services province and three-quarters of the study communes in 5.8 Types of Credit Quang Nam province. Some networks could mobilize ten Virtually all providers--contractors, suppliers and members and one network even had between 20 and masons--said that they gave some kind of credit service to 30 providers. their customers (Figure 23). Twelve provided credit to households and three also to masons, contractors and The networks were larger and more developed in the study public institutions (schools, health centers). All said they communes in Quang Nam province (that is, they provided did so to all categories of people, better-off or poor. What a wider range of services). The average size of networks in was important was that they knew the families and could Quang Nam was 5.5 members, against 3.7 in the study be sure that they would pay. As one supplier said: "Let communes in Thanh Hoa. people in whom I have confidence have some credit." According to those interviewed, the networks are important, (Provider #21) because they make it easy to refer customers to other network members and, if so desired, give a one-stop service, that is, Figure 23 also gives an overview of the kind of credit pro- the customer orders what he or she wants and the network vided. Providers said that they used a variety of financing members do everything. Moreover, the masons and contrac- services, mainly to enable poor people to install toilets. The tors can take on larger jobs and cope with peak times and all most common were interest-free loans without down pay- members can keep up more easily with new developments. ment and no time limit (14 cases). They were followed by interest-free loans with time limit and with or without Working in groups already existed before the pilot, but the down payment (seven and six cases respectively) and by project enhanced the mechanism: payment after delivery (seven cases). Those accepting down "After training, many people leave one group and set payments said they either decided the amount per case or up a new group, they build it up in the way that the asked for 50­70%. One of the suppliers stressed the limited project trained them. There are many new workers, size of the credit: "I can't do great [amounts], I am not a so the number of members increases." (Provider #12) company which can transfer money." (Provider #24) Those interviewed said that members of networks were The providers said that their repayment conditions were masons, suppliers of cement and other building materials, anything from "pay as soon as they can" (two providers), sellers of ceramic wares and producers of septic tank rings. "within one month" (one provider) to one to two months Network members mostly refer customers to other members (two providers), and three months (one provider), while or provide services and goods as a package. Those interviewed stated that networks were an important means of getting business. Half of the masons interviewed FIGURE 23: NUMBER OF PROVIDERS WHO REPORTED PROVIDING said: "People invite the group to build, if they know DIFFERENT TYPES OF CREDIT TO CUSTOMERS one member of the group." No credit Pay all on delivery However, in Hau Loc, which has the largest net- work, one member remarked: Loan with interest "Building a toilet is a small project and it in- and no time limit Down payment, rest volves only a few tasks. Moreover, masons in interest-free loan with time limit don't know how to fit (install) a water system, so it is difficult to cooperate." (Provider #28) Interest-free loan Interest-free loan without This confirms the other findings that sanitation without down payment, down payment and with no time limit time limit marketing must be part of a large business or com- bined with other work to be sustainable for the Source: Provider interviews, this study (N=21, more than one service possible per provider) providers. www.wsp.org 27 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Sustainability of Sanitation Supply Services one said: "I let some people in whom I have confidence owe total is more than 21, because some had done more than one money for three to five months." One provider said that he job previously. charged interest like the bank, but only after two months (Provider #20). From the conversations it emerged that the Most providers had worked first as part-time masons and had providers gave credit to about one-third of their gradually expanded their business through training by IDE, customers. learning from others, and self-development. Two-thirds of them said that they worked full-time throughout the year, 5.9 Providers' Origins and New Career although their sanitation business was not spread evenly Opportunities across the year. The others reported that they worked part- Of the 21 providers in the study sample, ten had completed time for all or most of the year. All of them said that these primary education, seven had some years of secondary edu- work patterns had not changed since the pilot project. cation, three had completed secondary education and one had a college degree. The average age was 46. The largest In Box 5, three former masons relate how the sanitation number of providers had previously worked as part-time marketing project gave them the opportunity to develop masons (12) or traders in agricultural or construction their career further by direct training, peer learning and the materials (5). Others had been full-time farmers (2); electri- toilet construction manual. cian (1); ring casters (2); well digger (1); and CHW (1). The BOX 5: RURAL SANITATION MARKETING PROVIDES CAREER OPPORTUNITY: FROM FARMER TO ENTREPRENEUR The first mason had been a farmer until 1997. In 1999 he began selling building materials. Until 2003 he only sold cement, bricks, and iron and steel bars. In 2003 the pilot project trained him to sell sanitary goods. Since then he has continued to expand. He now sells tiles, plastic goods such as pipes, and sanitary wares such as sinks, toi- lets, and hand basins. The second mason had quit secondary school after the first year and began working in 1997. During the pilot he noted that work was increasing and in 2006 he started a contracting business. At the time of the case study, he and his wife had an enterprise with 15 paid male workers. The third mason originally was a poor farmer. In 1996, he took up masonry part-time. In 1998, he became a full- time mason, working in shifts with six other masons, mostly friends and relatives. During the pilot project toilet de- mand increased, so he decided to specialize in sanitation. He was not trained by IDE, but learned from the project manual and other masons. He said that he belonged to a network of 20 masons and that customers came to him also from other communes for his skills and good price-quality mix. Normally, the network built about eight toilets per month, two masons for each toilet. The income of his family of five had increased and his life had improved. Some customers were late in payment, but they were people from his own commune, so he was not worried that they would not pay. To his great happiness, his oldest son had followed in his footsteps and is now also a mason. 28 Global Scaling Up Sanitation VI. Household Perspectives on Sanitary Toilets 6.1 Households Who Built a Toilet During TABLE 7: MOST CITED SOURCES OF INFORMATION and After the Pilot ABOUT TOILETS Focus group discussions with some participatory tools # of (time line, card sequencing, service and toilet ranking for Participants Rank Source Citing Source user satisfaction, and guided group discussion) were used 1 CHW/Health staff 34 to obtain the experiences and views of the households who 2 VWU 25 had built a toilet during the pilot and afterwards. In total, 61 householders participated in the sessions, 27 women 3 Radio (commune radio/loudspeaker) 23 and 34 men. Of those, 35 had built their toilet during the 4 Village/Commune workers 21 pilot project and 26 afterwards. Fifty-six were farmers, 5 Village Meetings 19 two were businesswomen, two were commune workers, 6 VH 15 and one was a photographer. 7 Other Unions/Coop Groups 13 8 IDE 4 6.1.1 Promotion of Toilets Among the Target Groups 9 People's Committee 4 In the FGDs, the participants were asked to list the sources 10 Informal (neighbor, relative, spouse) 4 of information that had been important to them in their Source: FGDs of toilet owners, this study decision to build a sanitary toilet. In total, the 61 partici- pants mentioned ten different sources (Table 7). The totals add up to more than 61 because more than one source could be mentioned. FIGURE 24: FGD PARTICIPANTS WHO BUILT TOILETS Table 7 shows that the CHW and other health staff were DURING AND AFTER PILOT, BY INFORMATION SOURCE the most important, followed by the VWU leaders, radio (especially the commune radio and loudspeaker broadcasts) 60 and other village and commune level workers. 50 % Participants 40 Figure 24 shows the differences between the FGD partici- pants who built during and after the pilot (35 participants) 30 and afterwards (26 participants). The participatory scoring 20 confirmed that the health workers and women leaders 10 (VWU) were the most important both during and after the pilot. This is in line with the findings in Chapter 4, where 0 o e op rke e ns U un VH al E TV st er 'te Pe wo lag di the promotion methods used by all promoters after the ID VW rm io le r th th Ra f C af l un vi al o fo 's e/ he W & In er pilot were reported. The participants also mentioned offi- th H m O C om cials from the commune level, such as the commune chair C and vice chair, who were not in the village promotion teams. During Pilot After Pilot Participants who built after the pilot mentioned the VHs less often, reflecting the reduced activity that the promoters Source: FGD data, this study (more than one source per participant possible) themselves also mentioned. www.wsp.org 29 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Household Perspectives on Sanitary Toilets More noticeable is the large role that the participants have than that of households who built their toilet afterwards given to the information spread through the commune radio (5.5 million VND). The reduction in investments is higher (the village loudspeaker system), for which the promoters still when it is taken into account that each year the prices wrote their own texts, even after the pilot project had ended. of materials and labor have increased. Few mentioned IDE workers as a source of information; this There was no difference in preferred toilet location: over finding is consistent with information obtained by IDE staff 80% of those who built their toilet during the pilot and who reported that they worked through local promoters and afterwards built their toilet in the yard. had no direct role in implementation. 6.1.3 Reasons for Toilet Construction Printed media, materials, and masons were hardly men- The main reasons cited by FGD participants for building a tioned. Of the participants who had built their toilet during toilet were (i) to improve health of family as well as com- the pilot, four mentioned the project brochures, two newspa- munity; (ii) to meet the Vietnamese standard for sanitary per articles, two advertisements, and one the mason. Among toilets; (iii) to help the environment; and (iv) to benefit the those who built or renovated afterwards, two said masons, community (Table 9). There were some differences between two the project brochures, and one the advertisements. the two groups, but they are too slight to ascribe any mean- ing to them. 6.1.2 Toilet Construction Methods Both households that built their toilet during the pilot and It is interesting that very few of those who built a toilet ei- afterwards overwhelmingly preferred to buy the materials ther during or after the pilot project mentioned conve- themselves and to hire a mason to do the construction. nience and privacy as motivating factors. This was not Many also preferred to transport the materials themselves. different for the women participants. The hypothesis is that Only two families in both groups built the toilet themselves this is a reflection of the context of the program, with toilets or helped the mason (Table 8). promoted through the local government staff and FGDs arranged through the VHs. The toilet investment costs varied from less than one million VND to over 10 million, as costs depended greatly on the 6.1.4 Type of Toilets size of the toilet and the materials chosen. Some people in- The FGDs revealed that the (semi-) septic tank model, al- cluded a shower or washing facilities or built a full-fledged ready very popular during the pilot project, has increased in bathroom. popularity and is the preferred model. Even the lowest in- come households preferred to save until they could install The average investment of the FDG households who built this model, rather than install a cheaper type. In families their toilet during the pilot was higher (7.1 million VND) with double vault composting toilets, husbands and wife TABLE 8: ARRANGEMENTS OF FGD PARTICIPANTS FOR TOILET CONSTRUCTION DURING AND AFTER PILOT Materials Supplied By Transportation Provided By* Toilet Built By No. of Purchased Mason and Respondents Themselves Provider Themselves Provider Themselves Themselves Mason During pilot 31 4 14 19 1 1 33 (N=35) After pilot 26 0 8 15 1 0 25 (N=26) Source: FGDs, this study; * 5 no reply 30 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Household Perspectives on Sanitary Toilets TABLE 9: REASONS HOUSEHOLDS GAVE FOR BUILDING A TOILET DURING AND AFTER PILOT Sanitary Standard Good Community Health Education Modern Family (Could Afford) Convenience Environment Cleanliness Economics Pollution / Privacy Reasons FGD Health Participants Gave for Building Their Toilets Participants who built during the pilot project 13 17 21 8 0 4 18 2 4 2 (N=35) Participants who built 6 12 12 13 1 5 14 2 9 0 afterwards (N=26) Source: FGDs, this study both empty the vault to use the compost on their rice, maize, average of 52 years. The purpose of the sessions was to and tobacco fields. Children do not want to do the work see why they had not installed a toilet, if they were still because it is unfamiliar to them and they dislike the smell. interested, and if the promotion and/or services could be The couples also do not like the work. They find it time- and improved for this group during continuation, replica- energy-consuming, dislike the smell, and fear negative im- tion, and scaling up. pacts on their health. They said that they continue using the compost for economic reasons, but that in future they would 6.2.1 Access to and Interest in Toilet Promotion try to build septic tank toilets, because their children expect According to the FGD participants, the toilet promotion this and it will be better for hygiene and health. activities had reached all but three of them. One lived in an isolated place in the mountains and two were working else- 6.1.5 User Satisfaction where and had not heard about the toilets from other peo- Satisfaction of the owners with their toilets was high. The ple either. All mentioned the CHWs, VWU leaders, and vast majority said that they were happy with the models, VHs as their main sources of information, but participants the design, the service, the cost, and the ease of operation. were not asked when they had actually learned about the However, eight participants reported problems with their toilets--during the pilot project or later. The commune toilet (clogging, one pit of the two vaults no longer usable, loudspeaker and TV were other key sources of information invasion of rainwater into the tanks, and toilet walls that mentioned by this group (Table 10). were not rainproof ). Clogging problems come especially from using plain paper instead of toilet paper for anal On average, participants in Thanh Hoa province reported cleansing or not using enough water for flushing. House- more information sources than those in Quang Nam prov- holds with septic tanks sometimes use chemicals to reduce ince. Only two participants mentioned masons. Most par- the speed of filling up. Twice a year, the husband will empty ticipants said that the promoters gave messages of cleanliness, a ready-bought package in the tank to soften the deposits health, and adherence to national standards on sanitation: and then add water to flush out the waste. · "Each house must have a toilet." (Participant #33) · "The toilet must be one of the standard types." 6.2 Households Without a Sanitary Toilet (Participant #21) In total, there were 60 participants, 27 women and 33 men, with no or unsanitary toilets. Fifty-one were farmers, Most participants mentioned village meetings, home visits, five housewives, two food sellers, one fisherman, and one meetings of the VWU, and messages over the commune retired person. Ages ranged from 25 to 76 years, with an loudspeaker as their sources of information. www.wsp.org 31 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Household Perspectives on Sanitary Toilets TABLE 10: SOURCES OF INFORMATION ON TOILETS GIVEN that they then practiced the "cat method," which is the low- BY THOSE WHO HAD NOT YET BUILT A TOILET est rung on the sanitation ladder and a safe alternative if no Thanh Quang toilet is at hand. (WSP 2007) Information Sources Total Hoa Nam 1 CHW 53 41 12 6.2.3 Reasons for Not Installing Sanitary Toilets 2 VH 38 36 2 For all but one participant, the reason for not building sani- 2 Radio/loudspeaker 38 32 6 tary toilets, in spite of having been reached by the promo- 3 TV 21 20 1 tion, was their lack of funds. Only one man said that he was 4 Women leader 19 12 7 not interested in building as long as he could not build a 5 People's Committee 16 12 4 new house. The others all said that they wanted to build a 6 VWU 15 7 8 sanitary toilet and a quarter of them have already set aside some money. Half of them also know how much they want 6 Neighbors 15 14 1 to invest: VND 3­4 million (6); 4­6 million (6); 6­10 mil- 7 Community worker 14 8 6 lion (10); and more than 10 million (5). 8 None 3 2 1 TOTAL 232 184 48 The reasons they mentioned for wanting to construct a Source: FGD data, this study. More than one source per person possible. toilet were, in order of frequency: cleanliness, safeguarding the environment, convenience, health, public interest (for 6.2.2 Current Places of Defecation the commune), adherence to the Vietnamese toilet standard, Of the 60 participants, 49 said that they used only one privacy, and importance for their children. place of defecation; the others used two places or more (Table 11). Almost half (28 households) had a traditional According to the participants, husbands and wives had the (unsanitary) pit latrine and 16 participants shared toilets, so same opinion: nine out of ten participants said that in their that 44 out of 60 households without sanitary toilet still use families they agreed on the need for a sanitary toilet and the some type of toilet. type that they wanted to install. Almost all households wanted a septic tank. Only one participant mentioned that However, around three-quarters of the participants said the husband had a different priority ("a good house first"). In that they (also) defecated in the open. This could be the three households, the husband and wife each wanted a differ- garden, the field, the beach, and at the river. Nevertheless, ent type of toilet and in one family the parents and children one-third of those reported using open defecation also said held different views on which toilet was best to install. TABLE 11: PLACES OF DEFECATION GIVEN BY FGD PARTICIPANTS WITHOUT SANITARY TOILET Open Defecation Shares Toilet Other Dug Latrine River/Pond Open Field Traditional Neighbor Relative Garden Beach Toilet Total Total Total Places Mentioned Thanh Hoa (N=29) 4 3 0 9 16 5 1 6 17 3 20 Quang Nam 0 24 2 1 27 6 4 10 11 19 29 (N=31) Total (N=60) 4 27 2 10 43 11 5 16 28 22 49 Source: FGD data, this study 32 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Household Perspectives on Sanitary Toilets TABLE 12: PREFERRED FINANCING OPTIONS FOR HOUSEHOLDS WITH A TOILET Loan from Bank Plan Other Ways of Financing Total Unspecific Loan VWU Children's Relative's Who Support Support Subsidy Savings Want Term Province (# of Bank Never Want Participants) 2 yr 3 yr 4 yr Loan Bank Loan Thanh Hoa 4 11 9 0 24 4 10 5 3 3 0 (N=29) Quang Nam 0 0 0 5 5 24 8 0 0 0 10 (N=31) Total 4 11 9 5 29 28 18 5 3 3 10 (N=60) Source: FGD data, this study 6.2.4 Suggestions for Overcoming Constraints · Learn about experiences from households that have Most participants had clear ideas about how they wanted to already built a toilet (six households). finance a new toilet (Table 12). In Thanh Hoa province, fami- lies favor bank loans, but in Quang Nam province, many One participant also wanted to know more about extra run- "don't dare to borrow for fear of not being able to pay back the ning costs for maintenance and to reduce the sludge. loan." Here, those without toilets prefer to save or get loans from relatives or through the VWU (savings and credit groups) While virtually everyone knew about the sanitary toilets, and also suggested that the government should subsidize toi- the different models and their costs and the benefits, those lets for the poor. Under the national Clean Water Program, who had not yet built a sanitary toilet said that they still communes can apply for a one-year allocation of a loan fund, wanted more detailed information to help them make a de- under which individual households can get an interest free or cision on installation (Table 13). The priority information low interest loan of maximum 4 million VND each for a toilet gaps that they mentioned relate to cost issues. They want and clean water supply. However, the amount allocated is lim- greater detail about the cost of the toilet components, ited and is for only one year and households are reluctant to building in stages, ways to finance the costs, and the costs of apply because of the administrative requirements. building a toilet in stages. The table below summarizes other information needs such as toilet models and designs, The FGD participants mentioned a number of ways in where one can buy cheaper materials, and cost and safety of which they themselves could reduce the costs to make sludge disposal. installation affordable: · Transport the materials themselves (six households); On the other hand, three participants were very explicit · Family constructs itself (two households) or its about not wanting any more information and promotion. members help in construction (three households); As one participant formulated it: · Buy the material in stages (three households); "I don't like to get any more information. If the gov- · Employ the mason in stages (three households); ernment gives money, I build a toilet. If not, I don't · Get training for self-construction (six households); build." (69-year-old farmer in Hai Thanh commune, · Get detailed cost-reduction advice from a mason Tinh Gia district, Thanh Hoa province) (seven households); www.wsp.org 33 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Household Perspectives on Sanitary Toilets TABLE 13: TOPICS ON WHICH FGD PARTICIPANTS WITHOUT SANITARY TOILET WANTED MORE INFORMATION Cost to Construct Cost Ranges Per Different Models Cost Ranges for to Cover Costs Sludge/ end Component Design Life Toilet Type Costs Per in Phases Cheapest Fair Price Per Type Disposal Fertilizer Provider Urine as Ways Province (# of Participants) Thanh Hoa (N=31) 29 28 28 23 26 1 0 0 0 0 Quang Nam (N=32) 3 4 4 4 4 1 6 1 3 3 Total (N=63) 32 32 32 27 30 2 6 1 3 3 Source: FGD data, this study 6.3 Observed Quality of Toilet Construction TABLE 14: NUMBER OF TOILETS WITH OBSERVED QUALITY and Hygiene BUILT DURING AND AFTER PILOT, AND MASON TRAINING In this section, the indicative results from some toilet obser- Mason Mason Not vations are reported. The purpose was to get an indication No. of Trained Trained Under When Built: Toilets Under IDE IDE of the extent to which the toilets constructed under the pilot and afterwards met the standards of MOH for con- During pilot 18 7 11 struction and hygiene, as detailed in Annex 7. After pilot 9 6 3 Total 27 13 14 The hygiene standards vary by type of toilet, but generally Source: Structured toilet observations, this study they reflect the following: enough water for flushing, no bad smell, no flies, no stagnant water/urine on floors, and no excreta/excreta smears in pans, etc., no mosquito larvae in water in or near toilet, no leakage from pit or tank, and a missing. Of those constructed during the pilot, IDE-trained rainproof superstructure. masons built one-third. For the toilets constructed after the pilot project this ratio was two-thirds. This could be ascer- In each study commune, the team visited the toilets of three tained because the local masons knew who had built each FGD participants together with the mason(s) who had toilet and if those persons had participated in the IDE- built them: two from owners who were satisfied and one organized training or not. who was not satisfied. The reason for the chosen ratio was the very low number of dissatisfied users in the FGDs. Four For scoring the quality of construction and hygiene, each more toilets were visited to ensure that all toilet types were toilet could get a value of one (lowest score) to five (highest represented. In total, the team members and local masons score) for each indicator that the MOH included in the observed 28 toilets together. The types observed were standard set for the particular type of toilet. The maximum double-vault pour-flush (6); ventilated improved pit (VIP) score on construction and hygiene was 5 x Y, in which Y (2); single-vault pour-flush (1); and septic tank (19). was the number of indicators for the toilet type concerned. The actual score for quality of construction and hygiene of Table 14 gives the details of when the toilets were constructed each toilet was the real score on scale 1­5 as a percentage of and by whom. For one toilet, the year of construction was the maximal score. 34 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Household Perspectives on Sanitary Toilets TABLE 15: OBSERVED MEETING OF MOH STANDARDS FIGURE 25: GRANDFATHER HELPS GRANDSON USE FOR TOILETS BUILT DURING AND AFTER PILOT THE TOILET Average Score Average Score Average for MOH for MOH Stan- Age of Construction dards on O&M Toilet Standards and Hygiene Period (in Years) (N 28) (N 28) 6+ 80% 78% 6 83% 80% During pilot 5 89% 89% 4 95% 92% After pilot 1 93% 100% Source: Structured toilet observations, this study Table 15 gives a summary of the average percentages achieved in each group (toilets built during the pilot and afterwards). The toilets built during the pilot project scored an average of 85% of the maximal score on the MOH con- struction standards. The toilets built after the pilot had an almost 100% score. However, from the figures in Table 15 this difference seems also to be related to the toilets' ages. 6.4 Views of the Toilet Owners The worst scores for construction and hygiene standards User households were generally very satisfied with their toi- (not reported in this table) were 57% and 53% (both only lets, irrespective of who had built them and when: one case) and were still above the 50% level. · "It was built by good masons, good quality." (Participant #3) On average, toilets built by IDE-trained masons had met · "The materials were good." (Participants #15, 18, 88% of the national standards, and those built by other 19, 20, 21, 25, 28) masons 90% (statistics not reported in the table). Who had · "It has ventilation and was built with good bricks." built the toilets thus made no difference for the adherence (Participant #26) to national construction standards. · "Everything is good." (Participant #3) Individual observations further indicated that toilets that However, some users also reported some problems with scored lowest had mostly been built with cheap materials to poor construction, referring to tank leakages or flooding of reduce construction costs. The most commonly observed tanks by rainwater: problems were signs of leakage in the ground and bad smells, · "The masons who built the toilet were not good, indicating cracked rings or leakages at connection points. because they were not trained under the sanitation project. I am dissatisfied that the walls are not water- The team also observed the place where people said they proof." (Participant #4) washed hands, if they reported this habit. Of the 22 house- · "Sometimes, the excreta storage tank is full with holds with this reported practice, 17 had soap present at the water, I must get the water out." (Participant #24) usual handwashing place. Some toilet training of children · "I must pump the water from the tank by force." was observed (Figure 25). (Participant #23) www.wsp.org 35 VII. Support from the Stakeholder Institutions Sustaining rural sanitation marketing and its results in the FIGURE 26: INTERVIEW WITH COMMUNE LEADER villages also needs an enabling environment from com- mune to national level. This chapter explores the attitudes and the continued support from the different types of stake- holders: the People's Committees and the health authorities at commune, district, and provincial level. The main stake- holders at the national level are the Ministry of Health, which is responsible for rural sanitation, and the RWSSP and its donors in rural sanitation. To assess the nature and sustainability of support from the civil servants at higher levels, ten semi-structured interviews were held with the vice chairs of the commune People's Committees or the heads of Cultural and Social Affairs. At the In the interviews the commune authorities were asked if district level, interviews were held with the leadership of the and how sanitation marketing support was sustained after district People's Committees and the district health officers. the pilot project had ended (Figure 26). Table 16 gives an At the provincial level, the vice directors of CERWASS were overview of activities by communes to support sanitation interviewed, as well as the vice director of the Center of Pre- marketing, showing that the range of activities is quite ventive Medicine in Quang Nam province. divergent. At the national level, interviews took place with the author- 7.1.1 Reasons for Continued Support ities of CERWASS, the health expert and the DANIDA In their interviews, the leaders in the more supportive advisor of the Preventive Health Department in MOH, the communes gave several reasons for the continued support. vice heads of Education and the Propaganda and Training Motivating factors given for including sanitation in annual Unit of the VWU, the coordinator of Rural Sanitation plans and resolutions and continued promotion and toilet Marketing of IDE, the country director of SNV, and rep- checks by the CHWs, VWU and VHs were the good results resentatives of the Australian Government Overseas Aid of rural sanitation marketing and (the annual competition Program (AusAID) and UNICEF. for the title of "cultural village." (Box 6) 7.1 Support of Sanitation Marketing As one chairman of a commune People's Committee by Communes explained: While the villages have been the core locations of rural "Every year, the district government evaluates vil- sanitation marketing, they have been supported by insti- lages for the title of `commune-level cultural village' tutions at other levels, especially the local government and and `district-level cultural village.' To get the title, a preventive health authorities in the communes and dis- village must meet the requirements regarding the tricts. Communes are the lowest level of local governance percentage of households using clean water and sani- and cover seven or eight villages. Table 7 showed that FGD tary toilets. The district and communal governments participants who installed toilets also cited commune verify the conditions before the recognition. How- workers and officials as important sources of sanitation ever, if a village does not meet the criteria, there is no information only less than the village promotion teams of sanction. We also use these criteria for the title of CHW, VWU and VH. `cultural family.' For Communist Party members 36 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions TABLE 16: COMMUNE ACTIVITIES TO SUPPORT SANITATION MARKETING Annual Resolution Monitoring Sanitation or Plan Concerted Construction Monitoring Nomination Saving Steering on Rural Action of & Quality of Sanitation of Cultural Clubs, Loan Commune Committee Sanitation Unions Work Coverage Families Program Hai Loc No data My Loc x x x x x x Hai Thanh x x Tinh Hai x Binh Trieu x x x x Tam Ahn Nam x x Tam Hoa x x x x x x Binh Hai x x Source: Commune authorities' interviews, this study. and the officials of the commune and village, these 7.1.2 Reasons for Less Support criteria are also included in the assessment of the Local commune leaders in less supportive communes gave fulfillment of responsibilities and duties." several reasons for the lack of support for the sanitation mar- keting strategy after the completion of the pilot project: · They were of the opinion that some families would continue to practice open defecation for reasons of BOX 6: CULTURAL HOUSEHOLD, VILLAGE, poverty and habit. COMMUNE, COMMUNAL HEALTH STATION, · They accepted that some households will still build AND DISTRICT new houses with old, unsanitary types of toilets, be- "A cultural household, village, commune, com- cause they see sanitation investments as private in- munal health station and district meet four criteria: vestments instead of an issue of public health and clean water, sanitary toilet, solid waste treatment environment. according to national regulations and treatment · They pointed out that families who lived in the of animal feces as per the national regulations. new Nghi Son Economic Zone were reluctant to These are also taken into account during the annual build sanitary toilets as long as they risked being evaluation of the local officials/Communist Party expelled and their land turned into industrial members on the fulfillment of their responsibilities. sites, as happened for the Petrochemical Refinery Complex Project (100 hectares), the FPC project If you are a Communist Party member and you are (10 hectares), and resettlement and road building an official or a state worker, and your family does (200 hectares). not have a sanitary toilet, you cannot be evaluated · Some complained that the promoted toilet models as a good official and a good Party member and and designs were not suitable for the very narrow your family cannot be evaluated as a cultural family." plots in their communes. · They have other priorities regarding public health ­Vice Chairman, Tinh Gia District People's than household toilets. In Hai Thanh commune, Committee for example, the priorities of the Commune People's www.wsp.org 37 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions Committee are a cemetery for Buddhist inhabitants not used at all or for other purposes, such as animal sheds so as to stop contamination from informal burials in and that if used for building toilets, these toilets were not the hills through rainwater runoff, and a solid waste always used or not used in a hygienic manner. As one com- collection and treatment plant: mune vice chairman said: "Environmental sanitation is a problem in the "After three years of implementation, we found that area. Our first problem is solid waste. It is esti- it takes time for people to raise their awareness. In mated that with two kilograms of solid waste per other projects in the past, the Government even household per day, we have six tons of waste a provided pre-cast slabs for local residents to build day. Our seafood is packed in nylon bags and sold toilets, but without promotion, they did not know to the Thanh Hoa factory, the local end custom- the usage and used those slabs for walls of pig and ers and the reefers coming from various places. cow barns. With this project, it seemed to be diffi- Nylon waste bags are as much a problem as house- cult at the beginning, but after being trained and hold waste. We do not have any garbage classifica- having knowledge on sanitation, many sanitary toi- tion, segregation and treatment. All that we can lets were constructed. Not as many as required, but do is encourage people to dry waste, then dispose the number of sanitary toilets increased from 10% or burn it. Plastic pieces or nylon bags should be to nearly 60%. Secondly, now people have knowl- left separately, as they burn only partially and edge on sanitation and the habit of hand washing cause toxic air and it takes a long time. We have before eating and after using toilets. To benefit from proposed a land area for the disposal and treat- the project, it is better to give them the fishing rod ment of collected waste to the district govern- than the fish." ment and are waiting for their approval. It is very difficult for us when we do not have land for These leaders also appreciated that the pilot project had treatment." given training on promotion and had supplied a manual with the different toilet models and construction guidelines In addition, there were quite divergent views on the no- for continuation. subsidy policy, as addressed in Section 7.2. Half of the communes had also made new sanitation action plans since the pilot project, e.g., setting new toilet targets 7.2 Sustainability of No Subsidy Approach (Tam Anh Nam) and integrating sanitation improvement A specific issue that emerged in the discussions with com- into other programs (Tam Hoa): mune leaders was the acceptance of the strategy of the pilot "We will try to persuade people and hope to build project not to provide any toilet subsidies, but to focus on about 100 toilets every year. 100% [coverage] is improving the local market, lower cost toilets, and low-cost impossible, but we aim at 90%." (Tam Anh Nam toilet loans. The interviews revealed two opposite outcomes commune) on acceptability and continued support of this strategy: "What we have gained here is that we integrate the 7.2.1 Positive Attitudes and Follow-Up content of the project into other programs. For ex- Several local authorities stressed that in the course of the pilot ample, programs of economic assistance, expanding project they came to appreciate the strategy of supporting the number of `cultural households' and creating capacity development and not individual toilet subsidies. fund rotation groups with the VWU." (Tam Hoa commune) They stressed that sanitation marketing with training and time for promotion was both more effective and sustainable than providing free toilet parts without promotion. Several The communes of My Loc, Binh Trieu and Tam Hoa have commune leaders recalled that these materials were either also continued the toilet loan program through the Social 38 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions Development Bank and local unions, such as the VWU and 7.3 District Views on Effectiveness and the Farmers' Union, as reported by this chairman of the Sustainability commune People's Committee: In this section, the findings from the interviews with the "In 2006 and 2007, we had interest-free and low- district authorities in three of the four study districts are interest bank-loan programs for poor households to presented (Thin Gia district in Thanh Hoa province and construct new toilets. The Social Development Bank Thanh Binh and Nui Thanh district in Quang Nam prov- also has loans for development of clean water and ince). A planned interview with a district stakeholder in environmental sanitation for poor people. The total Hau Loc district did not take place. amount of this program is up to 1.5 billion VND per loan." 7.3.1 Perceptions on Approach and Effectiveness of the Pilot Project All district leaders interviewed stressed the effectiveness of 7.2.2 Wrong Knowledge and Discontinuation the pilot project. Specific reported strengths were: of Pilot Strategy · Commitment: "IDE asked the district for a commit- At the same time, two commune leaders thought wrongly ment to increase the percentage of households with that the pilot project had given toilet subsidies to the poor, standard toilets to (in that district) 17% within three saying for example: "The cost for building each toilet is years. At the time, the percentage in the pilot com- 1.2 million VND, for which IDE provided only 200,000 munes was below 10%." VND." · Strategy: "We were also surprised by the approach of the project. They did not provide funding for construction, Two local leaders mentioned the discontinuity of the social but focused only on communication activities." loan program for sanitary households (maximum 4 million · Organizational support: "IDE has assisted us with a VND each for a toilet and clean water supply), including full organizational system from district level to com- this commune head of Social and Cultural Affairs: munes, villages, and residential clusters." "There are no credit programs for clean water and · Professional communication strategy: "Professional environmental sanitation in our commune. Some communication with various methods helped families wait until they can build a house to build change and raise the awareness of the local people the toilet. Poor households cannot afford the cost to on environmental sanitation and protection of the build standard toilets. At present in our commune it environment." needs at least six million VND to build a simple · Increased awareness, knowledge and skills: "The pro- standard toilet." fessional communication has raised the awareness, knowledge and skills to help residents overcome their In addition, several of the pilot study communes have specific difficulties to get access to improved toilets." discontinued the no-subsidy strategy. After the pilot proj- · Use of inside competition: "Different forms of com- ect they accepted new toilet projects in which interna- petitions for different groups of people: school chil- tional NGOs have re-established the direct toilet subsidies dren, women, farmers, etc. have also raised people's to (poor) households, e.g., in Tam Hoa and Tam Anh awareness and adoption of sanitary toilets." Nam: · Technical capacity development: "Another achieve- "Recently, we were offered assistance by the Pasteur ment is the technical staff who can carry out effective Institute for 100 households with 700,000 VND for works with low cost." each household." · Lower costs and better cost-awareness: "Before the "Over the last two years, 2007­2008, we got a fund- project, the residents thought it would cost 5­7 mil- ing of 120 million VND from East Meets West lion VND to build a toilet. Now it needs only Foundation for 400 toilets with [a subsidy of ] 1.0­1.2 million VND. So it is really effective from 300,000 VND for each." the economic aspect." www.wsp.org 39 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions · Greater coverage at higher speed: "These implementa- which will lead to behavior and social changes. This tion methods are very effective. The most important is always difficult. But when people have gained effectiveness is the increasing number of households knowledge and raised their awareness and changed who use sanitary toilets in the communes covered their behavior, it will be sustainable. So although the by the project in comparison with others. In accor- IDE project finished in 2005, the rate of toilet build- dance to our reports, the growth rates range from ing is higher every year." 4% to 6% per year. As for the concrete figures, you The district still maintains communication activities with know from this morning's meeting that the percent- women through the VWU. It also organizes contests for age of households with standard toilets in the project primary school students on knowledge of sanitarily toilets areas has been increased from about 30% to 50% and the benefits of rural sanitation programs. within two years, and even to 70­80% for some areas. So the number has been increased almost five Another way to sustain the sanitation program has been its times over two years. This result is really encourag- integration with the program "Building Cultural Families." ing for us." Cultural families must have sanitarily standard toilets. · Less open defecation: "Bad behaviors such as defecat- (Box 6) ing in open areas have been reduced much." How- ever, as mentioned in the heading this is a perception Perceived limitations in the sustainability of the approach which was not supported by evidence. are the depletion of the promotional materials, the absence · Better quality of life: "As staff, we think this [the sani- of financial allocations for new promotion materials, and tary toilets and freedom from open defecation] has the training of new promoters when existing ones are trans- made a great contribution to increasing the quality ferred. These questions were also raised at the provincial of life of the residents." level, as discussed in the next section. 7.3.2 Perceptions on Sustainability of Approach 7.4 Perceptions of the Provincial Sector and Results Authorities In general, the district authorities interviewed stressed that Interviews were held with the authorities in charge of envi- the nature of the tested approach (technical and communi- ronmental sanitation in the provinces of Thanh Hoa and cation capacity building, more affordable models of sani- Quang Nam and in charge of preventive health in the prov- tary toilets, no toilet subsidy) makes it possible for the inces and the vice director of the Center of Preventive participating communes to sustain the approach even after Medicine in Quang Nam province. Other than the dis- the pilot project's support has ended. tricts, the provinces had not been directly involved in the pilot project. The provincial authorities interviewed stressed In one of the districts, the chairman of the People's Com- the perceived strengths of the sanitation marketing mittee clearly expressed the difference between other proj- approach, but criticized the lack of provincial involvement. ects and rural sanitation marketing and the implications for sustainability: 7.4.1 Lack of Involvement of the Province "The approach used by IDE project is different from In his interview, one high official in CERWASS in Quang other projects in the areas. Some projects provide Nam province, who had been in that position since the mainly material support. This approach has an ad- early 1990s, stressed that the pilot project had been a vantage of being able to attract residents from the district-level project. The provincial authorities had there- beginning. But the disadvantage is that they will fore had no role in the developing, testing and sustaining of stop [the support] when the project finishes." the rural sanitation marketing approach. "IDE has a different approach. It was difficult at the "We have been informed about the project of IDE beginning, because the main input was communica- for a long time. They came here, talked to us, talked tion to provide people with the necessary knowledge, about co-operation, but then they carried out 40 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions everything by themselves. We don't know whether · Local supply of sanitation goods and services: "In recent they are still carrying out the project." years, I note that all kinds of sanitation materials are for sale right within communes, even toilet bowls. 7.4.2 Provincial Knowledge and Appreciation This is an advantage for local residents. And they sell of the Approach sanitation equipments even in some remote areas, Although they had not been directly involved, the three pro- but I do not know who the distributors are." vincial authorities interviewed were all aware of the pilot proj- · An effective approach in a difficult environment: "We ect and perceived it as effective for the following reasons: consider the result that IDE achieved remarkable. · Introduction of government cooperation for rural sani- They launched promotion in difficult areas: coastal tation: "In the past the government failed to mo- areas and areas with pollution from waste." bilize [the coastal communes] to construct toilets. They provided extension to farmers and fishermen 7.4.3 Sustainability of Sanitation Marketing and helped local people to improve their production as a Program and raise their income. However, regarding water and Under the new policy and program (see Section 1.2 above), sanitation, though the project staff was responsible the provinces are in charge of implementing the rural and active, they did not have a close cooperation." sanitation program. After discussing the effectiveness of (Figure 27) sanitation marketing, the provincial officials in CERWASS · High expertise on communication and social market- and the Preventive Health Department were therefore asked ing: "IDE used various approaches for different or- for their views and practices related to the longer-term sus- ganizations to make access [to sanitation] easier for tainability of a rural sanitation marketing program. the audience. In general, we think IDE staff is very capable and professional. They have been trained re- The two aspects that emerged from these questions were the ally well in communication skills. They use different financial sustainability of the promotion support and the forms of [of communication] and change them regu- adjustment of the provincial policies and programs. larly, depending on the target subjects. They some- · Financial sustainability: During the pilot project, the times worked during the day, sometimes at night [to three village promoters got an incentive of 20,000 reach and convince the target groups]." VND (USD1.20) per month. The four members of the Commune Sanitation Steering Committee re- ceived 100,000 VND (USD6) as they had to make a monthly report. The five District Steering Commit- FIGURE 27: COASTAL COMMUNES NOT EFFECTIVELY MOBILIZED IN THE PAST tee members got 800,000 VND (USD48) per person per month for training and coordination. According to one vice director of CERWASS the support for training of trainers, monitoring and reporting, allow- ances to promoters and funds for drinking water at village sanitation meetings are not affordable to the province: "IDE is a good project, we should promote it, but who will pay money for the promotion?" In his view, the local government can be effective as program implementer, but the central government should be a co-investor. · Current provincial rural sanitation policy and pro- gram. Quang Nam has a policy to subsidize toilets in isolated rural areas and continues to carry out an www.wsp.org 41 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions environmental sanitation program with ethnic mi- with the location where they work, so it may be norities in the mountainous areas of the province. known at the commune level, but not at district Implementation is through self-construction, there- level. When a period of duty finishes, the next per- fore without trained village masons, and with a toilet son in charge may not even know anything about subsidy in materials. The usual toilet model is the pit the work of the previous period. Or nothing is left. latrine: We [CERWASS] are responsible for the evaluation "They build dry pit toilets. The cost is not high. [of water supply and sanitation interventions] in the They excavate a pit of around one square meter. agriculture sector only." We provide them with the slab of reinforced con- crete, 2m x 2m, 10 cm thick. And we provide The Preventive Health Department also gets reports on them with metal sheets for roofing. The total sanitation coverage from their own professional lines, but quantity of materials is two bags of cement, 8 kg no data from other programs. As a result, there is no reliable of steel and 4 m² of metal sheet. On average, overview of progress in sanitation coverage and on differ- [each household] gets [materials to a value of ] ences in coverage between the different locations, popula- 600,000 VND (USD36) and they have to pay for tions and socio-economic groups. the rest. A completed latrine costs around 300,000-400,000 VND. The upper parts such as A sanitation survey recently done by the Preventive Health poles and roofing are removable. When the pit is Department of Tinh Gia district in Thanh Hoa province full, they fill it with soil. All they have to do is to had a sample size of only ten households per commune, too shift the concrete slab over a new pit." small to be representative for the whole population. How- ever, the budget of the district government does not allow The reasons for the current provincial strategy are: for larger and regular surveys. (i) the low payment capacity of the ethnic minori- ties; (ii) the low cost of pit toilets; (iii) the unsuit- As a result of these factors, there are only general indica- ability of septic tank toilets; (iv) the non-availability tions on rural sanitation progress: of cement and steel for the latrine slabs; (v) the "Through the reports from the districts about the re- absence of local experience with and expertise in duced percentage of poverty and diseases and the in- masonry work; and (vi) the high cost of bringing creased number of water supplies and sanitation facilities, in masons from the delta areas. Awareness and I think that the development is in a positive direction." construction have increased with this approach, but the strategic targets as set by the government have not been met. 7.5 Environmental Sustainability of the Approach 7.4.4 Monitoring of Sanitation Progress As reported in Chapters 3 to 7, the sustainability of sanitation Province-Wide marketing relates to the continued mobilization of demand, Besides provincial CERWASS, the Bureau of Agricultural supply of goods and services, increase in sanitation coverage, Settlement and the Committee of Ethnic Minorities Af- and support from the institutional environment. fairs, and a number of NGOs also implement sanitation programs in Quang Nam province. In general, the data on Environmental sustainability is defined here as the safe end dis- activities, outputs, and results are restricted to the programs posal of human feces in the form of excreta from filled-up toi- themselves. They are not aggregated at provincial level in a let pits and septic tanks. This topic was covered earlier in the rolling database. responses from the promoters (Section 4.5) and providers "Information concerning the projects and sources of (Section 5.2.4) and the consumers (Section 6.1). Septic tanks funding, etc. is known only by each organization were generally seen as the most hygienic option and their con- and is announced only in reports. This is common tents were wrongly thought to be "self-destroying"--in other for all agencies and organizations. They deal only words, many people did not realize that septic tanks must be 42 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions Both were also aware of the pilot project and supported the FIGURE 28: IN THANH HOA, THE HEALTH DEPARTMENT appropriateness of the approach for Vietnam: HAD CONCERNS ABOUT EXCRETA DISPOSAL AND REUSE "We used social marketing methods in several prov- inces with sponsored projects, but we think the method used by IDE is really effective." "I think the most important thing is to change resi- dents' behavior and thinking. If people realize the necessity, they will do it [construct and use sanitary toilets hygienically] themselves even without mate- rial assistance. And the problem will be solved more quickly. The approach used by IDE is reasonable for solving the problem of rural sanitation." Both participants stressed, however, that the national level was not formally involved: emptied regularly. Sludge can be reused, but only if well-com- "Actually I was not involved in the project." posted, or it must be safely disposed of. Only one interviewed "Personally I only know about the methods of social provider was aware of this opportunity and was thinking of marketing and the experience of implementation in offering a desludging service, but no questions were asked if the community, but I have never been directly in- this would be a sanitary service. volved in any projects. As for the IDE project, I only took part in the meetings and read the reports." In Than Hoa province the authorities expressed a concern about the time taken for the composting of the excreta It was further pointed out that rural sanitation implementa- (Figure 28). This was not always done or done long enough tion is at provincial level. While directives come from na- to complete the composting process before reusing the tional level, "Each province needs to set its own objectives treated excreta as fertilizer. and its own solutions. There is no single solution for every locality." Building the capacities of the provinces was seen as 7.6 Perceptions at Country Level the best way to realize the targets of the National Target At the country level, semi-structured interviews were held Program. with representatives from CERWASS, Ministry of Health "I think [that] in order to do it, in the next years we and VWU, the NGOs IDE and SNV, the donors AusAID, need to have clear orientation, especially on the issue DANIDA and UNICEF, and a manager of a large sanita- of rural environmental sanitation. I think the ap- tion company, Toto Industries, Ltd. proach used by the IDE projects in Thanh Hoa and Quang Nam is reasonable. We should focus on 7.6.1 Effectiveness and National Potential of Rural communication." Sanitation Marketing In their interviews, both representatives of CERWASS em- phasized that with the existing approach, Vietnam's MDG 7.6.2 Involvement of the Vietnam Women's Union targets cannot be reached: One of the key factors in the results of the rural sanitation "In general a lot of work needs to be done. I think it marketing (RSM) approach is the participation of the would need hundreds of years to solve all the prob- VWU. In the interview, its national representative ascribed lems of rural environmental sanitation." the good effects and sustainability of the rural sanitation "I think we can achieve if the criterion is only to have marketing project to the combination of the strengths of a number of toilets built. But to have standard toilets the VWU, the availability of lower-cost toilets, and the and operate them correctly I think it's impossible." training for the providers. www.wsp.org 43 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions She considered that the approach should and could be of NTP II. This will help to expand IEC, but methods for scaled up with and through the involvement of the VWU. mobilizing community participation and involvement of The VWU has a strong countrywide network at all levels: other unions beside the VWU should be strengthened. The groups, villages, communes, districts, provinces, and the representative of the VWU also stressed the need to central level. It has been involved in sanitation promotion strengthen the skills of its trainers and staff for community since the 1990s. It is also a member of the National Steering mobilization and participation. Committee of the NTP for rural clean water and environ- mental sanitation. A major challenge expressed by the CERWASS representative is also to have more evidence-based results on the longer- Furthermore, the VWU started the program that provides term effectiveness of IEC and social marketing investments: and guarantees household loans for clean water and sanitary "Actually we lack information about evaluation of toilets at nominal or no monthly interest from the Vietnam the projects, not only IDE. The evaluation is con- Bank of Social Policy. The VWU also stimulates women to ducted after 5­10 years, but I don't have access to the organize toilet saving clubs with monthly payments by all results. So we lack information about the effective- members. With 20 members and monthly payments of ness or sustainability of the project." VND 30,000/person it takes 20 months for all women to have a single vault sanitary toilet, provided the cost is no 7.6.4 Interviews with Other Stakeholders more than VND 600,000. However, in reality, most fami- Among the 14 partners that have signed agreements with the lies want costlier models or designs and take a much longer Ministry of Agriculture and Rural Development to support time to pay back their group loans, and the same happens rural sanitation and clean water, AusAID, DANIDA, and with bank loans (see also Folkard 2009a). This has limited DFID already provide or will provide both financial and the number of households that can use this instrument to technical support to Vietnam's rural sanitation program, finance their sanitary toilet. while the Dutch will continue to support it financially. 7.6.3 Challenges for Scaling Up AusAID Apart from the challenge of a financing strategy that en- In the interview, the senior sector specialist of AusAID ables poorer rural households to install the type of sanitary praised the experiments of GoVN with RSM and CLTS toilets that they want, one of the CERWASS representa- and the growing readiness to apply the new approaches in tives said that enhanced communication requires more fi- NTP II. For example, MOH now leads the new pilot in An nancial and human resources. Replication on a national Giang province as part of NTP II, with IDE in a capacity- scale can only be effective if the same professionalism is building role. Perceived areas for support mentioned were: used. This requires a special project or program to develop · Expansion of the range of sanitary toilet models, social marketing at scale and implement it district- and especially at lower cost; province-wide: · An agreed-upon national rural sanitation strategy; "The difficulty is who [is] to go and work for it. Social · Increased cooperation on sanitation between MOH marketing, as you know, is to create the needs and and all international and national NGOs working in provide ready goods for construction instead of direct rural sanitation; and investment in construction. But how can we create · Integration of, and skills for, collecting and analyz- the needs without projects? We lack resources." ing valid sanitation coverage statistics. Even large NGO programs lack these statistics or do not inte- The CERWASS official explained that under NTP I, the grate them with those of the government. As part of percentage of funding for information and communication the Participatory Poverty Assessments, the Vietnam- activities for rural clean water and environmental sanitation ese Government is familiar with PRA techniques for was less than 5% of the budget. After the evaluation of getting local data on poverty and these could well be NTP I, funding for IEC became about 10% of the budget applied in rural sanitation. 44 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions DANIDA training of sanitation providers so that proper installation In the interviews with DANIDA staff, it was said that materials and good skills are used. Integration of technical sanitation marketing is one of many good approaches to sanitation training in the curricula, and the education of promote sanitation and hygiene. However, it was recom- staff of technical training colleges are therefore other devel- mended to make provincial and district authorities aware of opment areas for sustainability and scaling up. the various good alternatives and leave adoption of the par- ticular strategy to local decision-making, as each approach Both the AusAID and DANIDA representatives inter- only suited a certain local area/community with specific viewed were of the opinion that the international and bilat- local conditions and context. Capacity building for the eral donor community united in the about-to-be revived local government and field staff was essential in view of sanitation group would be likely to react positively to gov- long-term sustainability. Further development for sanita- ernmental demand for technical assistance in order to scale tion alternatives for serving different groups of people with up and further develop the approach. different incomes, especially the poor, was also very impor- tant. In this context, DANIDA currently supports MOH SNV to promote more sanitary toilet models, including low-cost SNV reported on its piloting of CLTS in cooperation with options affordable for the poor. Together with AusAID and three provinces in the north and providing technical assis- the Netherlands, DANIDA also provided budget support tance to MOH and UNICEF in a fourth one. The approach to the Rural Water Supply and Sanitation Partnership is a good way to enhance sanitation demands in the villages. (RWSSP) National Target Programme II and was commit- ted to strengthening the government's structure, including An anthropological study was carried out in the north to for monitoring and evaluation GoVN et al. 2006). investigate motivating factors and barriers to ending open defecation and constructing and sustaining sanitary toilets. In a second interview it was mentioned that a rural sanita- However, the study only gave a snap shot of the current tion strategy is needed to give stronger direction and focus hygiene practices. Further research is needed to understand to sanitation programming. However, strategy develop- in depth the disease transmission route specific related to ment is taking a long time, not least because it is being de- water and sanitation for an intervention. It is relevant to veloped as part of a sector-wide sanitation strategy (U3SAP), develop and behavior change communication strategy which includes urban areas, under the leadership of the based on village and commune level investigation to de- Ministry of Construction. Reference was also made to the velop tools and tailored messages in hygiene promotion. At new standards for hygienic toilets, which are currently in the same time, further research is needed to look into the draft. These revised standards include six different models enabling environment to support the institutionalization of septic tank toilets as well as some lower-cost options, but process to anchor the hygiene component into the existing they do not yet have a philosophy and a strategy underlying health system. the range of options and its use. In each province, core district training teams have been The importance of the findings on sustained sanitary toilet trained that, in turn, train village facilitators. Training of adoption without financial incentives to government staff Trainers was done by Swan (Xuan) Mai College with sup- and/or toilet subsidies to households was confirmed, be- port from SNV. This training needs to be strengthened as cause the resources for nationwide application are lacking the anthropological study findings suggested shortcomings and such payments were shown to be unnecessary for good in facilitation skills. results. For further policy development, new pilots, but now with MOH in the lead, will be very important to find The village facilitators were linked to the government struc- the most cost-effective ways to help rural households adopt ture and were the same as the promoters in the sanitation safe toilets and good toilet hygiene. In order to meet the marketing project: CHWs, VWU leaders, VHs, plus school raised demand, any program should include technical teachers. These local teams triggered local demand and help www.wsp.org 45 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Support from the Stakeholder Institutions villages to make and realize village sanitation and hygiene sanitation progress, including access for the poor. This is the action plans. Experience showed that the facilitation skill of one of the main areas for SNV work to advance the sanita- these individuals is in question. It was observed that they tion and hygiene issue in the country. Sustainability and tended to give orders rather than facilitating the process-- hygiene were seen as missing links for CLTS and the focus understandable given the vertical structure of the country-- should be beyond demand creation. but more work is needed in this area. The supply component of rural sanitation marketing ap- In the opinion of the country director and the head of the proach was perceived as complementary to CLTS. The for- sanitation program of SNV, the supply component of rural mer made available the toilet designs, materials and sanitation marketing approach complements the CLTS ap- production, and construction skills that were weak in CLTS. proach. Rural sanitation marketing makes available the toi- let designs, materials and production, and construction Agreement between implementing non-governmental or- skills, which are all elements that are currently weak in ganizations (NGOs, UNICEF) is needed to achieve clarity CLTS. At the same time, SNV expressed the opinion that and harmony on rural sanitation strategies and principles. the RSM approach needs to promote a wider range of espe- cially low-cost designs and construction methods, and look UNICEF closer into the challenges of acquisition and transport in The representative from UNICEF said that the organization poor and isolated rural areas. At present, MOH has very is in favor of adopting sanitation marketing as part of a limited options and the authorities have been enforcing national sanitation strategy. In that case UNICEF would be construction. This was demonstrated in the three North willing to support the capacity building of the government West provinces where SNV works. In Lao Cai, the provin- cadres, VWU leaders, and the private sector. CLTS could be cial authorities passed a decision to form a toilet building adopted to enhance demand creation. The focus should be committee which instructs households to build sanitary increasingly on local government (districts and below). This latrines (septic tank, pour-flush, etc) for a 100% target by is also the most appropriate level for community-based February or December 2010 Furthermore, environmen- monitoring of rural sanitation, including access for the poor. tally sustainable and safe use of animal excreta, especially from pigs raised at home and by small and medium enter- prises (SMEs), as well as safe reuse and end disposal of Toto Industries Vietnam sludge from human and animal excreta need to be included An interview was also held with a manager of a large pro- in the program. ducer of sanitary wares in Vietnam, Toto Industries, on their interest in supporting the development of the knowl- CLTS could be linked to RSM to enhance demand cre- edge and skills of rural sanitation suppliers and masons on ation. The focus should be increasingly on local govern- a wider scale. His view was that Toto sells high quality sani- ment (districts and below). This was also seen as the most tary goods mainly for the urban market. At present, they do appropriate level for community-based monitoring of rural not yet have a strategy for the rural market. 46 Global Scaling Up Sanitation VIII. Scaling Up the Approach A final research question mentioned in Section 1.1 and the FIGURE 29: TINH GIA COASTAL AREA WITH NGHI SON ToR in Annex 1 was whether the marketing approach and ECONOMIC ZONE results have spread to other communes and districts. This chapter goes into this question and its underlying sub- questions: · Are there any signs of the approach spreading to neighboring communes in the pilot districts (the "spill-over effect")? · Have the pilot districts scaled up the approach to a district-wide approach or not, and why? And are there any observed impacts from this scaling up? · Is there any evidence of spontaneous development of sanitation market development without external intervention ("parallel development")? the households had sanitary toilets, but with the 8.1 Spill-Over and Parallel Development opening of the Nghi Son Economic Zone, now this Interviews with the providers confirmed that sanitation rate has reached 80% and even more. . . . Another products and services as provided under the pilot project example is Nghi Son commune. In Hai Thuong, Mai have spread to other, neighboring communes. Six providers Lam and Tinh Hai, you can see the change also." mentioned that they had expanded their work to neighbor- [Note: These communes are all in Nghi Son Economic ing communes. Five of them (Provider #s 3, 13, 14, 21 and Zone, but only Tinh Hai was a pilot commune]. 22) were members of sanitation networks, the other (Provider #20) was an independently working mason. However, such effects can partly be attributed to the sanita- tion marketing pilot project, as the spread has occurred in In addition, almost all providers (19 out of 21) said that neighboring communes only. As reported in Section 3.3, the since the pilot project many other masons and shops in same effect was not found in the comparative study com- their areas had taken up the construction of sanitary toilets munes which had the same general economic development, and the sale of sanitation goods. but which are located further from the pilot communes. 8.2 Scaling Up District-Wide District authorities in Tinh Gia and below in Nui Thanh In the scaling up of sanitation marketing to all communes district confirmed this development: "The promotion in the pilot districts and beyond, a distinction should be activities have positively affected other areas which are not made between attitudes and practices. Below, the findings under the project." are reported on both aspects from the interviews with com- mune, district, and provincial authorities. In addition, a district public health official in Tinh Gia dis- trict in Thanh Hoa province reported a more autonomous 8.2.1 Attitudes to Scaling Up "parallel development" in his area: In the interviews, several commune leaders recommended "But I think that the existence of Nghi Son Economic the replication of the piloted sanitation marketing approach Zone (Figure 29), the development of the economy of by other communes: the country in general and the local economy in par- "I think that the program should be multiplied in ticular, also have certain impacts. In Hai Ha com- the areas, with priority to the backward and poor mune, for example, in the past only around 10% of communes." (Tinh Hai commune) www.wsp.org 47 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Scaling Up the Approach FIGURE 30: INTERVIEW OF DISTRICT LEADER FIGURE 31: EFFECTS OF SCALING UP DISTRICT-WIDE IN NUI THANH DISTRICT 70 60 % Access to Sanitary Toilets 50 40 30 20 10 0 2005 2006 2007 2008 "This project is practical for people and should be During the After the applied in other communes. The beneficiaries are pilot project pilot project local residents. In implementation, they do not need % Hygienic Toilet Coverage in Nui Thanh District, Quang Nam Province financial support, they need promotion to raise Average 5 pilot communes Average other 12 communes awareness so that they can implement. Give the fish- ing rod, not the fish." (Binh Hai commune) Source: District statistics, this study "The model of this toilet project also needs to be applied in other districts/communes, as normally people can learn from each other. The good thing is that when trained masons of septic tanks do well, had achieved an average coverage of 63%. The lowest cover- others can also learn from them." (Figure 30). age in the 17 communes was 49%, just below the national The same attitude was also expressed by several district rural average of 50% and the highest was 96% (not shown authorities, such as in Nui Thanh district in Quang Nam in Figure 31). province: "The project areas can be considered as a model for other areas to follow." The Project Steering Committee of Hau Loc district in Thanh Hoa province also organized visits to and meetings 8.2.2 Scaling Up in Practice in pilot communes for the representatives of other After the pilot project, one district, Nui Thanh in Quang communes, so as to adopt the approach. However, they did Nam province, actually scaled up the sanitation marketing not organize any training events for these new communes approach with its own resources from five pilot communes and did not monitor the effects of the exposure. Box 7 con- to all 17 communes of the district. As shown in Figure 31, tains an excerpt from an earlier interview with this dis- three years into the pilot project, in 2005, the five pilot trict leader, who was then the district's vice chairman. communes still had a lower average sanitation coverage than the other 12 communes in the district. By the end of 8.3 Impacts from Parallel Development and the pilot, however, the pilot communes had surpassed the Scaling Up other communes. 8.3.1 Sustaining Good Quality Construction at Scale As reported above, evidence of larger scale "parallel develop- After this good result, the chairman of the district People's ment" (spontaneous supply services development without Committee urged the other local leaders to follow the ap- external support) was found in the coastal area of Tinh Gia proach in their communes. In 2007, these communes then in the communes close to Nghi Son Economic Zone. Here, started to catch up, and by the end of 2008, both groups the rapid expansion of demand and supply and the limited 48 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Scaling Up the Approach negative effects for the quality of construction and the sat- BOX 7: A DISTRICT LEADER'S VISION TO IMPROVE isfaction of the users: SANITATION IN NUI THANH DISTRICT "So far, there are ten thousand households who live In December 2002, the average rate of hygienic in the area of future site clearance, accounting for latrines in the communes in Nui Thanh, a district 1/5th of the fifty thousand households of the dis- located in south Quang Nam province, was only trict. I believe that the technical staff and the health 27.4%. The lowest commune rate was 4.45%. As workers did not properly supervise these households a keen observer and leader, the vice chairman of when they built their toilets. In Nghi Son and others the district People's Committee recognized the communes we have health staff to supervise toilet importance of hygiene and proper sanitation for construction, but [other than in the pilot commune people's health status for the local people. Earlier of Tinh Hai] they did not give supervision when sanitation projects had not been effective. needed and many households had completed the toi- let construction when they visited. Many toilets were When the IDE pilot program started in 2003, he constructed without consideration for all technical was skeptical because he did not think the market- regulations. I found that all mason groups had in- based approach would work in his district, where stalled the vent pipes [of the septic tanks] incorrectly. most people are farmers and fishermen and most I asked them why they used such small vent pipes. would not be able to afford to buy latrines with their They explained that this was for economic reasons. own money. The local leadership also doubted the Instead of pipes with a diameter of 90 mm, they used feasibility of an unsubsidized approach. However, pipes of 21 mm or 27 mm, which are cheaper. It is he was committed to making a difference. Using clear that [in scaling up] the proper technical process his prestige with local government, he promoted was not followed and the construction requirements the approach and helped set up the District Steer- were not met. Many people asked me why their toi- ing Committee and Commune and Village Steering lets have a bad smell, while they built sanitary mod- Committees in five pilot communes. els. I told them that they built incorrectly." After two years, he was very happy with the results His reported experience was that after the pilot project had and said Nui Thanh has never had such a suc- finished, the builders were not trained, so they built the cessful program. Earlier efforts had involved subsi- toilets incorrectly and the staff did not go to the households dies, but did not have the same results. Under the to instruct them on toilet construction. pilot project, access to sanitary toilets increased 13.62 percentage points in two years, compared The main reason in his view was that the CHWs were work- to a 4 percentage point annual increase earlier. His ing under the District Health Care Centre. Neither the dis- conclusion: "I fully support IDE's market-based trict health service nor the communes had the budget to strategies. These strategies not only help to im- train the local entrepreneurs and provide proper supervi- prove people's health but also ensure the sustain- sion when expansion was so rapid and on such a large scale ability of the program after IDE withdraws." as in Ngi Son, where many households were relocated and used their compensation money to build new houses with Source: Interview report, James Frias, Former Director IDE Vietnam sanitary toilets. capacities of the local authorities to guide this development 8.3.2 Perceived Impacts on Public Health made it impossible to sustain the technical construction Unlike for TSSM, there was no health impact evaluation of quality of the sanitary toilets. In an interview, a senior pub- the sanitation marketing project. However, because a suffi- lic health official of Tinh Gia District in Thanh Hoa prov- ciently large "critical mass" of sanitary toilets can make a ince reported that the rapid market development had substantial difference for public health (Esrey 1994), several www.wsp.org 49 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Scaling Up the Approach district health officials were asked about their perceptions 25% in 2003­2005 to 14­15% now. Therefore, the on the public health impact. Their responses reflected the project has had positive effects on people's health, different district access coverage levels for sanitary toilets. on poverty elimination, and diseases reduction. It is really an effective program, suitable for people in The district leadership in Nui Thanh, which at the time of poor rural and mountainous areas." the interview had a district-wide sanitary toilet coverage of 63%, reported positive correlations with public health, In Tinh Gia district, the average sanitation coverage for the child nutrition, and poverty reduction. district was much lower than in Nui Thanh (31% vs 63%). "From the environmental aspect it is also very effi- Here, the district leadership reported an increase in fecal- cient to improve rural environmental sanitation. oral diseases, which may well be associated with this low Diseases and even epidemics used to be very com- coverage and the absence of a critical mass. mon due to poor environmental sanitation. But "In the past, Tinh Gia was a poor district. Partly due since 2005 there has not been any epidemic in our to its [poor] sanitation, we used to be confronted area. That is the direct effect of the sanitary work as with fecal-oral diseases. Their incidence is still in- part of the health care. I think it has also positive creasing. We have looked for reasons, but due to our effects on other programs, such as the anti- limited financial budget from the local government, malnutrition program. Nowadays, about 16% of the we cannot conduct surveys. The only data which we children in the area have nutritional deficiencies, have comes from the reports of our line staff and this while the figure in 2003­2005 was 26­28%. So the shows that the proportion of households in the dis- situation has clearly improved. The percentage of trict who have sanitary toilets is only 31%." poor households has also been reduced, from about 50 Global Scaling Up Sanitation IX. Conclusions, Lessons, and Recommendations At a second Stakeholders Meeting on September 9, 2009, the without pilot project, support the conclusion that the re- team presented the preliminary conclusions and lessons in sults of greater and speedier access can be attributed mostly Vietnamese and English along with a summary of the find- to the marketing approach rather than to general economic ings. The findings had also been enumerated in the Prelimi- developments. Three major conclusions can be drawn relat- nary Report, done only in English, which was sent to the ing to the sustainability of this approach, specifically re- meeting participants in advance. The participants' list is given garding better promotion of demand and better meeting of in Annex 5. The feedback received was incorporated in this consumer demand by the supply side. end report, including the conclusions and recommendations for the national sanitation program reported in this Chapter. On the promotion side, the case study showed that a To these have been added the lessons for sanitation programs combination of existing local functionaries--in this case in other countries, including the countries of the TSSM proj- a combination of the village head, community health ect and SAWAP in the Mekong Delta. worker, and local leader of the Vietnam Women's Union-- were ready and did continue to promote rural sanitation as 9.1 Conclusions on Sustainability part of their regular tasks. This sustainability occurred in of Results and Approach communes where the initial commitment and support from 9.1.1 Sustainability of Sanitation Marketing Results higher government levels did not continue. From 2003 to 2006, the local government, MOH, VWU and IDE piloted a rural sanitation marketing approach in A second conclusion on promotion is that, other than on Thanh Hoa and Quang Nam provinces. As seen from the the supply side, there were no particular innovations. findings reported in Chapter 3, the approach has proved to Promotion continued, but at a lower level of effort. There be an effective and sustained strategy to speed up access to was no special strategy to enable new promoters to take over rural sanitation, using external funds for capacity building when the existing ones were to be transferred, to train instead of household subsidies. promoters in neighboring communes and districts, and to tailor promotion to the much more specific needs of the The average annual growth in rural sanitation coverage, poorest and remaining households who do not have which in the study sample was 6.4 percentage points per improved sanitation. year, became 7.5 percentage points in the two years after the pilot project had ended. On the supply side, the case study demonstrated that sus- tainability was achieved because the providers continued to These results were much better than in the two of the four develop their businesses, both on their own and through comparative communes without sanitation marketing for their networks. which longitudinal data could be collected. In the first comparative commune the annual sanitation coverage 9.1.3 Costs and Effectiveness of the Approach growth averaged 1.25 percentage point in 2003­2006 and Because the case study did not include a cost-effectiveness fell to 0.5 percentage point in 2007­2008. In the second study, no real conclusions can be drawn on this point. commune sanitation growth even became negative, that is, However, the original ratio of investment of 1:2 for the less than the annual growth in population. project and the households established during the pilot period seems acceptable. This is especially so because both 9.1.2 Sustainability of Sanitation Marketing Approach consumer and provider investments have continued to The use of a study sample with a mix of communes with grow without additional inputs for promotion from the high and low toilet adoption by regular and poor house- government's side. The original investments have thus con- holds, and the comparison with two matched communes tinued to pay off after the end of the pilot project. www.wsp.org 51 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations However, from the study it can also be concluded that this As reported by the providers, there were indeed signs of a effectiveness is unlikely to be sustained without new invest- natural spread of the approach. Other providers who had ments, particularly in terms of periodic consumer research, not been trained by the project copied the examples of capacity building (for new promoters and providers), advo- those who were trained. The newcomers to the field used cacy (for a supportive environment), further development observation, peer contacts and cooperation in networks, and supply of promotional materials, better linkage with and the IDE-developed toilet design and construction local mass media channels such as the commune broadcast- manual. As far as could be determined through focus group ing services, and the development of a special marketing discussions with toilet owners and a very small number of strategy to reach the poor. toilet observations in a non-representative toilet sample, there were no differences in quality of construction for ma- 9.1.4 Reaching the Poor sons trained during the pilot and masons who had learned Three important conclusions can be drawn from the findings the job themselves in the ways described above. in relation to reaching the poorest households. The first is that with their current approach the promoters did reach the In addition, the provider networks--both the existing ones poor. Virtually all the participants in the focus groups with that were sustained and the newly formed--had expanded householders without a toilet, or with an unsanitary type of their business to neighboring communes. Presumably, the toilet, had been reached by the information and wanted to households there had also come to know of their services, build a toilet, and one third were already saving for one. but since no questions were asked about how the business expansion was managed and no consumers in neighboring The second conclusion is that the approach has built in mea- communes were interviewed, no conclusions can be drawn sures to make the toilets more affordable for the poor, such as about how this natural expansion process has worked. construction over time and loans for construction. The pro- In one district, the district health authority reported that viders also offered different credit services for the poor and "parallel development" (spontaneous market developments continued to develop this service as they said that they pro- without external intervention) had occurred on a large vided credit more often now than during the pilot project. scale. This was in an area where economic development was so rapid that the capacity built by the pilot project and the However, as the focus discussion with those without sani- natural expansion described above were insufficient to meet tary toilet showed, the marketing strategy to serve the poor the growing demand. When many others began to build was not detailed enough to meet their requirements. Poor sanitary toilets, quality of construction and user satisfaction householders wanted much more detailed information dropped, due to the absence of training and consumer edu- about ways to cut costs, spread investments over time, and cation, and a lack of capacity of the local health staff to vet different ways of financing than provided under the existing construction and list masons that met the MOH construc- more general marketing approach. tion standards. There had also not been any new household studies to assess Although most authorities knew the pilot approach and its if changes in the factors influencing behaviors had occurred results and liked it very much, scaling up district-wide (pur- among the different types of consumer categories, so that posive replication by the district in all its communes) did marketing strategies could be adjusted accordingly. not happen automatically. Only one of the four study dis- tricts, Nui Thanh in Quang Nam province, gave the direc- 9.1.5 Spill-Over, Parallel Development, tive on the adoption of the approach and the training by the and Scaling Up district trainers to all its communes. The effects were im- Other study objectives were to investigate if a natural spread pressive. In two years, the other 12 communes had caught of the approach to neighboring communes ("spill-over up with the five pilot communes reaching an average sanita- effect") occurred and if there were any signs of spontaneous tion coverage of 63%. This district-wide average was 13 per- marketing developments without external intervention. centage points higher than the national average. 52 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations 9.1.6 Gender and Poverty Alleviation Lack of local government resources, which other authorities The strategy of the pilot project to target especially women gave as reason for not scaling up, seems to be less a reason through the women leaders and the heath workers has than lack of conviction. A demonstration was that provincial worked well in these two provinces. From the interview funds that could have been used for capacity development with the promoters, the providers and the FGDs, it became for sanitation marketing and refinement of the marketing clear that women remained the most interested in having strategy for the poor were used for toilet subsidies in poverty sanitary toilets, but that the couple (and sometimes their zones without great progress on sanitation access. children) made decisions for the installation jointly and harmoniously. However, this may be different for other re- A further condition for a sustainable program at scale is that gions in Vietnam and elsewhere, if in these areas there is less teams from the local governments at district and province agreement on sanitation as an investment priority between level become the program implementers. This is in fact al- members of rural households. ready happening in Yen Bai province in northern Vietnam, where IDE is no longer the project manager, but has be- Sanitation marketing further enabled men who worked part- come the trainer, while the district and provincial time in sanitation to move out of the agriculture and fishery authorities are in charge of the project. sectors and obtain better jobs with more career prospects in small-scale enterprise. Thus, it can be said that rural sanita- 9.2.2 Sanitation Monitoring tion marketing has contributed to Vietnam's policy and strat- A second major lesson is the need to have a simple, low- egy of rural poverty reduction, be it without a specific strategy cost, yet comprehensive, and computer-based ongoing for gender equity in the capacity development of the provid- monitoring system that allows the authorities to monitor ers. In the study area the latter had benefited only men. and compare rural sanitation coverage at commune, district, and provincial level. This monitoring system 9.1.7 Monitoring of Rural Sanitation Access needs to specify sanitation coverage for the different socio- A major conclusion that can further be drawn from the economic groups. Such a system is needed to facilitate findings is that there was no proper monitoring system in evidence-based reporting on rural sanitation progress the study communes, districts and provinces. Missing were: through the possibility to learn from the best performers (i) monitoring of toilet access for the different income and analyze problems in, and give support to, locations levels, so that it is possible to monitor sanitation coverage that lag behind. developments for the poor vs. the non-poor; (ii) the combi- nation of data from all the local sanitation projects of 9.2.3 Access for the Poor different government departments and NGOs; (iii) the ag- Because the commune authorities did not sustain the gregation and integration of the data into a simple, com- poverty-specific monitoring that IDE introduced during puterized, and comparative data system at the commune, the pilot project, it was not possible to learn if access for the district, and provincial levels. poor, which was lower during the pilot project, became bet- ter or worse or remained the same afterward. However, 9.2 Lessons Learned for Vietnam from the focus group discussions with householders with 9.2.1 Scaling Up of the Approach no or no sanitary toilet, it became clear that sanitation mar- The example of Nui Thanh showed that, once initially keting needs not only a general strategy suitable for the trained, districts can scale up the approach and achieve upper and middle classes, but also a much more finely good results of sanitation marketing district-wide with their tuned strategy for the poorest section of the communes in own resources. However, the scaling up in Nui Thanh hap- the particular program areas. pened because an influential "sanitation champion" took the lead and the district was willing to use the developed An important lesson was also that while both households capacity to train the promoters and providers in the other and providers used many different ways to facilitate the district communes. financing of their toilet construction, they were not www.wsp.org 53 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations evaluated on their comparative effectiveness. Neither were 9.3.1 Adjustment of National Rural Sanitation Strategy they combined into a concerted and general strategy that and Program would make it easier for poor households to participate in Given the good results on the sustainability of the approach the rural sanitation marketing program. and its results in general, rural sanitation marketing deserves to be made part of the national rural sanitation strat- 9.2.4 Toilet Subsidies egy and program. Furthermore, the provinces, which are the There were two major lessons learned in regard to toilet program implementers could be encouraged to include the subsidies: approach in their provincial strategy and action plan. The first was that without toilet subsidies access to toilets 9.3.2 Development of National Capacities could improve more rapidly than before, and continued to To strengthen capacity for rural sanitation marketing, vari- do so, when a proper rural sanitation marketing strategy was ous options could be considered. One option could be to applied effectively. develop a system of horizontal learning. Under such an ap- proach, district and provincial trainers and steering com- The second lesson was that for many of the local govern- mittees in pilot districts and provinces (now expanded to ment authorities and all but one of the FGD households some six provinces) orient and train their colleagues in without a sanitary toilet, government subsidies for the poor neighboring districts and provinces. were not the solution for rural toilet construction. Another option could be to involve rural education insti- In particular, about half of those interviewed at institutional tutes for training-of-trainers in a scaling-up program, such levels pointed out that subsidization on a national scale in as was done for CLTS with the use of a regional rural col- its existing form was very costly, difficult to sustain, and had lege. However, implementation will depend on the indi- problems of transparency and integrity (if subsidies for the vidual provinces. A first step for creating a demand for the poor are available, everyone tries to get on the list of poor approach among them would be for the RWSSP and the households). Subsidies in individual projects from NGOs supporting donors to organize exchange visits to the pilot and other actors were also reported as not being a good locations for the political leadership, VWU, heads of the solution, because they were short-term and served only preventive health departments, and other key stakeholders limited numbers of households. of the provinces in those regions. These lessons show there may be two ways forward. The first would be to develop and test a special marketing 9.3.3 Improvement of New Rural Sanitation strategy, tailored to serve the poor, such as mentioned Marketing Initiatives above. If working, this might well make it unnecessary to In new sanitation marketing programs it would be useful to have a countrywide toilet subsidy for poor households. The include investment for (i) periodic consumer research; second would be to develop a much better targeted toilet (ii) advocacy for sanitation and sanitation marketing; subsidy for the poor, which is transparent, accountable and (iii) capacity building of the authorities and the promoters locally-specific as described in Box 8 in Section 9.3.4. and the providers and their trainers, not only at start, but also periodically to train new actors over time; (iv) development of promotional materials and channels; 9.3 Recommendations for Further (v) and the integration of gender equity in provider capacity Development in Vietnam building. From the above conclusions, five specific recommendations were drawn for the further development of rural sanitation In particular it would be useful to institutionalize capacity in Vietnam. They are detailed in the next paragraphs. development by investigating the possibility that the 54 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations districts establish ongoing training programs for promoters and providers and/or incorporate training on rural sanita- BOX 8: TRANSPARENT, ACCOUNTABLE, AND tion marketing into the education programs of rural train- LOCALLY-SPECIFIC TOILET SUBSIDY FOR THE ing colleges. VERY POOR In the interviews, several problems with toilet subsidies based on national poverty criteria were 9.3.4 Development of a More Specific Approach given. for the Poor A major recommendation that emerged from the findings The problems noted included the large numbers and conclusions is to develop and test a special rural sani- of the poor based on national criteria and the lack tation marketing strategy for the poor (Box 8). This strat- of resources for providing a toilet subsidy to more egy could include, for example: more detailed information than a small number of households and for more on, and discussion of potential cost reductions; more than a short period of time. Problems of integrity evaluation of, and information sharing on, the different ("Are those on the lists really poor?") and trans- ways of financing for households and providers; and a parency and accountability in allocation ("When more detailed trajectory for staged construction, such as resources are not sufficient, who gets a subsidy buying and storing materials over time (less sensitive to and based on which criteria and decision-making inflation), building in more stages, making an x-year con- process?") are other common problems with a struction plan for a toilet/bathroom, and uniting to buy nationwide rural poverty standard, and with toi- goods and services in bulk. let subsidies based on it. These have been the main reasons for developing a targeted toilet Possible elements for such a strategy that emerged from subsidy which is transparent, accountable and the discussions and interviews were: locally-specific. · Conduct formative research to get more insight into the barriers and facilitators for the poor to upgrade The approach uses participatory set indicators unsanitary toilets or construct sanitary toilets. This is (e.g., through a democratic process in a local needed because in this case study no in-depth study council or a PRA activity with a meeting that of these aspects was carried out. equitably represents the different sections in the · Train promoters and masons to fine-tune informa- community) to identify the locally very poor, who tion to the special needs and demands of the poor need a subsidy most. It then makes the choice that emerge from such as study. From this case transparent by displaying the criteria and selected study it emerged that the current information on households. Accountability is ensured by linking models and costs was too general for the poor and listings to actual allocation in cash or kind, and that this group wanted more details on, and discus- actual toilet construction. Some local govern- sion of, possible ways to save costs, buy materials ments also use the income from a local tax, such and construct over time, save or make money from as transport or house construction tax, to estab- productive use of excreta in combination with a lish their own permanent fund for a toilet subsidy more attractive design of the composting toilet (the for the very poor. use and current toilet model were considered out- of-date), and different ways to finance investments, each with their pros and cons. However, the interviews and FGDs brought to light several · Develop and test better financing mechanisms in possibilities for testing: an applied research project. From the case study it · Promoters and providers could be trained to give emerged that for toilet financing no single solution the poor an informed choice not only on technolo- fitted all. gies, but also on the financing options and their www.wsp.org 55 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations respective pros and cons. In each network one or · It generates valid and class-specific data, or in any two persons should further have detailed knowl- case poor-specific. edge on how to tap into the various loans and sav- · It is progressive, that is, new data is added each ings schemes, and promoters and providers should year while those of the preceding years remain refer potential customers to these persons. available. · In their training, the providers could get addi- · It is low-cost, user-friendly, and runs on existing tional information on potential business financing software. services and the implications of each type. How- · It can be used by local health staff and authorities ever, this strategy does not extend to sanitation from village-level up without elaborate and expen- loans for small-scale providers. sive training. · Promoters and providers could be trained to give · It uses participatory methods to increase aware- poor households a much more detailed trajectory ness, transparency and accountability. for a staged construction of a modern toilet than the · It combines the data from different government current message that they can first build the upper and NGO programs. ground part with temporary materials and then · It is possible to aggregate the data into simple, gradually replace the upper part with more perma- computerized databases such as spreadsheets that nent and attractive materials. They could inform the make it possible to compare change across com- customers about, for example, which permanent ma- munes, districts and provinces. terials they can buy and store over time, which parts · It uses data at each level for trend analysis, plan- they can build in permanent form and which as tem- ning, monitoring, accountability, and adaptive porary parts, and how to make, for example, a three- management (that is, acting upon findings from year toilet or bathroom construction plan. analysis to improve results). · Networks and others in the overall supply chain could be encouraged to produce their own low-cost An action research project as part of NTP II could de- promotional materials. These could inform house- velop and test, on a demand basis, such a system with a holds who want to build a modern toilet on the de- group of communes, districts and some provinces. sign and bill of quantities of the different models, give information on where low- and no-cost local materials could (and should not) be used, and which 9.3.6 Combining Rural Sanitation Marketing materials they could buy and store instead of saving with Other Approaches for such a model and losing a substantial part of the Much might finally be gained from combining rural sanita- capital to inflation. tion marketing with CLTS and other approaches (e.g., · Promoters could encourage households to form community health clubs, domestic hygiene improvement groups and get discounts when buying materials groups), which MOH, SNV, UNICEF and others pilot in in bulk and hiring masons together. The resulting other parts of Vietnam, especially to address open defeca- economies of scale would benefit everyone and tion and link better sanitation with good hand-washing make it easier to negotiate with the local provid- habits and a safe drinking water chain. This is further dis- ers for better deals in materials, transport, and cussed in the next section. construction. 9.4 Lessons for Wider Application 9.3.5 Development of a Better Rural Sanitation and in Other Countries Monitoring System From the case study on sustainability a number of lessons The case study showed that tracking sanitation access would can be drawn for other rural sanitation programs such as be greatly assisted if a simple monitoring system could be TSSM and SAWAP. They are detailed in the sections developed with the following characteristics: below. 56 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations 9.4.1 Sanitation Marketing so may make it harder and more costly to get the same 9.4.1.1 Promotion by the Triumvirate results in the same short period. A first set of factors important for the success of RSM in Vietnam has been the use of a team of three project-trained, For example, CHWs are present in India, Indonesia and institutionalized local frontline workers at the village level Tanzania, which are the three focus countries of the Global (CHW, VH, and VWU leader) and the methods employed Scaling Up Sanitation Project but as far as is known, in by them. The teams used a mix of IPC methods, consisting Tanzania they are not stationed down to community level of talks and discussions (including by trained toilet masons) and in India and Indonesia not down to village level. This in special sanitation and other meetings, and home visits. will make it harder for the CHW workers in these countries They also used messages that were based on consumer to play a similar crucial role in rural sanitation marketing as research in the project areas. they did in Vietnam, unless higher-level CHWs can cooper- ate closely with village-level volunteers and organizations. The frontline workers were all existing staff, of whom the CHWs and VWU leaders already promoted sanitation and With regard to women leaders as sanitation promoters, hygiene before the project as part of their government-paid there may also be differences in their availability, influence, regular work. The project gave them training to improve mobility, payment, and training in other locations. their communication skills, learn about the range of tech- Formative research is therefore needed to assess if they nologies and use messages based on consumer research, and could promote sanitation in other countries and parts of not on their own perceptions and earlier training. countries, including to some extent in Vietnam itself. Tanzania has, for example, a national women's union and The involvement of the three types of workers, their train- Indonesia a national women's program. Both have leaders ing and the messages and the mix of methods used have down to the commune level, and pending insights from been very effective in achieving a four-fold higher increase further study their women leaders could be involved in the during the pilot project in the construction of new sanitary same way as they were in Vietnam, as promotion of health toilets and the upgrading of unsanitary ones than in the and hygiene is part of their function. A national women's three previous years (see Figure 6). program does not exist in India. Here, the Child Environment Development program, GoI and UNICEF, The approach in rural Vietnam may be replicable to some which promoted safe water, sanitation and hygiene in 57 degree in other countries. However, much will depend on districts in the 14 poorest states, used program-paid the local conditions. The numbers of households to be and-contracted women promoters instead of CHWs and reached by the local promoters, their willingness to women leaders. An investigation would be needed to know participate in and their experiences with working as a team, what happened to these women and the sanitation the ease of access, local transport, transport time situation, promotion after the Child Environment Development and the familiarity with and trust of the local promoters program ended, and what other alternatives to raise and leadership may all play a role. In Vietnam, the demands for sanitary toilets and follow up quality of community health workers, women leaders, and village construction and use might be available. Many countries heads were government-employed. They were stationed at further have elected and government-paid heads at the the village level (one commune in the study area consisted lowest government (commune) level. However, not every of some seven villages) and the teams were formed and country has paid village-level heads, as in Vietnam, whom trained by the district authorities. Two of the three team the government can ask to promote toilets through, among members also had sanitation promotion included in their others, home visits to individual households as part of their tasks and had done promotion before. Finally, the project work. Interest in, commitment to, and credibility and settlements were densely populated and covered relatively acceptability of such home visits for promoting toilets may small areas. Some or all of these factors may be different in also vary. At the same time, village leaders in (among other countries and in other parts of Vietnam as well, and others) Bangladesh, India, and Tanzania have played a role www.wsp.org 57 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations in promoting sanitation in CLTS programs. Part of the 9.4.1.3 Support from Other Local Organizations combination of the strengths of RSM and CLTS would be Another lesson from the case study is that both during and to study the ways in which village heads are best involved after the pilot project, the local promoters were supported in these approaches and to harmonize and blend the by other local organizations. The Farmers' Union, Soldiers' approaches in the different political, administrative, and Union, Youth Union, and Old People's Union invited pro- socio-cultural conditions. moters to their monthly meetings to raise the sanitation issue and promoted improved sanitation among their mem- An interesting lesson from Vietnam has further been that bers. When such organizations are present in other coun- the abolishment of the monthly promotion incentive equal tries, it will be useful to advocate for and achieve their to USD1.20 at the end of the pilot period did not put an support. Schoolteachers and children also supported pro- end to the promotion activities. Although the intensity motion in some Vietnamese pilot communes, although and variety of promotion methods declined, promotion there was no systematic involvement and the promoters re- had become institutionalized, i.e., sanitation became a mained the lead. This was different in Nepal and Pakistan, fixed subject in meetings and was done on one specific day where school-led rural sanitation program have had good of the month, which each commune gave its own special results (Wicken et al. 2008). name. In the study sample, the rate of progress in sanita- tion coverage also remained the same as during the pilot 9.4.2 Private Sector Development project, and two of the three villages that had lagged High annual economic growth rates and the labor surpluses behind caught up. from small-scale agriculture and fisheries have been typical for the socio-economic environment in the Vietnamese Where no promoters at the local level are available within pilot project region both during and after the pilot project. the formal government system, one option could be to see After the abolishment of the communal farming system in if the CHWs could organize, build the capacity, and moni- 1986, Vietnam's agricultural production levels increased tor local volunteers, such as a local sanitation, water or sharply. This brought a decline in rural poverty and an in- health committee, the local women's group, youth club, or creased demand for non-agricultural goods, especially in the local community and school health clubs to combine the higher potential regions. At the same time, land scarcity elements of RSM and CLTS. gave rise to unprecedented migration to small and large urban centers (Tacoli 2004). 9.4.1.2 Promotion by the Local Private Sector A second characteristic of the successful rural sanitation When approached by IDE, both small farmers, who already marketing approach in Vietnam is the participation of the worked as masons in the off-season, and small private entre- local private sector in the marketing of improved sanitation preneurs, who dealt in agricultural supplies and general through information dispensed during calls from potential construction goods, responded to the opportunity to diver- customers, talks at meetings, home visits to potential cli- sify their businesses. The training by IDE and their stimulus ents, etc. to form networks of delivery chains with fellow workers and family businesses came at the right time to build the Both in Vietnam and in other countries this potential could capacities of those selected so they could make the best use be developed. From the study findings that some 10% of of this changed environment. Since then, this economic their business is in sanitation, it is not realistic to expect and social development has continued and other providers that small businesses invest more in information, commu- in the same and neighboring communes have copied the nication and education individually. However the larger local examples on a small scale through observation, talks, businesses in the supply chain and/or certain persons within and self-study of the construction manuals made available their business networks may have the potential for more by IDE. It should further be noted that none of the entre- active promotion and their capacity to do could be preneurs, established or new, got any capital or loans to developed. start with or expand to sanitary wares and services. 58 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations IDE's strategy was that the project did the technical and mar- 9.4.3 National Toilet Standards ket research and financed the strengthening of the capacities A further characteristic of the pilot project in Vietnam was of selected local entrepreneurs in areas where a market might the presence and expansion of national standards for emerge. The project gave no material support to either entre- sanitary toilets, defined by MOH, and the emphasis on preneurs or households and did not provide follow-up sup- those standards in marketing, supply, and training. Under port either. Local business people and customer households the prevailing socio-political culture in the country, the were to lead by example and personal communication to sus- promoters placed a lot of emphasis on meeting the tain sanitation growth. This approach has worked well in the standards. Households, villages and communes all aspired above-described economic and social environment as long as to having the title of "cultured" household, village etc., a growth of demand and supply was sufficiently gradual. The sanitary toilet being one of the criteria for such title. approach is quite different from the strategy pioneered by Meeting all these criteria is even compulsory for village UNICEF in Bangladesh and India, and now scaled up by heads and other party officials. Surprisingly, however, the GoI (2007) to give subsidies to local governments, NGOs standards did not apply to the offices and meeting halls of and women groups to start specialized production centers the People's Committees--the national policy set targets and sanitary marts, and to operate a revolving toilet fund. for institutions, but these were related to schools and health stations (who invited local providers to make Capacity building of small enterprises without subsidiza- toilets), while the People's Committees did not do so for tion and imposed specialization may also work quite well in their offices and halls. similar environments elsewhere, although the Han Viet- namese have one of those cultures in which the spirits of These titles are honorary, other than for example India, enterprise and trade are highly developed. The approach where GoI (GoI 2007) gives a financial award for every did, however, not work in that part of the pilot area that had community that has achieved ODF status, which is not a very steep growth in development, because peer learning necessarily sustained and verified over time. (See Khurana and quality control mechanisms could not keep up with the et al. 2008). high opportunities and speed for construction. From experience with CLTS, having national minimum The strategy has also not been fine-tuned enough in regards standards on toilet construction and use checked by the to offered toilet models and materials (e.g., lighter and local CHW is a valuable feature and worth replicating. As cheaper fiberglass and plastic pans and platforms), phased far as is known, none of the TSSM countries have yet ad- construction, and informed ways of financing to serve the opted national standards for sanitary toilets. India pro- needs of the poor. Through information, observation, and motes two sanitary models in its national program for the mass media, these groups aspired to a modern lifestyle rural sanitation, a single and a double vault pour flush and would not compromise their demand for what at pres- toilet, but local bodies must set and check the standards ent is considered the highest achievable level: a septic tank (GoI 2007). toilet with ceramic squatting platform or sitting toilet, and if so desired, expandable to a full-fledged bathroom. These The current toilet standards of MOH of Vietnam are, how- ambitions may not only be an issue for further develop- ever, unrealistically high, especially for the poorest and most ment in Vietnam, but may also be at play in all rural areas isolated parts of the country. The demand for ceramic plat- where education, information, and communication in- forms and sitting toilets was growing among consumers and creases the aspiration for not just any toilet, but for a model their children, many of whom aspired to the urban lifestyles with high-status features. A more refined building and fi- that they get to know from TV and visits to town. However, nancing strategy could give poor households an informed they are also subject to breakage during transport and their choice which is more tailored to their needs, instead of pro- material, shape, and weight make them hard to transport in moting established, more general schemes such as local toi- large quantities by the providers, or on the back of a motor- let loan funds and traditional saving clubs. cycle or bicycle by the consumers. www.wsp.org 59 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations In practice, it also seemed that the consumers' aim for a 9.4.5 Open-Defecation Free Status sanitary toilet according to the national standard was syn- The focus of the rural sanitation marketing pilot project in onymous with the people's aspirations for a modern toilet, Vietnam has been on sustainable marketing of sanitary since as mentioned even the poorest households wanted to household toilets without government or project subsidy. build a (semi-) septic tank model, and people also aspired There was no participatory assessment of open defecation to have bathrooms. As pointed out above, the growing de- and no pursuit of obtaining and sustaining an ODF status. mand for urban-style sanitation and the ranking of septic From the group discussions with householders without a tank toilets as the highest standard has especially had nega- toilet it emerged however that those without toilets do prac- tive implications for the marketing of composting toilets tice open defecation at least part of the time, when they do (which in their current design were too crude and not not use a toilet belonging to a neighbor or relative (sharing combinable with bathrooms), and for the forecasted long- was quite common). term environmental sustainability of improved rural sanitation. Also according to the discussions, people were aware that open defecation brought health risks and many said they 9.4.4 Toilet Subsidy practiced the cat method of defecating in a small hole and All households in the pilot project study built, and went covering the excreta afterwards. The case study team did not on, building toilets without direct subsidy. However, be- validate this reported practice, however, in visits to open cause there was no decision on abolishing toilet subsidiza- defecation sites. From the FGDs and the promoter inter- tion in favor of a more fine-tuned strategy of sanitation views it emerged that once households have built a demand- marketing with research and capacity building, authorities based toilet, all household members use the toilet except the at all levels also accepted or undertook projects with sub- youngest children, but that their stools are also deposited in sidies both at the same time of the pilot project and after- the toilet. wards. It is crucial, that a national policy on this point be established. The case study confirmed that coverage in- There are two emerging lessons regarding ODF status. The crease was sustained without such subsidy at the much first is that the desirable behavior of toilet-use-by-all has higher rate achieved during the pilot project. There is, as benefited from a demand-based toilet approach that said, however, a need to widen the range of lower cost is combined with the promotion of a limited number of models, while retaining high-status elements such as shiny clear sanitary behaviors and a team of dedicated and and colored pans and tiles and the potential of upgrading trained locally institutionalized staff with clearly defined to a small bathroom, and test a more refined strategy to functions and tasks. serve the local poor. The second lesson is that all rural sanitation programs, in- The subsidy debate also continues in, for example, Bangla- cluding those using sanitation marketing, CLTS, commu- desh and India. In Bangladesh, it was found that targeted nity health clubs and other approaches, need to include an subsidies are needed for the ultra poor, which is not neces- integrated strategy to end open defecation. Indeed, orga- sarily the same as being included the poverty lists (see nized visits to common open defecation areas and participa- Kabir et al. in Wicken et al. 2008). In India, individual tory observations on evidence of open defecation may well states can decide to give a subsidy (called incentive) to all, further stimulate demand for sanitary toilet construction to households on the Below Poverty Line lists, or on an and use. Including a strategy to end open defecation may individual basis. A comparative study by WaterAid in five reinforce the cost-effectiveness of sanitation marketing. states with different subsidy regimes revealed however that subsidy as such did not increase coverage (Khurana et al. 9.4.6 Sustainable Capacity Building 2009). In Indonesia, on the other hand, the national pro- Another valuable characteristic of the pilot project in gram does not provide toilet subsidies (Mukherjee et al. Vietnam has been that IDE trained a group of government 2009). staff as trainers of the promoters. In their turn, these teams 60 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations gave training courses in the district capitals to promoters Ongoing capacity building will also be a concern in other and providers from the pilot communes and villages in their countries. Both in Vietnam and the other countries, it will districts. This approach made it possible that, after the pilot be essential to formulate a long-term strategy, program, and had finished, one district head could invite all other com- budget for capacity development, and build a team of mas- munes and villages in his district to send their teams for ter trainers in the different parts of the country if the ap- training. The subsequent implementation raised the average proach is to be continued and spread. It should also be overall district coverage to 62% in two years, with peaks of considered whether education on rural sanitation market- up to 92% coverage. In a second district, there was no for- ing could be integrated into the countries' education system mal replication of training, but other communes were en- for CHWs, women leaders and the administrative and couraged to visit pilot communes. political bureaucracy. However, other leaders did not follow suit, probably be- 9.4.7 Gender Equity cause of lack of provincial policies, national policy, and Also noticeable from the case study on sustainability of rural peer contacts/competition. In Vietnam, the provinces are sanitation marketing in Vietnam was that a gender approach responsible for implementing rural sanitation and clean was included in sanitation promotion, but not in capacity water policies. The national policy has not yet adopted the development for providers. With one exception, the provid- approach and the provincial authorities had not partici- ers that were trained in the study area were all men. pated in the pilot project. Thus, there was no institutional context that encouraged scaling out to whole districts in In all regions and countries where poor women already work the pilot area. in infrastructure as unskilled day labor (e.g., as road workers and mason helpers), they would benefit greatly from oppor- Nor is the adopted capacity-building approach self- tunities of doing skilled and regular masonry work in their sustaining. The authorities have not stimulated local de- own communities. These poor, landless, or otherwise mar- mand for training in other communes and the trainers ginalized women, especially those widowed and divorced, themselves are unlikely to give training in other locations are often sexually exploited by the masons and have no other after they have been transferred, which happens every two sources of income on off-days and in the rainy season. to three years. In addition, new staff replacing them will Where poor women were trained as toilet masons, they not develop the same capacity-building skills, unless they proved to be highly committed toilet promoters and skilled are given specific training. The interviews with the district craftswomen with a strong eye for neat work and proper authorities showed that because there was no policy, no finishing (IRC et al. 2007). Both male and female house- budget, and no team of governmental master trainers, ca- holders further appreciated the presence of women masons pacity building for rural sanitation marketing had, in prac- in their house or compound during times that male family tice, already disappeared. members were away (Kurup et al. 1998 and Sijbesma 2006). Hence, there is a great need to integrate capacity building in 9.4.8 Comparative Management those Vietnamese institutions that can train the trainers of A final lesson from the Vietnam case study is that after the the promoters, the authorities, and such local professional project and the financial incentive for monitoring and promoters as the CHW for whom sanitation promotion reporting had ended, local sanitation monitoring and man- and toilet quality control is part of their job. For the capac- agement also stopped. This affected the total data chain, ity building of the providers, there is a need to institutional- from village, to commune, district, and province. Although ize the training of the district training teams that train key various persons (such as the commune statistics officer) and providers in each village. Since the capacity building will organizations (such as the commune health posts, or project increase the acquisition of sanitary goods in the rural areas, NGOs) collected and reported statistics each year, these were it might be possible to interest large Vietnamese supply not consolidated and validated in a single, poverty-specific companies of sanitary wares in sponsoring these courses. rural sanitation data base covering, for example, the periods www.wsp.org 61 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Conclusions, Lessons, and Recommendations of NTP I and II. The statistics were not aggregated at each The sustainability of such sanitation monitoring and man- level or used to report to the promoters and local authorities agement will clearly depend on its integration into the about comparative results, nor were they used continue to country system from commune level upward, if it is not to manage rural sanitation marketing as a program. stop after the end of the project, as it did in the case study area in Vietnam. This has been a missed opportunity, especially for district and provincial health officials and People's Committee lead- To expand human capacity, various capacity development ers, who could have found out how the different communes options could be considered. One option would be a sys- were doing over time and why, stimulated inter-commune tem of horizontal learning. Under such an approach, dis- and district learning, and helped laggards to overcome trict and provincial trainers and steering committees in constraints. pilot districts and provinces (now expanded to some six provinces) would orient and train their colleagues in Such comparative management is often also missing in neighboring districts and provinces. Another option would other rural sanitation programs. Reportedly, the Global be to involve rural education institutes for training-of- Scaling Up Sanitation Project districts in Indonesia now trainers in a scaling-up program, as has already been done routinely measure and report unit costs and outcomes, and with a regional rural college for CLTS capacity building in district capacity building for result- and evidence-based the north. monitoring has started. More participatory and transparent monitoring may further enhance sanitation coverage, help sustain ODF status, and make governance accountable. 62 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 1: Terms of Reference Annex 1: Terms of Reference Assessing the Sustainability of the Sanitation Marketing Approach Case Study: The Support to the Small Scale Private Sector Development and Marketing for Sanitation in Rural Areas Project in the Vietnamese Provinces of Thanh Hoa and Quang Nam Terms of Reference 2. Background 1. Purpose TSSM In close conjunction with its partners in Vietnam, the In a number of countries, WSP is guiding the "Total Sanita- Water and Sanitation Program (WSP) proposes to carry out tion and Sanitation Marketing (TSSM): New Approaches to a Case Study of an earlier sanitation marketing project en- Stimulate and Scale Up Sanitation Demand and Supply titled, "Support to the Small Scale Private Sector Develop- Project." The long-term vision for this effort is to help meet/ ment and Marketing for Sanitation in Rural Areas Project contribute to meeting the basic sanitation needs of the rural in the Vietnamese provinces of Thanh Hoa and Quang poor in developing countries who do not currently have ac- Nam." The project was implemented from 2003­2005 with cess to safe and hygienic sanitation. Through TSSM, WSP technical assistance from International Development En- and its partners aim to develop practical knowledge for de- terprises (IDE) in two provinces of Vietnam. signing sanitation and hygiene programs that are effective at improving health and are sustainable at large scale for rural To this end, WSP wishes to contract a consultant firm to con- villages, small towns and informal urban settlements. TSSM duct the Case Study which will assess the IDE­supported will test proven and promising approaches to create demand project 2­3 years after project completion, and will capture for sanitation, and to improve the supply of sanitation-related lessons learned regarding the scaling up, replicability and sus- products and services in order to increase household access to tainability of (1) the local government/institutional programs, safe and sustainable sanitation, create open defecation­free (2) the local private sector market in providing sanitation and communities, and promote improved hygiene practices. hygiene related products and services and, (3) the ability of the households to access affordable and appropriate sanitation Globally, evidence exists on how to effectively increase sani- products and services from the local private sector. The Case tation access and improve health conditions, but more ex- Study will also look at the interest from local government to perience and knowledge are needed to scale up these adopt and perpetuate the market-based approach within their programmatic approaches in countries with different con- long-term institutional programs. In particular, the Case ditions, and to ensure that the poorest and most vulnerable Study will look at both, the degree of adoption of the market rural and urban poor families gain access to sanitation. based approach by authorities in the implementing districts TSSM is being carried out in three different countries and the "spill-over" effects that may have occurred in non- (India, Indonesia and Tanzania), and from the very begin- implementing districts within the implementing provinces. ning the key question that will be monitored and evaluated In addition, consultant firm will assess whether "parallel is how to scale up and sustain these approaches, and then developments" occurred in non-project, non-spill-over areas. how to replicate in other areas (often with different culture, Greater detail can be found in the Framework for Assessing traditions and practices) and in other countries. To this the Sustainability of the Sanitation Marketing Approach. end, TSSM carries out a structured process to develop the www.wsp.org 63 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 1: Terms of Reference practical knowledge and tools to replicate and scale up these SAWAP projects that the new study will help support are: programs at a reasonable cost and within the financial and "Support to Improving the Knowledge Research and Ap- institutional constraints of new countries with different plication Cycle" and "Mobilizing the Domestic Private Sec- cultures. tor for Water Supply and Sanitation," both led by Vietnam; "Development of a Sustainable Management Model on The Scaling Up Sanitation program in Indonesia, India and Rural Sanitation," led by Cambodia, and "Development of Tanzania gives equal attention to demand, supply and an Sustainable Management Models on Urban Sanitation" (in- enabling environment. The Community Led Total Sanita- cluding small towns), led by Lao PDR. tion approach (CLTS) is used to create demand. The Sani- tation Market Based Approach (SMBA) is used to stimulate Cambodia Sanitation Market Supply demand, strengthen supply and gets into market research, and Demand Studies product development, local entrepreneur capacity building In Cambodia, two studies were carried out in preparation and business development. The project sees both CLTS and for a sanitation marketing pilot project (see below for more SMBA as two essential and mutually reinforcing approaches information on sanitation marketing). The first study ex- for sustained Sanitation and Hygiene Behavior change at amined the demand for sanitation among the population in scale. In addition, the project works on improving local three provinces and urban centers. Latrine owners and non- regulatory frameworks, national policies and strategies in owners were surveyed, to develop a picture about sanitation order that they make possible unhampered growth of the awareness and practices, but also about preferences, afford- demand and supply forces in local sanitation markets. ability and perceived advantages and disadvantages of la- trine ownership. The second study undertook a sanitation SAWAP supply chain analysis in the same rural and urban areas, SAWAP is a new demand-responsive, programmatic, multi- examining everything from importers to wholesalers, retail- country technical assistance program, under way since early ers and masons/contractors. The studies were designed to 2007, supported by WSP-East Asia and the Pacific (WSP- shed light on the reasons for the persistently low sanitation EAP). The initiative focuses on joint support to nationally- uptake in Cambodia's communities (rural sanitation cover- led efforts in the sanitation, hygiene and water supply age according to the Joint Monitoring Program stood at 8% sector, and on selected inter-country initiatives between between 1998 and 2005, increasing to 16% by 2007). The Cambodia, Lao PDR and Vietnam, with two provinces of findings were used to design a sanitation marketing pilot Southern China progressively joining in. The new initiative which will be implemented in one province over a period of is centered on the Mekong Region, a cluster of countries three years. The pilot will take into account ongoing CLTS and major provinces (Cambodia, Lao PDR, Vietnam and efforts, resulting in an approach similar to TSSM. Yunnan and Guangxi provinces of China) loosely linked by the Mekong basin and in many other economic, historic Sanitation Marketing and cultural ways. With its high needs and promising op- Sanitation Marketing is an innovative approach to sanita- portunities for inter-country networking and partnership, tion. The basic premise of this approach is to unleash the the Mekong region is a focus area for WSP-EAP support. power of the small- and medium-scale private sector in the provision of sanitation services and to use techniques of SAWAP's two parallel activity clusters are identifying and commercial marketing to analyze the themes and messages scaling up sustainable solutions and mobilizing resources that would generate demand for these services and lead to to achieve the MDGs. Countries have initially agreed on sustained behavioral change. six specific SAWAP-supported cross-boundary projects, several of which will be relevant to the planned study, and The sanitation marketing approach adopts the following on an approach to link and cross-resource existing WSP- principles: supported country and regional activities through a com- · Learning about the market: This principle is about mon SAWAP framework. The relevant cross-boundary understanding demand and supply through an 64 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 1: Terms of Reference analysis of the sanitation market: suppliers of sanita- in regulations and policies--including land use re- tion infrastructure and maintenance services, reasons quirements and licenses, construction standards, for installation of sanitation solutions, constraints and, in informal urban areas, disposal options. Sub- (legal, institutional, knowledge, and financial) that sidy policies are needed for marketing, promotion, prevent the expansion of the sanitation industry, etc. and industry development, and possibly output- · Promoting demand: Based on the results of the mar- based subsidies are needed for the very poor. ket studies, a marketing strategy is developed to pro- · Building an enabling environment: At commune, mote demand for sanitation services. The marketing district, and provincial levels, in line with decen- strategy uses a variety of messages targeted to differ- tralization policies, as well as at national policy and ent audiences, as well as different media--commer- strategy level. cial advertising techniques (through a combination of appropriate media such as print, radio, and TV), Sanitation Marketing in Vietnam and more direct promotion to the consumer through In 2003, the international NGO International Develop- NGOs, Department of Health outreach teams, and ment Enterprises (IDE) with funding from the Danish In- others--within a consistent framework of well- ternational Development Agency (DANIDA), launched a designed messages to generate demand and change project to stimulate the acquisition and use of hygienic behavior. sanitation in two provinces in Vietnam (Thanh Hoa and · Developing the right products: In many cases, one of Quang Nam). IDE developed a range of options that were the key constraints to the development of a local- affordable and appealing to potential customers. IDE then ized sanitation industry is the lack of knowledge of developed, through capacity building, business develop- technological options that can serve as the basis for ment support, credentialing, a local network of masons to innovation and adaptation in the local market, at af- deliver these options. To better understand the drivers of fordable prices to the local population. However, the sanitation demand, IDE and local masons assessed consum- Sanitation Market Based approach does not promote ers' willingness to pay for sanitation and its perceived ben- a single technology but instead focuses on the con- efits. They used the assessment results to promote the sumer's choice. A broader range of options for con- benefits and availability of the sanitation options through struction and maintenance of sanitation solutions, with a variety of installation and operation costs, is needed for the market to supply all households, at FIGURE: LATRINE CONSTRUCTION IN A SANITATION MARKETING PROGRAM IN VIETNAM different levels of income, with solutions they can afford. In many developing countries the heteroge- 7,000 neous nature of the ethnic groups and cultures means 5,985 6,251 that different areas may require different designs and 6,000 Number of Latrines Built options--is this a limitation to going to scale? 5,000 · Developing a thriving industry: Capacity building 4,000 of service providers becomes essential to develop a 3,000 sustainable market. The most common weak areas include lack of: commercial skills, access to credit, 2,000 1,496 legal recognition, and associations to build mutual 1,000 confidence and skills. Overall, the nascent local sani- 0 tation services industry requires support to develop Yearly Average Total 2002­2003 2004 2002­2003 in most countries. · Adapting policies and subsidies: The delivery of sani- Source: "Harnessing Market Power for Rural Sanitation: Private Sector tation services based on the small scale domestic Sanitation Delivery in Vietnam," WSP Field Note, February 2005, Jaime Frias and Nilanjana Mukherjee. private sector requires, in most countries, changes www.wsp.org 65 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 1: Terms of Reference appropriate media channels and tailored messages. The fig- · Team norms for working together ure below illustrates the rapid increase and scale-up in cov- · Agreed consultative, open, process for working with erage. Although the average number of latrines constructed stakeholders and others. in the district over the period 2000­2003 was less than 1,500, during the first year of the program in 2004, 6,250 3.4 Draft detailed research protocol and present to stake- latrines were built by the small-scale private sector. holder review group and finalize based on comments received. IDE has recently extended the Project to another province (Yen Bai) with support from a Spanish NGO, utilizing sim- 3.5 Draft and finalize--based on comments--the research ilar approaches to that used in Thanh Hoa and Quang instruments (questionnaires and guides) and coordinate Nam. translations and independent back-translation. 3. Scope of Work 3.6 Draft interviewer guidelines and instructions and fi- 3.1 Plan a consultative process to maximize interest and nalize based on comments, recruit and train interviewers commitment to the study findings among the maximum and focus group moderators as required. number of stakeholders, including, but not limited to: one- to-one consultations, preliminary and final half-day work- 3.7 Coordinate and supervise fieldwork to ensure quality shops, and opportunity for review of framework and final control. draft outputs by (i) the stakeholder review group, and (ii) a wider group of interested sector partners. 3.7 Conduct selected interviews (e.g., stakeholders). 3.2 Collect and review background materials including 3.8. Enter clean data and analyze data. but not limited to: · GoV RWSS Strategy and Action Plan 3.9 Prepare and present preliminary findings in Power- · 2005 RWSS GoV/Donor Joint Sector Review Point format at a stakeholder review group meeting. · Harnessing market Power for Rural Sanitation, WSP Field Note, February 2005, Jaime Frias and 3.10 Coach local research firm every step of the process Nilanjana Mukherjee and build capacity as needed to ensure international quality · Water Supply and Sanitation Strategy for Vietnam, standards and methods are met and used throughout. Building on a solid foundation, World Bank work- ing paper, 2006 3.11 Prepare final draft and final report based on review · Investing in the Market, Scaling Up market based and comments. All reports will be written in professional- approaches for small-scale sanitation in Vietnam, level English and meet international quality standards. WSP/IDE/SEI, Dan Salter, September 2005 · IDE post-project evaluation report 4. Deliverables/Outputs · Project Document for the new Yen Bai project All Outputs will be produced in both Vietnamese and Eng- · Thematic Study on Sanitation and HIV/AIDS in lish and will subject to quality approval by WSP. They are as Vietnam (5-7 December 2004). follows: · Draft and final research protocol 3.3 Participate in a team planning meeting with WSP/ · Draft and final research instruments (questionnaires, VN to agree on: discussion guides) translated and back-translated · Individual team member roles and responsibilities · Syntax and data files (for quantitative research) and · Expected deliverables full transcripts · Approval of draft documents and tools · Preliminary results and recommendations in PPT · Work plan with schedule presentation 66 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 1: Terms of Reference · Final report (framework, draft and final). English 6. Management of Activity version will be written and edited professionally and The Consultant firm will be co-managed by the WSP/HQ meet international quality standards. Senior Social Marketing Specialist for the Scaling Up Total Sanitation and Sanitation Marketing project and the 5. Estimated Schedule Country Team Leader, Vietnam WSP-EAP. The Consultant firm will also seek periodic guidance from the Steering Key Milestones Mar Apr May June July Group and facilitating inputs from DWR/MARD. Research protocol and tools finalized 7. Level of Effort Fieldwork Preliminary findings Working Duration Illustrative Team Members (weeks) Stakeholder group review meetings Senior International Social, Sanitation 5 Final report disseminated and Hygiene Specialist Sanitary Engineer 6 Financial Specialist 6 Communication Specialist 10 www.wsp.org 67 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 2: Composition of the Study Team Annex 2: Composition of the Study Team 1. Dr. Christine Sijbesma, PhD Sociology. Team leader. 6. Ms. Ho Kim Uyen, MA Sociology. Community Community management, hygiene promotion, gen- development and health. ADCOM; der. IRC; 7. Mr. Le Duc Hanh, PhD candidate in Social Anthro- 2. Dr. Truong Xuan Truong, PhD Sociology. Field team pology. Household perspectives. ADCOM; leader. Communication and community development. 8. Mr. Nguyen Tuan Minh, MA Sociology. Data analysis. ADCOM; ADCOM; 3. Dr. Ha Viet Hung, PhD Demography. Demography 9. Ms. Nguyen Nhu Trang, BA Sociology. Gender and and data analysis. ADCOM; development. ADCOM; 4. Ms. Nguyen Hong Sam, MA Economics: Enterprise 10. Ms. Dinh Ngoc Bich, MBA: Middle and small-scale finance and community development. ADCOM; commercial enterprises. ADCOM. 5. Ms. Nguyen Kim Thai, BA Engineering. Water and sanitation technology and environmental engineering. ADCOM; 68 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 3: Participants and Feedback, First Consultative Meeting Annex 3: Participants and Feedback, First Consultative Meeting (Hanoi, Vietnam; 06 March 2009) Participants 1 J.S.J. Sujeewandas World Vision 2 Tran Thi Tuyet Hanh CEEN/HSPH 3 Lene Jensen DANIDA/RWSS-NTP2 4 Hoang Trung Thanh World Vision 5 Chris Tretheway WSP/SAWAP 6 Jacqueline Devine WSP Washington 7 Tran Thanh Thuy Care Vietnam 8 Juhani Efraimsson WS & Small Tower 9 Ha Van Mang CEEN 10 Ta Thuong Huyen CEEN 11 Phan Thanh Son NCERWASS 12 Nguyen Xuan Quang MARD 13 Dang Huong Giang Vietnam Women's Union 14 Tran Thi Kieu Hanh Vietnam Children's Fund 15 Le Thanh Chung Bank for Social Policy of Vietnam 16 Nguyen Danh Soan RWSSP/MARD 17 Do Thuy Trang National Institute of Hygiene and Epidemiology, SANIVAT 18 Dang Thi Van Ha Institute of Environmental Sciences and Engineering, CEFACOM 19 Pham Duc Phuc SANIVAT 20 Hoang Thuy Loan Institute of Environmental Sciences and Engineering, CEFAC 21 Nguyen Hong Sam VIWASE 22 Dang Quoc Viet World Vision 23 Do Manh Cuong MoH, Healthy and Environment Division 24 Dinh Ngoc Bich Vietnam Academy of Social Sciences 25 Nghiem Thi Duc IDE (International Development Enterprises) 26 Nguyen Phuoc Binh Thanh RNE (Royal Netherlands Embassy) 27 Nguyen Dinh Dung PATH 28 Nguyen Duy Thinh SRD 29 Nguyen Tra SNV 30 Nguyen Thanh Hien UNICEF 31 Nguyen Minh Huong Vietnam News 32 Rick Mc. Goman VUFO­NGO Resource Centre Vietnam 33 Kari Mukula FINNIDA www.wsp.org 69 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 3: Participants and Feedback, First Consultative Meeting Feedback · Role divisions between public and private sectors The participants suggested adding the following areas of and the communities attention to the study design: · Hygiene behaviors--as promoted and actual · Institutional analysis influence · Legal framework/rules & regulations at local level · Health impacts (district & commune) · Differences between regions and communes and · Limitations of current technologies/technology reasons choices: · Quality of toilets 0 convenience of different models/user satisfaction 0 Standards for different types 0 environmental aspects 0 Differences in quality over time 0 degree to which users made suggestions for · Exchange of study questions with MoH & IDE design · Cooperation with Cost-Benefit Study for World 0 adaptations to local physical conditions and Bank. customs in the study 70 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 4: Participants, Second Consultative Meeting Annex 4: Participants, Second Consultative Meeting (Hanoi, Vietnam; 08 September 2009) Name Organization Ms. Nguyen Nhy Trang ADCOM Ms. Dinh Ngoc Bich ADCOM Mr. Nguyen Danh Soan RWSSP/MARD Ms. Lene Jensen Rural Water Supply and Sanitation National Target Program Ms. Nguyen Thuy Ai Centre for Rural Water Supply and Environmental Sanitation (CERWASS) Ms. Pham Bich Ngoc RWSSP/MARD Ms. Lê Th Minh Hnh RWSSP/MARD Ms. Emeline Cammack RWSSP/MARD Ms. Nguyen Thi Hong Diem MoH, Preventive Medicine Department Mr. Pham Sy Liem Vietnam Federation of Civil Engineering Association Ms. Nguyen Hong Khanh Administration of Technical Infrastructure/Ministry of Construction Mr. Cao Xuân Ngc Health Care Department, Hu Lc District, Thanh Hoa Province Mr. Nguyn Bá Phng Health Care Department, Tnh Gia District, Thanh Hoa Province Ms. Tran Thi Hong Vietnamese Women's Union Ms. Nguyen Kim Nga WSP Vietnam Ms. Nguyen Hien Minh WSP Vietnam Ms. Isabel C. Blackett WSP Regional Team, Jakarta Ms. Jacqueline Devine WSP Washington Ms. Nguyen Diem Hang World Bank/WSP Mr. Chris Trethewey World Bank/WSP/SAWAP Ms. Nghiêm Th c IDE Vietnam Mr. Nguyn Quý Hòa PLAN Vietnam Ms. Nguyn Du Hin CARE Vietnam Mr. Ahmar Hashmi PATH Mr. Nguyen Van Son UNICEF Mr. Thanh Lâm SNV Mr. Bruck Aregai SNV Ms. Nguyen Lam Giang HELVETAS Mr. Dietmar Wenz Kf W Bankengruppe Mr. Oskar Kass FINNIDA Mr. Ton Tuan Nghia WHO Ms. Tran Thi Kieu Hanh Vietnam Children's Fund Mr. Do Thuy Trang SANIVAT Project, National Institute of Hygiene and Epidemiology, Hanoi School of Public Health (NIHE-HSPH) www.wsp.org 71 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 4: Participants, Second Consultative Meeting Mr. Vuong Tuan Anh SANIVAT Project, National Institute of Hygiene and Epidemiology, Hanoi School of Public Health (NIHE-HSPH) Ms. Minh Chau Nguyen East Meets West Foundation (EMWF) Ms Phan Huyen Dan CEFACOM Institute of Environmental Sciences and Engineering Ms. Christine Sijbesma IRC International Water and Sanitation Centre, The Hague Dr. Truong Xuan Truong ADCOM Mr Le Duc Phuc ADCOM Consultant Firm Mr. Kimberley Patrick FrOG Tech Representative Office Ms. Ngoc Dung BORDA Mr. Nguyen Van Hung BORDA Ms. Nguyen Thu Ha Lien Aid Mr. Thomas Janny FRC Ms. Cao Thi Van Hau FRC Mr Ngo Quoc Dung CWS Mr Nguyen Van Ty CWS Mr. Nguyen Tri Dung Oxfam GB Mr. Pierre BOUGAUD EAST Mr. Karem ABOU-SAMRA EAST Ms. Tran Thi Thu An UNICEF Ms. Truong Thuy Hang Rural Sanitation Marketing Study Ms. Nguyen Nhu Trang Rural Sanitation Marketing Study Mr. Antti Nykänen Water and Sanitation Program for Small Towns in Vietnam Ms. Pham Thu Huong UN-HABITAT/Water for Asian Cities (WAC) Ms. Nguyen Thi Hong Hai ADCOM Ms. Phung Thi Yen ADCOM Ms. Tran Thi Xuan Thuy ADCOM Mr. Le Ngoc Binh ADCOM Mr. Ha Viet Hung ADCOM Mr. Nguyen Tuan Minh ADCOM Ms. Nguyen Thi Hang ADCOM Mr. Nguyen Viet Hung National Institute of Hygiene and Epidemiology, Hanoi School of Public Health (NIHE-HSPH) Mr. Le Sy Thang Water Resources Development and Conservation Centre (TERCOD) Ms. Le Thi Thanh Xuan SANIVAT Project, National Institute of Hygiene and Epidemiology, Hanoi School of Public Health (NIHE-HSPH) Ms. Duong Tu Oanh NCERWASS Mr. Nguyen Van Quang IDE Vietnam Mr. Eduardo Martin Cooperación al Desarrollo y Promoción de Actividades Asistenciales (CODESPA)/National Office 72 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 5: Functionaries Interviewed Annex 5: Functionaries Interviewed # District Province Functionary Interviewed 1 Tinh Gia Thanh Hoa Vice Director, Tinh Gia District Health Care Centre 2 Tinh Gia Thanh Hoa Vice Director, District Health Care Centre 3 Thang Binh Quang Nam Vice Chairman, District People's Committee 4 Nui Thanh Quang Nam Chairman, District People's Committee # Province Functionary Interviewed 1 Thanh Hoa Vice Director, CERWASS 2 Quang Nam Vice Director, Centre for Preventive Medicine 3 Quang Nam Vice Director, CERWASS # Commune District Province Functionary Interviewed 1 My Loc Hau Loc Thanh Hoa Chairman, Commune's People's Committee 2 Hai Thanh Tinh Gia Thanh Hoa Vice Chairman, Commune's People's Committee 3 Hai Thanh Tinh Gia Thanh Hoa Head, Cultural and Social Affairs 4 Tinh Hai Tinh Gia Thanh Hoa Vice Chairman, Commune's People's Committee 5 Tinh Hai Tinh Gia Thanh Hoa Head, Board of Culture and Communication 6 Binh Trieu Thang Binh Quang Nam Vice Chairman, Commune's People's Committee 7 Binh Trieu Thang Binh Quang Nam Head, Board of Culture and Communication 8 Tam Hoa Nui Thanh Quang Nam Chairman, Commune's People's Committee 9 Tam Hoa Nui Thanh Quang Nam Head, Cultural and Social Affairs 10 Tam Anh Nui Thanh Quang Nam Vice Chairman, Commune's People's Committee # National Level Institution Functionary Interviewed 1 National Center for Water and Rural Sanitation Deputy Director 2 Head, Communication Department 3 Vietnamese Health Expert, Preventive Medicine Department Ministry of Health 4 Authorities DANIDA Adviser 5 Vice Head, Department for Education Vietnam Women's Union 6 Vice Head, Propaganda and Training Unit 7 AusAID Senior Program Officer, Water and Sanitation 8 Dutch Development Organization SNV Adviser, Sanitation Marketing Program 9 IDE Coordinator, Rural Sanitation Marketing External Program Agencies 10 UNICEF Manager, Program for Water-Sanitation-Environment 11 DANIDA Program Officer, Water and Sanitation 12 Private Sector Toto Industries Manager www.wsp.org 73 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 6: Quality Standards for Sanitary Toilets, Ministry of Health Vietnam Annex 6: Quality Standards for Sanitary Toilets, Ministry of Health Vietnam Construction e. Toilet platform has a water seal Double-Vault Composting Toilet f. Vault has a ventilation pipe a. Avoid building in regularly flooded areas b. Distance from clean water source at least 10m Hygiene Operation and Use c. Excreta storage is not below ground; the wall of the Double-Vault Composting Toilet storage vault is at least 20cm higher than the land a. The floor is clean without excreta or excreta-soiled d. The excreta storage vault has a tight cover without paper cracks b. Waste papers are thrown in the hole or a basket, and e. Floor is smooth and urine or water won't stagnate hole or basket is closed with a cover f. Toilet platform has water seal c. No bad smell d. No flies or insects in the toilets Ventilated Improved Pit Toilet e. Enough water at hand to flush the toilet after use a. Avoid building in regularly flooded areas f. No mosquito larva in water storage (if present) and b. Distance from clean water source at least 10m urine storage c. Floor and water seals are smooth and urine or water g. Excreta are not taken out of the compost vault within won't stagnate 6 months after closing the vault to excreta disposal d. If the toilet has a water seal, it is undamaged and h. The hole used is always shut, vault is tight filled with water e. The hole for excreta has a cover Ventilated Improved Pit Toilet f. The toilet is rainwater proof a. The floor is clean without excreta or excreta-soiled g. Ventilation pipe has a diameter of at least 9cm and paper is at least 40cm higher than the toilet roof, and has b. Waste papers are thrown in the hole or a basket, and a fly screen hole or basket is closed with a cover c. Have enough water at hand to flush the toilet after Single Vault Pour Flush Toilet use a. Walls provide privacy and are water proof d. No bad smell b. Vault entrance is cemented with water-proof material e. No flies or insects in the toilets c. Floor and water seal are smooth and urine or water f. No mosquito larva in water storage (if present) and won't stagnate urine storage d. Water seal, it is undamaged and filled with water g. Toilet hole is always tightly shut e. The toilet roof is rainwater-proof f. Fluids from excreta storage tank do not flood the Single Vault Pour Flush Toilet floor or are not absorbed by it a. Enough water for cleansing and flushing b. No bad smell Septic Tank Toilet c. The floor is clean without excreta or excreta-soiled a. Treatment storage has three parts paper b. Excreta storage tank is not sunk d. Toilet paper is put into the hole (if it is self de- c. The cover of the excreta storage tank is tightly coated stroyed), or into waste baskets with cover without any cracks e. No flies in the toilets d. Floor is smooth and urine or water won't stagnate f. No mosquito larvae in water storage 74 Global Scaling Up Sanitation Case Study on Sustainability of Rural Sanitation Marketing in Vietnam Annex 6: Quality Standards for Sanitary Toilets, Ministry of Health Vietnam g. Toilet platform is clean, no excreta or excreta smears e. Toilet floor is smooth and urine or water won't visible stagnate h. Toilet is rainwater proof f. Toilet paper is put into the hole (if toilet is flush- able), or into a waste basket with cover Septic Tank Toilet g. No flies in the toilets a. Toilet has enough water for cleansing and flushing h. Toilet platform is clean, no excreta or excreta smears b. No mosquito larvae in water storage reservoir visible c. No bad smell i. Toilet is rainwater proof d. Water from treatment storage tank runs to absorbing hole or sewer and doesn't flow freely around www.wsp.org 75 Case Study on Sustainability of Rural Sanitation Marketing in Vietnam References References Bolt, Eveline. 1998. 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