Report No. 44485-UG Uganda Environmental Sanitation Addressing Institutional and Financial Challenges February 2010 Africa Urban and Water Department (AFTUW) in collaboration with the Water and Sanitation Program and the Environment Department Document of the World Bank Acr onyms and Abbr eviations ARI acute respiratory infection CAO chief administrative officer CBO community-based organization CDCG community development conditional grant CDM Clean Development Mechanism cfu colony-forming units CIDI Community Integrated Development Initiatives CLTS community-led total sanitation COWESER Community Welfare Services CSD Community Services Department DANIDA Danish International Development Agency DDHS District Department of Health Services DED German Development Service (Deutscher Entwicklungsdienst) DFID U.K. Department for International Development DWD Directorate of Water Development, Ministry of Water and Environment DWO district water officer DWRM Directorate of Water Resources Management, Ministry of Water and Environment DWSCC District Water and Sanitation Coordination Committee DWSCG district water and sanitation conditional grant EHD Environmental Health Division, Ministry of Health FDS Fiscal Decentralization Strategy GDP gross domestic product GTZ German Agency for Technical Cooperation (Deutsche Gesellschaft für Technische Zusammenarbeit) HIASS Health Inspectors' Annual Sanitation Survey IDA International Development Association IMWG interministerial working group JPF Joint Partnership Fund JWSSPS Joint Water and Sanitation Sector Program Support KACODA Kasubi Community Development Association KCC Kampala City Council KDS Kampala Declaration on Sanitation LC local council LGDP Local Government Development Program MDG Millennium Development Goal MES Ministry of Education and Sports MFPED Ministry of Finance, Planning, and Economic Development MGLSD Ministry of Gender, Labour, and Social Development MH Ministry of Health MLG Ministry of Local Government MLHUD Ministry of Land, Housing, and Urban Development MOU Memorandum of Understanding MWE Ministry of Water and Environment MWLE Ministry of Water, Lands, and Environment (to 2006) MTEF Medium-Term Expenditure Framework NEMA National Environment Management Authority NGO nongovernmental organization NSWG National Sanitation Working Group N-UP Nabugabu-Updeal Joint Venture ii NWSC National Water and Sewerage Corporation OAG Office of the Auditor General PAF Poverty Action Fund PCU project coordination unit PEA Private Emptiers Association PEAP Poverty Eradication Action Plan PHC primary health care PHCCG primary health care conditional grant (nonwage) PHD Public Health Department PRSP Poverty Reduction Strategy Paper SFG school facilities grant (for primary schools) Sida Swedish International Development Cooperation Authority SWAP sectorwide approach TSU technical support unit TTC thermotolerant coliform (bacteria) UCDA Urban Community Development Association UPE universal primary education UWASNET Uganda Water and Sanitation NGO Network VHT village health team VIP latrine ventilated improved pit latrine US$1 = 1,750 Ugandan shillings (U Sh). iii Contents Acknowledgments vii Executive Summary 1 1. Introduction 9 Objectives 10 Definitions and scope of the study 11 Approach and methodology 11 Structure of the report 11 2. The Political Economy of Sanitation and Hygiene in Uganda 13 Slow improvement in sanitation and hygiene indicators 13 Service delivery in the context of broader governance reforms 18 Policy and legal framework for addressing sanitation and hygiene 19 Organizational dilemmas 20 Marginalization of sanitation within the fiscal decentralization framework 24 Lack of incentives for cross-sectoral coordination at the national level 26 Institutional challenges delivering on-site sanitation in rural areas 28 Sanitation in urban areas 30 Sewerage infrastructure: Role of the National Water and Sewarage Corporation 33 Role of NGOs in sanitation and hygiene in Uganda 35 Role of the private sector in sanitation and hygiene in Uganda 36 Role of development partners 38 Conclusion 39 3. Lessons from Good-Practice Examples: Two Promising Cases 40 The case of Rakai District: Scaling up model villages 40 The case of Luwero town: Rapid improvements in sanitation indicators 43 Lessons from promising stories 47 Conclusion 48 4. Establishing a Dedicated Budget Line for Sanitation and Hygiene 49 Options for transferring earmarked funds to districts 49 Activities to be funded by the new financing mechanism 60 Accounting and external audit 64 Timing 64 Allocation mechanisms and financing sources 65 Conclusions and recommendations 66 iv 5. Solid Waste and Drainage Management in Urban Uganda 68 Solid waste and drainage in urban Uganda: The scope of the problem 68 Framework for addressing solid waste and drainage at the national level 74 KCC and solid waste and drainage management in Kampala 76 Solid waste collection and transport by the private sector in Kampala 83 Role of NGOs in mitigating lack of service to poor urban areas 84 Importance of informal sector workers in waste disposal 85 Local governments' financial difficulties and the CDM 86 Role of the World Bank and other donors 87 Conclusion 87 6. Conclusions and Recommendations 89 Recommendations for excreta-related sanitation and hygiene 89 Recommendations for solid waste management and drainage 94 Appendix A. Sanitation Memorandum of Understanding 98 Appendix B. List of Stakeholders Consulted and Interviewed 100 Appendix C. Guidelines for Sector Conditional Grants 105 Appendix D. Revenues of Local Governments 107 Bibliography 110 Boxes 2.1 Sanitation planning illustrated: Nakawa Division, Kampala 4.1 Areas subsidized by conditional grants under Uganda's existing subsidy policy 5.1 Evolution of the policy, institutional, and legal framework for solid waste management and drainage 5.2 Political corruption in local government 5.3 Collaborating rather than competing with the informal sector v Tables 2.1 Trends in health-related outcomes, 1990 to 2003, and national targets 2.2 Water and sanitation indicators, 2004 2.3 Main sanitation laws and regulations 2.4 Organizational mandates at the national level 2.5 Examples of NGOs and types of sanitation- and hygiene-related activity 4.1 Trade-offs between options for structuring the integrated budget line 4.2 Summary of costs of sanitation and hygiene promotion financing strategy, by implementing agency 5.1 Urban centers in Uganda, 1969 to 2002 5.2 Solid waste and drainage in major urban centers, 2007 5.3 Population, economic growth, and generation of solid waste, 1985 to 2007 5.4 Types, sources, and amounts of solid waste and collection and disposal rates 5.5 Household solid waste disposal methods in urban centers, 2002 5.6 Nitrogen, phosphorus, and thermotolerant coliform bacteria in drainage systems in Kampala 5.7 Kampala City budget and financing, by fiscal year 5.8 Local government revenues and solid waste financing allocations and amounts needed, by fiscal year 5.9 Estimates of solid waste generated in municipalities with composting projects 5.10 Estimates of generation of solid waste in urban centers, 2007 to 2020 6.1 Recommendations for excreta-related sanitation and hygiene 6.2 Recommendations for solid waste management and drainage C1 Conditional grants and main features of implementation guidelines D.1 Main sources of own revenue for local governments, by fiscal year D.2 Central government and own sources of funding of local governments, by fiscal year D.3 Allocation of sanitation budget, by subsector and by fiscal year D.4 Sanitation budget, by institution and by fiscal year Figures 2.1 Latrine coverage, 1960 to 2007 2.2 Socioeconomic differences in health outcomes, 2007 4.1 Responsibilities and flows using earmarking within existing sector conditional grants 4.2 Responsibilities and flows under a cross-ministerial sector conditional grant 4.3 Responsibilities and flows under an anchor line ministry sector conditional grant 4.4 Responsibilities and flows under an LGDP hygiene and sanitation top-up/grant 4.5 National schedule for financial planning 5.1 Institutional framework for solid waste management 5.2 Organizational arrangements for solid waste management and drainage, Kampala 5.3 Trends in local government revenues, 1999­2005 vi Acknowledgments This report was prepared by a World Bank team led by Poonam Pillai, senior environmental specialist, and Samuel Dawuna Mutono, senior water and sanitation specialist. The core team included Michael Dahlgaard, financial consultant; Ousseynou Diop, senior water and sanitation specialist; Harriet Nattabi, water and sanitation specialist; Peter Okwero, senior health specialist; Sixto A. Requena, consultant; Maria Fernanda Garcia Rincon, consultant; Ronnie Rwanwanja, consultant; Alexandra Sears, program assistant; and Kameel Virjee, financial specialist. The peer reviewers for the study were Ernesto Sanchez Triana, lead environmental engineer; Eduardo A. Perez, senior water and sanitation specialist; and Andreas Knapp, water and sanitation specialist. The extended team included Kulsum Ahmed, Solomon Alemu, Francis Ato Brown, Piers Cross, Wambui G. Gichuri, Ede Ijjasz, Peace Lawanga, and Marie Claire Li. Comments and support from the extended team are gratefully acknowledged. A special thanks to Solomon Alemu for his consistent support and guidance throughout the preparation of this report. The team also thanks Nancy Levine and Linda Starke for editing and to Jim Cantrell for helping finalize the document. The report was prepared in close collaboration with the government of Uganda, in particular with the Ministries of Health; Water and Environment; Education and Sports; Local Government; Gender, Labour, and Social Development; and Finance, Planning, and Economic Development. Collaboration with donors, particularly those involved in the Water and Sanitation Working Group, was central to the preparation of the analysis. An ongoing dialogue and partnership was maintained with the National Sanitation Working Group. The report reflects a collaborative effort on the part of the Urban and Water Unit, Africa Region 1 (AFTUW); the Water and Sanitation Program; and the Environment Department of the World Bank. The team is grateful to the Bank Netherlands Partnership and the Water and Sanitation Program for providing funding for the preparation of the background studies on which the report is based. The report was supervised by John McIntire, country director for Tanzania, Burundi, and Uganda; Kundhavi Kadiresan, country manager, Uganda; and Jaime Biderman, sector manager, AFTUW. Guidance from Jaehyang So, manager of the Water and Sanitation Program, and James Warren Evans, director of the Environment Department, is gratefully acknowledged. vii Executive Summar y 1. Over the past 10 years the government of Uganda has endeavored to increase latrine coverage and promote hygiene with a view to improving health outcomes. In 1997, in the Kampala Declaration for Sanitation, leaders from all of Uganda's districts pledged to improve sanitation. Then in 2001, three ministries--the Ministry of Water, Lands, and Environment; the Ministry of Education and Sports; and the Ministry of Health--signed a Memorandum of Understanding to clarify institutional responsibilities with respect to sanitation and hygiene and to improve implementation at the district and local levels. The three ministries agreed to put in place institutional arrangements to prioritize resources for excreta-related sanitation and hygiene programs. 2. Latrine coverage has grown slowly, however, from 49 percent in 1997 to 59 percent in 2007. Recent studies suggest that only 14 percent of Ugandan households practice hand- washing. Overall, 56 percent of the urban population has access to safe water, and rural water coverage is 63 percent. About 41 percent of schools have hand-washing facilities, 56 percent have water supply, and 19 percent have soap or ash available for washing hands. 3. Inadequate sanitation and hygiene damage health among the poorest segments of society; the under-five mortality rate for the poorest is twice that for the richest. The burden of preventable disease contributes to low productivity, undermines efforts to reduce poverty, and compromises the country's ability to meet the targets in its Poverty Eradication Action Plan and attain its Millennium Development Goals. The government faces significant challenges in implementing the 2001 Sanitation Memorandum of Understanding (MOU), and it has asked for World Bank assistance in improving its implementation. This report responds to the government's request. 4. Although the main focus of this report is on excreta-related sanitation and hygiene, the 2006 joint sector review for water and sanitation also requested clarification of existing mandates for two specific aspects of environmental sanitation, namely solid waste management and drainage and asked whether these two issues should be included in the memorandum. Accordingly, this report also explores the institutional issues linked with municipal solid waste management and urban drainage. Because of limitations of time and scope, it examines these particular issues only in Kampala. Objectives 5. The purpose of the study is to provide the government of Uganda with recommendations on reforming the Sanitation Memorandum of Understanding. The report focuses on three specific areas: The institutional and political-economy factors relevant to the implementation of the sanitation memorandum Options for implementing a budget line for sanitation Institutional and governance issues linked with solid waste management and drainage, focusing on Kampala as a case study. While sanitation commonly includes infrastructure and services required for the safe management of human excreta (for example, latrines, sewers, and wastewater treatment), 1 this report primarily focuses on on-site sanitation, which is used by 90 percent of the Ugandan population. More detailed analyses of governance issues linked with sewerage and wastewater infrastructure need to be carried out as a follow-up to this report. Appr oach and methodology 6. The analysis presented in this report is based on research and consultations carried out between June 2007 and November 2008. The study involved discussions with various governmental stakeholders at the national, district, and municipal levels, nongovernmental organizations (NGOs), and relevant donor groups. In addition, several workshops were organized to get feedback and build consensus around the main findings and recommendations of the study. Results from these workshops have been incorporated into the report. Costing of recommendations was not part of the terms of reference of this study and needs to be carried out as a follow-up to this report. Value added and results 7. Analysis and recommendations from the report have already had several tangible results. A presentation based on the report in February 2009 contributed to Uganda's First Lady expressing an interest in championing the cause of sanitation and hygiene in Uganda. This was also picked up by the local media, thus contributing to advocacy on sanitation and hygiene. There is strong ownership of the recommendations by the Ministry of Water and Environment (MWE), relevant sector ministries, and donors involved in funding sanitation-related activities in Uganda. The findings and recommendations have been endorsed by the water and sanitation subsector working group, and some of the recommendations have also been included in the water and sanitation subsector investment plan and the draft National Development Plan. The Permanent Secretary of the MWE used some of the recommendations of the report in a letter to the Ministry of Finance, Planning, and Economic Development to argue for an integrated budget line for sanitation and hygiene. The process of dialogue undertaken as part of the preparation of this report and widespread support from sector ministries and donors contributed to initiation of accounting procedures by the Ministry of Finance, Planning and Economic Development (MFPED) for setting up an integrated budget line for sanitation and hygiene. This process has now come to fruition and, as per the recommendations of this study, the MFPED agreed to implement the budget line for sanitation. An interministerial committee to coordinate the budget line has also been constituted and its composition is being discussed. Recommendations for excr eta-r elated sanitation and hygiene 8. Based on the analysis carried out in this report, the main messages and recommendations for reforming and improving implementation of the Sanitation MOU are as follows. 2 Implement a dedicated budget line for sanitation 9. It is recommended that a dedicated budget line be established through a sanitation and hygiene top-up to the Local Government Development Program grant. This subsector- specific top-up would be provided by the MFPED and supervised by the Ministry of Local Government (MLG). The administrative responsibility would rest with the MLG and the technical responsibility with the line ministries--the Ministries of Water and Environment; Health; Education and Sports; and Gender, Labour, and Social Development. An interministerial working group made up of representatives from the MLG and the four line ministries should be formed to develop guidelines for the use of the dedicated budget line and to agree on relevant performance indicators and accountability mechanisms, under the guidance of the National Sanitation Working Group (NSWG). This option is consistent with the government's Fiscal Dectralization Strategy. Reform the Sanitation Memorandum of Understanding as part of a package of guidelines for implementing the integrated budget line 10. The integrated budget line is an important mechanism for earmarking funds for sanitation and hygiene, but the analysis presented in this report shows that by itself it will not be sufficient to improve sanitation and hygiene indicators. Underlying institutional and organizational issues will also have to be addressed. Accordingly, it is recommended that the implementation of the integrated budget line be combined with reform of the Sanitation MOU and clarification of institutional mandates. In addition to the ministries identified in the existing memorandum, the Ministry of Local Government, the Ministry of Gender, Labour, and Social Development, and local governments should be signatories, and their mandates should be clarified. These steps will overcome some of the difficulties in implementing the existing memorandum. Establish a system of rewards and incentives at the national level 11. Allocation of funds to local governments should be accompanied by explicit performance agreements. For instance, local governments should be given incentives to put in place and enforce sanitation bylaws. Contractual agreements between local governments should include specific high-impact interventions to encourage results- oriented behavior so that officials at various local government levels will deliver on agreed-on targets. Good-practice examples of accelerated sanitation coverage in Uganda and in other countries highlight the importance of instituting financial rewards and incentives at every government level. Public finance should be used to create awareness, promote exchange visits and hygiene education, encourage sustainable technologies such as ecological sanitation, and build the capacity of stakeholders. Offer incentives to form district and town water, sanitation, and hygiene committees 12. A consistent factor in the better-performing districts and towns in Uganda is the presence of a water and sanitation coordinating body. A committee of this kind promotes integrated planning and budgeting, improves synergies (and therefore leads to better utilization of resources), and facilitates involvement of nongovernmental organizations and, where possible, the private sector. It also provides a forum in which community 3 development officers, health inspectors, and water and sanitation officers can work together. It is recommended that local governments establish and strengthen district and town water and sanitation coordination committees. Access to funds from the integrated budget line should be linked to formation of these bodies. Provide technical support to urban and rural local governments 13. Experience in Uganda suggests that technical support units (TSUs) in the water and sanitation sector are important in building the capacity of local governments, assisting with budgeting and planning, and providing technical advice on construction and maintenance. TSUs also form an important link between the Directorate of Water Development and local governments, through national-level coordination provided by the central TSU secretariat. TSUs should therefore be strengthened. It is also recommended that measures be devised to provide technical support to local governments in both rural and urban areas with respect to planning, budgeting for, and implementing sanitation and hygiene activities. Improve staffing of and support for the health inspectorate 14. Good-practice cases demonstrate that a key ingredient of improvements in sanitation at the district level is to fill all positions on the health inspectorate staff and give staff members adequate allowances and transportation. With a daytime population of over 2.5 million, Kampala has only 12 health inspectorate staff members, who receive poor support. This understaffing contributes to poor sanitary conditions in the city. It is recommended that health inspectorate positions at local government levels in both towns and districts be filled and that the officers be adequately facilitated. Enforce the Public Health Act and sanitation bylaws 15. In some cases local governments do not have sanitation bylaws in place; in others, the bylaws exist but are often not enforced. It is recommended that all local governments enact sanitation bylaws that include clear requirements for construction of latrines, specification of roles and mandates, enumeration of activities affecting public health that are legal or illegal, and clearly articulated fines and penalties. The better-performing areas are marked by strong enforcement by communities and district and town staffs. Having updated laws in place is a first step in the process. Establish mechanisms for public recognition of local government leaders 16. An important lesson from the better-performing districts and municipalities is that the active involvement of leaders at all levels, including opinion leaders, is vital for the allocation of budgets to hygiene and sanitation and the enforcement of local sanitation bylaws. An annual system of public recognition should be instituted to honor local leaders who prioritize sanitation and support enforcement of the laws. Combine latrine coverage programs with promotion of hand-washing with soap 17. Hand-washing is one of the most effective means of preventing diarrheal disease, along with safe stool disposal and safe household water treatment. Evidence indicates that improved hand-washing, in particular with soap, can have a major impact on public 4 health in any country and can significantly reduce two leading causes of childhood mortality: diarrheal disease and acute respiratory infection (ARI). Washing hands with soap at the right times can reduce instances of diarrhea by 35 to 50 percent and reduce ARI by 30 percent. Even though hand-washing may be a better option for disease prevention than any single vaccine, it is often neglected. It is recommended that programs for latrine coverage should, at a minimum, be combined with promotion of hand-washing with soap, especially at critical times--after visiting the latrine, before eating, and before feeding a baby. Support should also be provided to the national hand-washing campaign. Improve accountability of local governments for meeting targets 18. One of the core issues underlying weak fulfillment of sanitation and hygiene targets at the local government level is lack of accountability mechanisms. Better monitoring and enforcement by relevant line ministries, especially the Ministry of Local Government, of agreed-on sanitation and hygiene targets is needed, and incentives should be provided to local governments to improve agreed-on sanitation and hygiene targets. Improve cross-sectoral coordination and strengthen capacity for planning and budgeting at the national level 19. A stronger link needs to be forged between strategic planning and budgeting for environmental health issues, particularly in the Environmental Health Division of the Ministry of Health. Cross-sectoral coordination between ministries on issues such as identification of common indicators and coordination of assistance to local governments will also help support local government capacity and improve sanitation and hygiene. Emphasize importance of open-defecation-free status 20. Examination of good-practice districts in Uganda shows that even villages that have reached 100 percent latrine coverage are not necessarily free of open defecation. Shifting away from open defecation (through the use of community-led total sanitation) is an important behavioral step in moving up the sanitation ladder to hygienic facilities and should be emphasized. Support collection of information and dissemination to the public 21. An important bottleneck in local governments is lack of systematically collected information on excreta-related sanitation and hygiene. Even in Kampala, it was difficult to find accurate information about the number of pit latrines, the percentages of the population with different types of latrine, the number of private sector operators, and so on. It was also unclear whether the information was supposed to be collected at the divisional level or by Kampala City Council (KCC) headquarters. It is recommended that systematic collection of information about sanitation, hygiene, solid waste collection, and drainage be pursued by all local governments. Such information can help improve planning and budgeting for environmental sanitation in general, and sharing the information with the public can strengthen citizen involvement and thus promote accountability of the public sector for service delivery. 5 Recommendations for solid waste management and dr ainage 22. The main recommendations linked with solid waste management and drainage are as follows. Do not include solid waste management in the revised Sanitation Memorandum of Understanding 23. In response to the query from the 2006 joint sector review for water and sanitation, it is recommended that solid waste not be included in the revised MOU. Mandates for solid waste at the national level are relatively clear and rest primarily with the National Environment Management Authority (NEMA), with other bodies such as the Directorate of Water Development (DWD) playing a regulatory role. At the national level, what needs to be improved is these agencies' regulatory and monitoring roles. Do not include solid waste in the integrated budget line for sanitation 24. The inclusion of solid waste in the dedicated sanitation budget line would risk, once again, neglect of excreta-related sanitation and hygiene. For solid waste management, other funding mechanisms can be harnessed. Current World Bank projects are already supporting revenue generation from waste through the Clean Development Mechanism. Other options include the establishment of a municipal trust fund, as has been done elsewhere. Prepare a national solid waste management strategy and financing strategy 25. Given Uganda's rapid urbanization, the challenges linked with solid waste management are likely to increase. At present, municipalities are devising ad hoc mechanisms for dealing with various aspects of the issue. It is recommended that Uganda develop a national solid waste management strategy, with principles for sustainable financing for the sector based on international best practice. Such a strategy could be useful in providing guidance to municipalities on how to develop their solid waste management frameworks. A national strategy would need to be articulated by NEMA, the national policy maker for solid waste management. A similar function is performed in the United States by the Environmental Protection Agency, which is responsible for designing a national strategy, policies, and laws, with state and local governments in charge of implementation. 26. A national solid waste management strategy should clarify the roles of all key actors, including local governments, the private sector, NGOs, and informal sector workers. It should provide guidance on various aspects of solid waste management such as separation at source, collection, transport, recycling, reuse, and disposal. It should also include provisions for the consolidation of private sector participation as a practical instrument for improving governance and financing in the solid waste management sector. Consider including drainage in the integrated budget line 27. Whether drainage should be included in the budget line needs to be further discussed. Poor drainage is closely linked with the water and health sectors. In Kampala, for example, urban drains carry effluents from pit latrines and the sewerage system that eventually get into Lake Victoria, degrading water quality and posing significant health 6 risks for the surrounding population. Planning for drainage at the local government level has been greatly neglected. One reason for including drainage in the sanitation budget line (and in associated guidelines) would be to enable coordinated planning and budgeting for both excreta-related sanitation and drainage management at the local level. The risk of including drainage in the budget line is that it may cut into funding for excreta-related sanitation and hygiene. Clarify responsibility for drainage and establish a working group responsible for drainage at the national level 28. The policy-making function for drainage at the national level belongs to the Ministry of Water and Environment, but it is unclear which agency within the ministry has the lead role. The ministry should clarify this mandate and establish a working group that includes the Directorate of Water Resources Management (DWRM); the National Environment Management Authority; the National Water and Sewerage Corporation; the Ministry of Works, which has a policy-making role in road construction; and the Ministry of Local Government, in view of its mandate to strengthen the capacity of local governments. The task of the working group would be to develop strategic guidance on drainage for municipalities and local governments. Build KCC and local government capacity for solid waste and drainage mandates 29. A major issue with the Kampala City Council is its limited human resource capacity for addressing mandates for solid waste and drainage. For instance, the sole staff member assigned to work on drainage was seconded to work on a separate project. Capacity in this area needs to be increased. Formalize relations with private sector stakeholders involved in the collection and transport of solid waste 30. Private sector operators play a significant role in solid waste collection and transport in Kampala, but many do not have formal contracts with the municipality. This makes it difficult for division-level staff who have the prime responsibility for collection and transport to supervise the work of private sector contractors, and it contributes to poor service delivery. Formalizing these contracts and supporting greater transparency in access to the terms of the contracts by KCC and divisional staff would promote accountability and also add to the city's revenue base because the contractors would then be paying taxes. 31. Consolidation of private sector participation should be part of a program for the commercialization of solid waste management service provision. A fully commercialized service would have several benefits: well-defined contracts and separation of solid waste management accounts from local government budgets would yield greater value for money (since expenditures would be tied to explicit milestones), improve accountability, and minimize political interference. It would also allow improved handling of projects for municipal composting and capture of landfill gases. 7 Revise the KCC solid waste ordinance provisions on informal sector workers and facilitate organization of these workers into cooperatives 32. Although there is support among KCC and divisional staff for the Kampala solid waste ordinance, it has important shortcomings that need to be addressed. The ordinance should be revised to acknowledge the important contributions of informal sector workers. Informal waste collection and recycling workers typically constitute 2 percent of the population of developing-country cities, yet in Kampala their vital services are often not recognized or adequately rewarded. KCC should support the formation of cooperatives of these workers so that they can have access to loans, health care, and training. Introduce regulation on landfill gases at the national level 33. At present, there is no regulation on exploitation of landfill gases. One should be put in place. Here, too, NEMA can take a lead role. Improve enforcement of Kampala's solid waste ordinance 34. KCC's solid waste ordinance provides the legal basis for proper storage, collection, and disposal of waste. Nevertheless, because of limited enforcement by KCC officials, there is rampant illegal dumping of garbage in non-designated areas of the city. Stronger political leadership for enforcing the ordinance is needed. The city could hire day and night patrols to improve monitoring and enforcement, and divisional staff could help form community teams to assist enforcement. Strengthen the regulatory roles of NEMA and the DWRM 35. A critical issue is the monitoring of effluents released into major drainage systems. Given that NEMA and the DWRM have the primary responsibility for monitoring, their regulatory roles need to be strengthened. NEMA should also be more active in coordinating the activities of the various donors involved in solid waste management. 8 1. Intr oduction 1. Improved access to sanitation and hygiene can make an integral contribution to improving health outcomes and reducing poverty. Over the past decade, the government of Uganda has implemented a range of policy and institutional reforms to improve excreta-related sanitation and hygiene and to promote well-being. In recognition of its impact on the national disease burden, particularly high diarrheal disease morbidity and infant and child mortality and morbidity, sanitation is becoming an increasing priority in Uganda at the national level (Uganda 2004a). It is a key element of the government's environmental health policy and is supported by the 2004­09 Poverty Eradication Action Plan (PEAP) and the country's commitment to the United Nations Millennium Development Goals (MDGs). 2. A significant reform measure undertaken by the government in this context was the signing in 2001 of a Memorandum of Understanding (MOU) between the Ministry of Water, Lands, and Environment (MWLE), the Ministry of Education and Sports (MES), and the Ministry of Health (MH) to clarify institutional responsibilities with respect to sanitation and hygiene and improve implementation at the district and local levels (see Appendix A). Under the memorandum, the three ministries agreed to put in place institutional arrangements, including cooperation mechanisms, and to prioritize resources with respect to excreta-related sanitation and hygiene. 3. Despite these and other initiatives, improvements in access to excreta-related sanitation, in hygiene, and in related health outcomes have been slow. The government faces significant challenges in implementing the MOU and has asked for World Bank assistance in assessing how it is performing. This report is a response to the government's request. 4. The efforts to improve sanitation and environmental health outcomes have taken place in the context of broader institutional and economic reforms. Among the more significant of these is decentralization of service delivery responsibilities to the district and subnational levels. In addition, the government of Uganda has embraced market liberalization through removal of price controls and privatization of state-run enterprises and has facilitated a more active role for private sector firms in service delivery. These changes have had a significant impact on how health, environmental, and water and sanitation services are delivered at the local level. Yet it is estimated that in 2006/07 only 63 percent of Ugandans in rural areas and 56 percent in urban areas had access to water services (Uganda 2007c). 1 About 59 percent of Ugandan households and schools had access to latrines, and 8 percent had access to a sewerage system (ibid.). Inadequate access to clean water and sanitation and poor hygiene practices are linked to waterborne diseases such as cholera, dysentery, diarrhea, and gastrointestinal worms. It is estimated that 70­80 percent of the total national disease burden is related to poor sanitation (Uganda 2005a). 5. Among the key factors that hinder improvements in service delivery are underlying institutional, financial, and governance constraints (World Bank 2005). Thus the 1 Access is defined as the percentage of people within 1.5 kilometers (rural) or 0.2 kilometers (urban) of an improved water source. 9 opportunities for improved coordination created by the Sanitation MOU are not being fully realized. One measure proposed by sector colleagues to address lack of prioritization is an integrated budget line for sanitation and hygiene. In particular, the government and the 2006 joint sector review for water and sanitation have requested guidance on how such a budget line can be implemented. This study responds to that request, as well. 6. The Sanitation MOU specifically focused on excreta-related sanitation and hygiene and did not address broader environmental sanitation issues such as solid waste management and drainage--issues that have recently drawn considerable attention, particularly in urban and periurban areas. In Kampala, for instance, about 1,500 metric tons of garbage are produced daily by households, industries, institutions, and markets (Sebunya 2007). Yet almost 60 percent of the waste generated in the city is not collected, highlighting difficulties in waste collection and disposal (Womakuyu 2008). Poor waste management is linked to a number of environmental and health hazards, including outbreaks of dysentery, cholera, and malaria, even though it is weakly correlated with morbidity and mortality in comparison with excreta-related sanitation and hygiene. 2 Although there is considerable debate about how exactly to improve solid waste management and drainage, whether through reform of the Sanitation MOU or other mechanisms, there is increasing consensus on the need to look at past approaches and improve service delivery in this context. Objectives 7. The purpose of this study is to provide the government of Uganda with recommendations on reforming the Sanitation Memorandum of Understanding. The analysis focuses on three specific issues. 8. First, the study examines the institutional and political economy factors at the national and local government levels to explain why sanitation and hygiene have been marginalized, why funding for these activities has been limited, and the institutional changes that are needed to reform and improve implementation of the Sanitation MOU. The study also draws on an analysis of good-practice cases in both urban and rural areas. Second, in response to a specific request from the Joint Water and Sanitation Sector Working Group, the study examines the best options for introducing an integrated budget line for sanitation. Third, the study assesses institutional and governance issues linked with solid waste management, focusing on Kampala as a case study. 9. Analysis of institutional issues associated with sanitation and hygiene is important for a number of reasons. First, although the sanitation memorandum to some extent clarified mandates at the national level, a better understanding is needed of how these mandates are being implemented at the local level. Second, institutional analysis can shed light on how national-level priorities and targets determined by sector ministries connect with local-level planning and priority-setting processes. Third, it can help assess whether an integrated budget line is indeed sufficient or whether other institutional constraints also 2 Economic analysis of the marginal cost of reduction of water-related diseases in other countries (for example, Peru) shows that excreta-related sanitation and hygiene are more strongly correlated with mortality and morbidity than are safe disposal of solid and liquid waste and drainage. 10 need to be addressed to improve accountability in the use of the funds for sanitation and hygiene promotion. Fourth, an analysis of well-performing districts and municipalities can explain how these areas succeeded despite governance constraints similar to other jurisdictions. Finally, analysis of institutional issues linked with solid waste and drainage, although confined to a case study of Kampala, can highlight performance issues that constrain improvements in service delivery and can identify potential entry points for further engagement in this area. Definitions and scope of the study 10. In this study, sanitation refers to the infrastructure and services required for safe management of human excreta (for example, latrines, sewers, and wastewater treatment). Hygiene refers to human behaviors related to safe management of excreta. Environmental sanitation is used more broadly to refer to isolation of human excreta from the environment; maintenance of the safe water chain; the sustained practice of good personal, domestic, public, and food hygiene; safe disposal of solid and liquid wastes; drainage; and control of disease vectors and vermin.3 11. The main focus of the report is on excreta-related sanitation and hygiene. The emphasis is mainly on on-site sanitation because in Uganda more than 90 percent of the population relies on this in some form; only about 8 percent has access to sewerage infrastructure. Analysis of solid waste management and drainage is less detailed because of limitations of budget and time and because of the greater health impact of excreta- related sanitation and hygiene. Appr oach and methodology 12. The analysis is based on documentary and field-based research carried out between June 2007 and November 2008. The research involved discussions with various governmental and nongovernmental stakeholders and with representatives of key donor organizations (see Appendix B). Fieldwork was carried out in Rakai, Lyantonde, Mukono, and Wakiso Districts; in Kampala; and in the small towns of Soroti and Luwero. In October 2007 the study on options for establishing an integrated budget line for sanitation was presented to the joint sector review for water and sanitation and at a workshop in Kampala organized by the World Bank and the National Sanitation Working Group. Findings and recommendations from this report were also discussed at a stakeholder workshop hosted by the Ministry of Water and Environment and organized by the World Bank in October 2008. Feedback from those discussions has been incorporated into the report. Str uctur e of the r epor t 13. Chapter 2 describes key policy and institutional initiatives for addressing sanitation and hygiene and highlights the factors and processes that have contributed to low prioritization of these issues at the national and local government levels. Chapter 3 3 See http://intranet.worldbank.org/WBSITE/INTRANET/SECTORS/INTWSS/INTTOPSANHYG/0,,contentM DK:21147365~menuPK:1923148~pagePK:64168324~piPK:64168339~theSitePK:1923126,00.html.These definitions are also consistent with Uganda's National Environmental Health Policy (Uganda 2005c). 11 focuses on case-study analysis of selected districts and municipalities to highlight factors that have contributed to improved sanitation and hygiene. Chapter 4 examines four options for implementing an integrated budget line for sanitation and hygiene. It discusses the trade-offs between these options and recommends one of the four. Chapter 5 focuses on solid waste management and drainage, in response to government interest in this issue. It considers whether the Sanitation Memorandum of Understanding should include solid waste management and drainage. Finally, Chapter 6 presents the main conclusions and recommendations of the report. Costing of recommendations was outside the study terms of reference agreed to with the government and needs to be carried out as a follow-up to this report. 12 2. The Political Economy of Sanitation and Hygiene in Uganda 14. While excreta-related sanitation and hygiene have been chronically marginalized by key sector ministries, in the past few years there has been more emphasis on sanitation at higher levels of government, including the Ministry of Finance, Planning, and Economic Development (MFPED). In part, the interest stems from infant mortality studies showing how Uganda's disease burden is linked to poor hygiene and inadequate sanitation facilities and practices (see table 2.1). Although key sanitation and hygiene indicators have improved in the past 10 years, progress has been slow compared with the country's targets under the Poverty Eradication Action Plan and the Millennium Development Goals. This chapter describes the policy initiatives that have been undertaken in the past decade to improve access to excreta-related sanitation and hygiene and examines the institutional factors that underlie weak implementation of the Sanitation Memorandum of Understanding. The analysis explains why prioritization and funding for sanitation and hygiene at the district and local levels have been limited and why the Sanitation MOU needs to be reformed. Table 2.1 Trends in health-related outcomes, 1990 to 2003, and national targets PEAP target, 1990 1995 2000 2005 2005 MDG target, 2015 Infant mortality rate 122 81 88 79 68 Reduce by two-thirds, to (deaths/1,000 live births) 41 deaths per 1,000 live births Under-five mortality rate 180 147 152 136 103 Reduce by two-thirds, to (deaths/1,000 live births) 60 deaths per 1,000 live births Maternal mortality ratio 527 506 505 -- 354 Reduce by three-fourths, (deaths/100,000 live births) to 131 deaths per 100,000 live births Source: Uganda 2005a, table 1.1. For 2005, World Health Organization data. Note: --, not available. MDG, Millennium Development Goal; PEAP, Poverty Eradication Action Plan. Slow impr ovement in sanitation and hygiene indicators 15. In the 1960s, latrine coverage in Uganda was over 90 percent due to clearly articulated public health legislation, enforcement of local bylaws, and facilitation of local health inspectors. Coverage declined steeply in the 1970s during the civil war and in the past decade has been improving slowly (see figure 2.1). 4 4 The water and sanitation sector performance measurement framework (Uganda 2007c) defines three golden indicators relevant for integrated sanitation and hygiene: sanitation access use--the percentage of the population with access to and use of improved and basic latrines and toilets; hygiene access and use-- the percentage of the population with access to and use of hand-washing facilities; and water quality (safe water chain; percentage of water samples taken at the point of collection or discharge that complies with national standards). 13 Figure 2.1 Latrine coverage, 1960 to 2007 Trends in latrine coverage: 1960 - 2007 100 80 60 %age 40 20 0 1960 1970 1980 1990 2000 2002 2004 2005 2006 2007 Year Source: Uganda 2008. 16. The Water and Sanitation Sector Performance Report for 2007 (Uganda 2007c) reported the percentage of the population with access to sanitation in 2006/07 as 59 percent, compared with 49 percent in 1997. 5 Although Uganda's latrine coverage is higher than in some other regions (see table 2.2), at this pace it will be difficult for the country to meet its MDG and PEAP/Poverty Reduction Strategy Paper (PRSP) targets for latrine coverage (72 and 80 percent, respectively). 17. Turning to hand-washing (by adults, with soap after defecation), 14 percent of households had access to and were using hand-washing facilities in fiscal 2006/07 (Uganda 2007c, 27). Comprehensive national-level data for 2001 or earlier are not available. The figures are based on research carried out in 10 districts showing that 14 percent of mothers with children under age 5 wash their hands with soap after visiting the toilet, 19 percent of caregivers wash hands with soap after cleaning a baby's bottom, and only 6 percent wash their hands before feeding a child (Uganda 2007c, 77). The government has recently implemented a pilot hand-washing campaign, and a national launch of the program is being planned with a target of increasing hand-washing to 50 percent nationally by fiscal 2014/15. A baseline study undertaken for the national hand- washing campaign concluded that hand-washing with soap at critical junctures is not a common practice in Uganda, despite a history of promotional activities. 5 In Uganda a traditional latrine is typically made out of temporary (local) materials like logs, mud, and wattle wall or grass/dry banana leaves, with the floor made of rammed murram or soil/clay that may be smeared with cow dung. A traditional improved latrine has a SanPlat, slab, or cemented floor. Access to latrines here includes a combination of latrines, including traditional and improved latrines (including VIPS and flush toilets). The majority of the people use traditional latrines. The statistics provided here and reported in the Water and Sanitation Sector Performance Report (Uganda 2007c) are based on information from the health inspectorate staff, based on their assessment of the condition of the latrines. The Uganda Bureau of Statistics uses information given by the communities in interviews and does not include verification. Efforts to harmonize this information with the bureau are under way. 14 Table 2.2 Water and sanitation indicators, 2004 (percent) East and South Uganda Southern Africa Asia Access to improved drinking water Total 60 56 85 Urban 87 86 94 Rural 56 42 81 MDG 2015 target 72 74 86 Access to improved sanitation Total 43 38 37 Urban 54 58 63 Rural 41 30 27 MDG 2015 target 71 68 59 Under-five mortality rate (deaths/1,000 live births) 138 149 92 Diarrhea prevalence (percent of children under five) 19.6 -- -- Source: UNICEF (2008) for diarrhea prevalence; World Bank 2008c. Note: --, not available. MDG, Millennium Development Goal. 18. According to a school sanitation study, 41 percent of schools had hand-washing facilities; of these, 56 percent had a water source, and 19 percent had soap or ash available for washing hands (Uganda 2006d). The school sanitation study also found that the availability of soap and a water source near latrines is a key factor in hand-washing. Some studies have revealed a variation between districts in hand-washing practices ranging from less than 10 percent to over 90 percent (Uganda 2006e, 7). Prevalence of on-site sanitation with limited access to sewerage 19. Uganda's population is currently estimated at 26 million, and about 22 million people, or 85 percent of the total, live in rural areas. Excreta disposal facilities in Uganda mainly include ordinary pit latrines (mostly in rural settings, small growth centers, and rural schools), ventilated improved pit (VIP) latrines (middle- and upper-class households and some institutions), EcoSan toilets (middle-class households and demonstration constructions), and flush toilets (upper- and middle-class households in urban areas and where potable water is available). According to raw data from the 2002 census, 16 percent of the population lacks access to any toilet facility (UBOS 2002). It seems to be common practice in the districts visited as part of this study to build a pit latrine and then when it is full to abandon it and dig a new one. 20. Latrine coverage varies by district, from 1 to 98 percent. Kampala is the best- performing town, with 94 percent of the population having access to improved sanitation. The districts with the best latrine coverage are Rukungiri, 98 percent; Bushenyi, 91 percent; Kabale, 89 percent; Kabarole, 86 percent; Masaka, 86 percent; Mukono, 86 percent; Ntungamo, 86 percent; Ibanda, 80 percent; Kasese, 80 percent; and Kaliro, 79 percent (Uganda 2007c, 205). There is good latrine coverage in most of the southeast of the country. The worst coverage is in the northwest districts in the conflict-affected areas 15 (Uganda 2006e). In some areas, such as Bushenyi, Rukungiri, and Kabale, the main problem is not latrine coverage but hand-washing with soap. 21. As of June 2007, national sewerage service coverage stood at about 8 percent. The large towns of Kampala, Jinja, Entebbe, Tororo, Mbale, Masaka, Mbarara, Lira, Gulu, Fort Portal, Kabale, and Soroti have access to sewerage facilities, but a mere 6 percent of the total population in the towns is covered (Uganda 2007c). New sewer connections have been low, at about 250 connections per year, with 2 percent growth in the last three years. Reasons for low connections include limited sewerage network coverage, reluctance to connect on the part of those who already have on-site sanitation facilities (as they would have to pay higher tariffs), and poor urban planning. In small towns, the high investment cost for sewerage remains a limiting factor (Uganda 2007c). 22. In Kampala, although 72 percent of the city's daytime population has access to safe water supplied by the National Water and Sewerage Corporation (NWSC), only 8.5 percent is served by the public sewer system. Most city residents depend on septic tanks and non-waterborne options such as pit latrines and EcoSans. Many of these facilities are serviced by cesspool emptiers that ferry the waste to a centralized sewage treatment plant run by the NWSC at Bugolobi in central Kampala. Septic tanks are used for richer homes and buildings, while typically pit latrines serve poorer blocks. 23. Improvements in sanitation need to be accompanied by expansion of safe water coverage. Overall urban water supply coverage stands at about 56 percent of the population, and rural water coverage is 63 percent (Uganda 2007c).The target for 2015 is to have 100 percent safe water coverage in urban areas and 77 percent in rural areas. 24. The compliance of wastewater treatment facilities with national standards is low, as indicated by results on municipal effluents from wastewater treatment facilities in all the large towns under the NWSC. Analysis of 223 data sets for fiscal 2006/07 found conformity to wastewater standards to be 12 percent for biological oxygen demand, 26 percent for phosphorus, and 40 percent for total suspended solids. Noncompliance with standards by wastewater treatment plants is polluting water bodies, especially Lake Victoria, from which raw water for the large towns is abstracted. 25. Although the pupil-stance ratio for school sanitation has steadily improved, from 150:1 in 1997 to 69:1 in 2006, it lags behind the target of 40:1 (Uganda 2007c, 27). There are indications that the situation has improved following construction of latrines at schools (Uganda 2007c, 117). Implications of poor access to sanitation and hygiene for health outcomes 26. Despite major gains in public health services, the number of persons suffering from ill health related to environmental sanitation and hygiene has continued to rise, especially among infants and young children. Worldwide, diarrhea kills about 4,900 people daily. In 2004 one-third of all deaths in Sub-Saharan Africa were in the under-five age group. A recent report on child survival shows that Africa is the only continent where the number of deaths among children under age 5 has been increasing since the 1970s (UNICEF 2008). Many of these children die of preventable and curable diseases. Malaria causes 18 percent of all under-five deaths in Africa, but diarrheal diseases and pneumonia-- illnesses that flourish in poor communities where residents are often undernourished and 16 sanitation is compromised--account for an additional 40 percent (UNICEF 2008). At any given time, almost half of the world's people suffer from one or more of the main diseases associated with lack of adequate sanitation or water supply. 27. Preventable diseases account for 75 percent of the disease burden in Uganda (Uganda 2005c, 4). Sanitation-related diseases such as diarrhea, eye infections, intestinal worms, skin infections, and malaria account for nearly half the outpatient visits in the country and are major causes of mortality and morbidity (Uganda 2000). The high incidence of diarrhea is also a leading cause of nutritional stunting, which was 38 percent as of 2006 (Uganda 2007a). Repeated bouts of diarrhea before age 1 contribute to vitamin deficiency and malnutrition, which increases the likelihood of suffering longer attacks of diarrhea in the future. Diarrhea also impedes infant weight gain (Uganda 2005c, 4). In schools, the problem of limited or absent sanitation facilities has contributed to school dropout rates, particularly among adolescent girls (Uganda 2005c, 4). The outbreak of hepatitis E in northern Uganda since 2008 is also due to poor sanitation and hygiene. The 2006 Human Development Report found that access to an improved water source reduces the risk of infant mortality by 23 percent in Uganda (UNDP 2006). Access to improved sanitation has an even greater effect. 28. Schistosomiasis and intestinal worms are widely distributed. Schistosomiasis is reported in 30 of Uganda's 45 districts. Intestinal worms are a serious public health problem throughout the country, largely because of poor sanitary conditions. 6 On the brighter side, the number of guinea worm cases has been reduced from 126,369 reported cases in 1992 to 71 by July 2000, and from 16 original endemic districts to only 3-- Moroto, Kotido, and Kitgum. 7 Disproportionate impact of limited access to sanitation on the poor 29. As in other developing countries, health outcomes in Uganda are the worst for the poorest segments of society (see figure 2.2). For example, the overall under-five mortality rate is 152 deaths per 1,000 live births, but the rate for the poorest is twice as high as that for the richest (Uganda 2005b). Poor sanitation and hygiene exact the highest toll on the most vulnerable groups in both rural and urban areas. In northern Uganda, the prolonged conflict between the Lord's Resistance Army and the government has made implementation of improved water and sanitation very difficult. It is estimated that more than 1.4 million people were forced to leave their homes. Thousands were killed in the violence, and many more died from disease and malnutrition as a direct result of the conflict. The main causes of under-five mortality in the region are fever and diarrhea, which may be closely linked to lack of sanitation. 6 Uganda, Ministry of Health, "Blood Transfusion Services," Ministry of Health Online. http://www.health.go.ug/blood_trans.htm. 7 Uganda, Ministry of Health, "Guinea Worm Eradication Status in Uganda," Ministry of Health Online. http://www.health.go.ug/disease_guineaworm.htm. 17 Figure 2.2 Socioeconomic differences in health outcomes, 2007 2.20 2.00 Inter-quintile Ratio 1.80 1.60 1.40 1.20 1.00 Lowest Second Middle Fourth Highest Wealth Quintiles IMR U5MR TFR Source: Uganda 2005a. Note: IMR, infant mortality rate; TFR, total fertility rate; U5MR, under-five mortality rate. Ser vice deliver y in the context of br oader gover nance r efor ms 30. Even though Uganda's gross domestic product (GDP) grew at average annual rates of 6.9 percent in the 1990s and 5.5 percent during 1999­2005, in 2003 some 37.7 percent of the population still lived below the poverty line (World Bank 2008d). To foster overall economic growth, reduce poverty, and improve service delivery, a key set of reforms undertaken by the government relates to decentralization, whereby administrative, financial, and political power was devolved to districts and local governments. 8 Politically, decentralization has been seen as a tool for achieving national consensus among regional and ethnic groups. One result has been the proliferation of districts--the highest tier of local government--from 33 in 1980 to 78 in 2006 and to 80 currently. This poses numerous administrative and capacity challenges to local governments in meeting their service delivery mandates, including those relating to sanitation and hygiene. 31. Another important development is the increasing application of the sectorwide approach (SWAP) to planning and development. SWAPs for health and education were adopted in 2001; for water and sanitation, in 2002. Adoption of a SWAP signals a shift away from primarily project-focused donor assistance to a more coordinated approach taken by donors to support agreed-on national development objectives. In principle, the use of SWAP signals common policies and strategies, a defined institutional framework for all stakeholders, agreed-on sector investment plans, periodic reviews, and improved monitoring and accountability. In the health sector, for instance, reforms under SWAP emphasize the simplification of procedures between donors and government and an agreement to implement a common national strategic plan using uniform management systems. One of SWAP's shortcomings has been its focus on donor harmonization at the cost of finding ways to improve quality of care and local service delivery (Jeppsson et al. 2005). These reforms and initiatives have influenced the approach to sanitation and hygiene promotion in Uganda. 8 For recent discussions of the history of decentralization, see Francis and James (2003); Ahmad, Brosio, and Gonzalez (2006). 18 Policy and legal fr amewor k for addr essing sanitation and hygiene 32. Policies and legislation related to environmental health date back to the early 1960s (see table 2.3). The Public Health Act passed in 1964 and updated in 2000 is the overarching law that provides the basis for safeguarding public health. It clarifies the powers of national and local governmental authorities in the prevention and suppression of infectious, epidemic, and venereal diseases; the provision of sanitation and housing; and the prohibition of public nuisances. It also clarifies the rights of local governments to provide public sewers and sewage disposal works and the rights of owners and occupiers to drain into public sewers. In addition, a number of other laws and regulations have been prepared that pertain to waste and water pollution, such as the Water Act, the National Environmental Management Act, and waste regulations. Table 2.3 Main sanitation laws and regulations Provision Implementer Summary Public Health Act Ministry of The Public Health Act is the primary legal basis for dealing with a range (1964) Health; local of diseases and preserving public health. It contains provisions on governments infectious diseases, sanitation, sewerage, drainage, water, food supply, and certain epidemic diseases. The act was updated in 2000. Sanitation- and Local Each local government is supposed to make its own sanitation waste-related governments ordinances and bylaws. Poor enforcement is a major problem. Some bylaws local governments have not enacted such laws. Water Act (ch. Ministry of Under the act, a waste discharge permit is required for anyone to dispose 152 of the law Water and of waste into any water. It is the function of the appointed authority, the code of 2000) Environment National Water and Sewerage Corporation (NWSC), to provide and (MWE)/ manage sewerage services. Directorate of Water Resources Management (DWRM) Water (Waste MWE/DWRM These regulations set out the procedure for seeking permission to Discharge) discharge effluent or waste onto land or into the aquatic environment. Regulations, 1998 Industries have called for revision on the grounds that the regulations are too stringent. Sewerage MWE/DWRM This statute applies to sewerage areas and specifies requirements for Regulations emitting trade waste into sewerage works. It also deals with applications (Statutory Inst. 5 to construct or extend private sewer works. of 1999) National National Environmental legislation is managed and enforced by NEMA. The law Environment Environment defines "waste" as any matter that is waste, radioactive matter (whether Regulations Management liquid, solid, or gaseous) that is discharged, emitted, or deposited into the (Statutory Authority environment in such volume, composition, or manner as to cause an Instrument 153-2) (NEMA) alteration of the environment. Source: Authors' compilation. Note: For the Public Health Act, see Southern African Legal Information Institute (SAFLII), "Uganda: Laws of Uganda," http://www.saflii.org/ug/legis/consol_act/pha1935281135/. Local governments have the main mandate for service delivery and are tasked with preparing and implementing their own bylaws and ordinances for addressing a range of issues, including sanitation, solid waste management, and drainage for the protection of public health in their areas of jurisdiction. In many cases, however, local governments have not prepared these bylaws, and where laws do exist, enforcement is very weak. 33. In 1997 a National Sanitation Forum was held to raise the profile of sanitation and to develop a national program of action. The forum produced the Kampala Declaration on Sanitation (KDS), which had strong backing and support from political leaders of all 45 19 districts existing at the time. Local government leaders committed themselves to a 10- point strategy to improve sanitation, highlighting factors such as committed leadership, community mobilization, and a focus on districts and urban authorities. Despite support from district leaders, the effectiveness of the KDS was limited due to ambiguity regarding institutional mandates and clarification on financial mechanisms for provision of sanitation and hygiene. The 2001 Memorandum of Understanding: Clarification of institutional mandates at the national level 34. In 2001, in an effort to improve sanitation coverage and clarify institutional mandates, a Memorandum of Understanding was signed by the Ministry of Water, Lands, and Environment, the Ministry of Health, and the Ministry of Education and Sports (see Appendix A). 9 The memorandum identified the responsibilities of the lead central institutions as follows: The Ministry of Water, Lands, and Environment is responsible for planning investment in sewerage services and public facilities in towns and rural growth centers. The Ministry of Health is responsible for household hygiene and sanitation. The Ministry of Education and Sports is responsible for school latrine construction and hygiene education. 35. With the signing of the MOU, it was agreed that the three lead ministries would implement these institutional responsibilities, including prioritization of resources for sanitation and hygiene promotion. As described below, the splitting of mandates between the three ministries impeded a coordinated approach toward sanitation and hygiene promotion at the district and local levels. 36. In 2005 an environmental health policy was prepared. Given the extent to which Uganda's disease burden is considered preventable, the policy heavily emphasizes integrated and preventive health strategies and the promotion of domestic, school, and basic hygiene (Uganda 2005c, 7). It also focuses on other aspects of environmental health such as food safety and vector control. The policy was launched at the Health Assembly of 2005, which has broad participation including district chairpersons and chief administrative officers (CAOs), and in 2006, was also presented to the district health inspectors' annual workshop. Or ganizational dilemmas 37. Within the three ministries, key actors with a formal mandate with respect to delivery of sanitation and hygiene include the Directorate of Water Development (DWD) in the Ministry of Water and Environment, relevant units in the Ministry of Education and Sports, and the Environmental Health Division (EHD) in the Ministry of Health (see table 2.4). The National Sanitation Working Group (NSWG) acts as a coordinator for ministries, donors, and other stakeholders on sanitation and hygiene issues. 9 The Ministry of Water, Lands, and Environment was restructured in 2006 and became the Ministry of Water and Environment. Mandates related to land passed to the new Ministry of Land, Housing, and Urban Development, whose responsibilities and functions are currently evolving and being defined. 20 Need to strengthen the Environmental Health Division 38. The Environmental Health Division in the Ministry of Health has the main responsibility for developing policies on sanitation and hygiene promotion and ensuring their implementation. It is also responsible for development of relevant standards, technical guidelines, and legislation; coordination of national sanitation activities; and provision of technical support and operational guidance to local government environmental health services. Under the Memorandum of Understanding, its primary mandate is hygiene promotion at the household level, which is implemented by district health officers. 39. Despite the importance of its mandate, this is a relatively weak division, with just eight staff members. While in the past EHD's role included deployment and control of all public health inspectors in the country, with decentralization the division primarily provides technical assistance to districts. Further, it regularly prepares three-year strategic plans for environmental health, but the extent to which planning and budgeting take place in accordance with the strategic plan is not clear. The EHD budget--approximately 60 million Ugandan shillings (U Sh) in fiscal 2008--is a very small fraction of the total budget of the Ministry of Health (U Sh 418 billion in fiscal 2007/08, according to the Ministry of Health Annual Health Sector Performance Report for that period), an indication of the status of preventive approaches among the ministry's priorities. One factor that influences access to resources is the ability of the leadership to plan, budget, and lobby for resources. Existing leadership on this issue has been weak and needs to be strengthened. Given the importance of preventive approaches to the reduction of Uganda's overall disease burden, the EHD should play a much more prominent role in the ministry than it currently does. Growing support for sanitation in Ministry of Water and Environment 40. Within the Ministry of Water and Environment, the main directorate responsible for sanitation-related activities is the Directorate of Water Development. Traditionally, its main focus has been on water supply and water resources management, with latrine construction in a relatively marginal position. The ministry is also responsible for supporting the planning and provision of sewerage, which it does through the National Water and Sewerage Corporation. 21 Table 2.4 Organizational mandates at the national level Implementing line ministry and department Mandate or function Ministry of Health Household sanitation and promotion Environmental Health Policy setting and updating; production of norms and guidelines Division (EHD) Approval of primary health care conditional grant (PHCCG) work plans and budgets (sanitation unit in cooperation with planning division) Assistance by area support teams to local authorities in developing adequate work plans and budgets Ministry of Education and Training hygiene promoters Sports School of Hygiene Institute of Public Health (Mulago) Ministry of Education and School sanitation and hygiene promotion Sports Policy setting and updating; production of norms and guidelines Preprimary and Primary School Department, Education (PPDE) Planning Department, Education (PDE) Ministry of Water and Investment in public sanitation facilities and hygiene promotion Environment Policy setting and updating; production of norms and guidelines Directorate of Water Development (DWD) Implementation of public sanitation facilities and sewerage Urban Water Department (UWD) National Water and Sewerage Corporation (NWSC) Ministry of Water and Investment in public sanitation facilities and hygiene promotion Environment Policy setting and updating; production of norms and guidelines DWD Rural Water Department Approval of district water and sanitation conditional grant (DWSCG) work plans and budgets Sector working groups Coordination of multisectoral activities within sanitation and hygiene National Sanitation promotion Working Group (NSWG) Operationalize the sanitation memorandum of understanding; establish clear budget lines for sanitation; promote hygiene and sanitation. Ministry of Gender, Labour, Community sanitation and hygiene awareness raising and training; and Social Development enhancement of capacity of communities and stakeholders to deliver (MGLSD) services effectively Department of Gender, Approval of community development conditional grant (CDCG) work Culture, and Community plans and budgets Development Ministry of Local Promotion of democratic governance, advocacy, transparency, and Government (MLG) accountability; development of management and administrative capacity; provision of technical support and guidance for all local authorities across sectors Source: Uganda 2005d. 22 41. DWD's technical support to districts on rural water and sanitation issues through eight technical support units (TSUs) has become very successful. TSUs consist of a water and sanitation specialist, a public health specialist, and a community development specialist and have been very successful in setting up district water and sanitation committees and developing goodwill among district-level stakeholders. A midterm evaluation of the TSUs carried out by the DWD in May 2005 revealed that district capacity has improved remarkably because of their support. 42. Sanitation and hygiene are also gaining support from MWE's highest officials. The minister is very supportive and the ministry's permanent secretary has highlighted the importance of sanitation in many speeches and activities. Within DWD, a position has also been created to coordinate sanitation activities with other ministries and stakeholders and support TSU linkages with the center. Limited staffing for sanitation and hygiene in the Ministry of Education and Sports 43. The Ministry of Education and Sports is responsible for school latrine construction and hygiene promotion. The main responsibility lies with its Preprimary and Primary School Department, which is supposed to work closely with the ministry's Planning Department. However, the Preprimary and Primary School Department has only two staff members charged with supporting school sanitation issues, which is also a neglected area within the ministry in terms of resource allocation. Raising the profile of sanitation--The role of the National Sanitation Working Group 44. Over the past five years a coordinating body, the National Sanitation Working Group, has played a very important role in raising the profile of integrated sanitation and hygiene. It was established in 2003 and includes representatives from the EHD, the Ministry of Education and Sports, the DWD, donors, and the Uganda Water and Sanitation NGO Network (UWASNET). At present the group is chaired by a representative of a donor group, since the participating stakeholders are not yet ready to accept the chairpersonship from one of the ministries. Its main mandate is to operationalize the Sanitation MOU, integrate sanitation and hygiene promotion into sector operations, and improve cross-sectoral coordination. The NSWG meets regularly and has been very successful in improving coordination in the sector and lobbying for integrated sanitation and hygiene promotion in the PEAP, joint sector reviews, and the current Health Sector Strategic Plan (Uganda 2005a). Nevertheless, it faces a number of challenges: The group has no representatives from the National Environment Management Authority. Participation by ministries other than the Ministry of Health (for example, the Ministry of Local Government) is not very regular. On average, attendance at the meetings consists of 26 percent government officers, 26 percent development partners, 33 percent NGOs, and 15 percent technical assistants. 10 The NSWG takes on issues identified by stakeholder ministries and NGOs represented by UWASNET, but it largely deals with sanitation subsector undertakings that are generated at joint sector review meetings and approved by 10 Technical assistants are the relevant advisers attached to the Ministry of Water and Environment or the Ministry of Health who attend NSWG meetings as members. 23 the National Water and Sanitation Sector Working Group. The NSWG reports to the joint sector review and joint technical review meetings on progress made on these undertakings and other related sanitation and hygiene activities. Its link to local governments, however, is mainly through representation of local governments (which are supposed to be represented by a member of the TSU secretariat) rather than through active engagement at the local government level. The NSWG has pushed for establishment of district water and sanitation coordination committees (DWSCCs) to mirror the NSWG at the district level. The NSWG does not have a clear road map for its activities that details expected outputs, a time frame, and measurable indicators for outputs. The NSWG has lacked the information on investment activities being undertaken by various donors that would allow for coordination of those activities. The NSWG could play a stronger role in collecting and sharing such information. Mar ginalization of sanitation within the fiscal decentr alization fr amewor k 45. In addition to being marginalized within sector ministries in terms of resources and staffing, sanitation and hygiene have also been neglected within sector budgets. To understand this, it is important to consider the broader fiscal constraints facing local governments. Imbalance between central government transfers and mandates for service delivery 46. Budget resources are consolidated at the national level and flow through the Ministry of Finance, Planning, and Economic Development to the sector ministries. Of the total national budget, only 27­30 percent goes to local governments (Uganda 2007b). Furthermore, 94 percent of the resources used at the local government level are transfers from the central government. Local governments have the main responsibility for service delivery, yet they receive a disproportionately small percentage of funding to meet their mandates. Over the years the share of revenue generated locally compared with the total resources available to local governments has declined (see Chapter 5), implying significant reliance of local governments on central government transfers. Decision making within the conditional grant structure: Little space for local government discretion 47. The central government makes funds available to districts through unconditional grants, sector conditional grants, and equalization grants. Conditional grants are programmed by sectoral ministries at the national level and are earmarked to reflect national sectoral programs in the districts. 48. Almost 80 percent of the transfers from the central to local governments are in the form of sector conditional grants (Francis and James 2003; Ahmad, Brosio, and Gonzalez 2006). Thus, allocation decisions for most resources going to local governments are already predetermined by sectoral ministries at the central level. Equalization grants are meant to support districts that are lagging, but these grants constitute a very small percentage (less than 1 percent in 2001) of total central government transfers to districts (Francis and James 2003). Unconditional grants are mainly spent on general management 24 and administration, including councilors' wages and allowances, and have minimal reporting requirements. 49. In keeping with Uganda's broader decentralization strategy, priority setting and decision making on how these funds can be allocated are supposed to be done at the district level in accordance with the three-year rolling district development plan. The line ministries have a technical supervisory role in approving the work plans and budgets for sector conditional grants and in approving quarterly performance and progress reports. Given the earmarking by sectoral ministries, there are constraints on how these funds can be used at the district and local levels. This inflexibility has reduced the decision-making power of local authorities (Francis and James 2003). Sources and flow of funds for sanitation and hygiene under current arrangements 50. On-budget public funding for the districts and municipalities for sanitation and hygiene is channeled through three main conditional grants: Primary health care conditional grants (PHCCGs) from the Ministry of Health School facilities grants (SFGs) from the Ministry of Education and Sports District water and sanitation conditional grants from the Ministry of Water and Environment. 51. Use of these grants is governed by guidelines prepared by the respective sectoral ministries (see Appendix C). The sector conditional grants each require 15 percent cofinancing by the local government. The cofinancing could be in the form of unconditional grants from the central government; equalization grants from the central government; Local Government Development Program (LGDP) grants from the central government; or local government revenues. 52. The main sources of off-budget financing for sanitation and hygiene are household investment in sanitation facilities; user charges and tariffs; microfinance available to communities and consumers (minor, in practice); NGO and donor projects (grants and loans); and investments made by the private sector with the aim of securing a return on the investments. 53. According to the mandates set out in the Sanitation MOU and in existing sectoral guidelines, construction of school and public latrines and promotion of household hygiene receive 100 percent public funding, but there is no subsidy for household latrine construction. Household latrine construction is fully borne by the households or is supported by NGO and donor projects. Vague conditional grant guidelines for sanitation and hygiene 54. Each of the sector conditional grants mentioned above is subject to conditions, thus limiting resources for sanitation and hygiene. For example, 50 percent of the primary health care conditional grant is earmarked for drug purchases, and the reminder has to be distributed among other primary health care programs, of which environmental health is one. Similarly, priority in the water and sanitation sector conditional grants and in the total budget of the Ministry of Water and Environment is given to water supply. In the school facilities grant--which is being phased out and replaced by the universal primary 25 education capitation grant--the emphasis is on improving pupil-teacher ratios, pupil- classroom ratios, and pupil-book ratios (see Appendix C). 55. Furthermore, although the guidelines for the sector conditional grants recommend that a percentage of the funds be used for sanitation and hygiene promotion, this is not a requirement. So far, the MFPED has taken the view that each sector should prioritize within its ceiling. For the water and sanitation conditional grant, a guideline states that up to 12 percent can be spent by local governments on hygiene promotion, but this is not mandatory. The ambiguity of these guidelines has contributed to a lack of priority for sanitation and hygiene in various sector agendas. Evidence for neglect of sanitation and hygiene in sector conditional grants 56. Analysis of sector conditional grants shows that a very small percentage is spent on sanitation and hygiene promotion. A study commissioned by DWD in 2006 showed that 3.67­4.21 percent went for promotion of hygienic use of water and sanitation in fiscal 2002/03, 2003/04, and 2004/05. The corresponding figure in the SFG budget line for increased access to sanitation facilities was between 1.23 and 2.35 percent (Uganda 2006a). SFG funds were used toward the construction of new sanitation facilities, as the SFG does not cover promotion, operation and maintenance, or replacement of existing toilets and latrines. It was not possible to determine expenditures on sanitation and hygiene promotion under the primary health care conditional grant due to limitations of data. Previous studies have used a PHCCG estimate of 2 percent as a national average for spending on sanitation and hygiene promotion (Uganda 2005d, 12). Estimates made as part of this study show that approximately 0.001 percent of the LGDP grant is used for sanitation and hygiene-related activities. Thus, in the service delivery mandate given to local governments by the Fiscal Dectralization Strategy, sanitation and hygiene are low on the priority list. Lack of incentives for cr oss-sector al coor dination at the national level 57. In addition to the factors discussed above, incentives for collective action and inter- sectoral coordination with respect to sanitation and hygiene have also been lacking. Some relate to the organizational histories and relationships of the sector ministries involved; others have to do with the design of the Memorandum of Understanding. Implications of the shift from a primarily project-driven approach to budget support for sanitation and hygiene 58. In the 1990s, sanitation-related activities were funded through water and sanitation projects, with the Ministry of Water, Lands, and Environment as the main implementing agency. With the shift to earmarked budget support in the late 1990s, most of these projects were phased out. This development coincided with the signing of the Sanitation MOU in 2001. Interviews with officials in the sector ministries suggested that because of the past history of water and sanitation projects being funded by the MWLE, there was an expectation by officials in the Ministry of Health and the Ministry of Education and Sports that the successor to the MWLE--the Ministry of Water and Environment-- would fund latrine construction and hygiene promotion. 26 59. There was also an expectation by some actors--in particular, the Ministries of Health and of Education and Sports--that their sector ceilings would increase with the transfer of responsibilities, as identified in the Sanitation MOU, in parallel with a decrease in the ceiling assigned to the Ministry of Water and Environment. The MOU, however, was a statement clarifying institutional responsibilities and was not linked to any adjustment in sector ceilings or allocation of extra funds. Interviews with sanitation and hygiene stakeholders suggest that the respective line ministries are using the lack of extra resources (in connection with the memorandum) as a rationale for the seemingly low priority being accorded sanitation and hygiene. 60. With the shift toward budget support, each ministry had to plan and budget for resources, and each proved to have its own sectoral biases. For instance, it has been pointed out that Ministry of Health staff do not pay sufficient attention to preventive approaches (Jeppsson et al. 2005). Curative health is a main priority for the Ministry of Health, and in the same way primary and secondary education are priorities for the Ministry of Education and Sports, while water supply is a priority for the Ministry of Water and Environment. Sanitation and hygiene have consequently been pushed aside by these priorities and have not attracted resources within the conditional grants. Gaps in the Sanitation Memorandum of Understanding: Incomplete clarification of mandates and responsibilities for funding 61. The 2001 Sanitation MOU defines key responsibilities and mandates, but it contains numerous ambiguities. 62. First, the MOU does not mention the mandate of the Ministry of Local Government (MLG) or the Ministry of Gender, Labour, and Social Development (MGLSD). Given the oversight role of the MLG in monitoring, advising, and providing technical assistance to all local governments, it is important to include it in the sanitation memorandum. The MGLSD is charged with developing policies and guidelines with respect to community mobilization and empowerment, gender responsiveness, and mentoring of community development workers (Uganda 2006b, 47), and it also needs to be included in a revised sanitation memorandum. 63. Second, the memorandum does not differentiate between mandates for excreta-related sanitation and for environmental sanitation in general, which includes solid waste management and drainage. Mandates for the latter issues also need to be clarified in the Sanitation MOU. 64. Third, the memorandum does not clarify responsibilities for excreta-related sanitation at the district level or other local government levels, nor does it distinguish between rural and urban issues. In the context of urban issues, the role of the National Water and Sewerage Corporation is critical and should be spelled out in the MOU. 65. Fourth, the MOU does not clarify the issue of funding--its sources, mechanisms, and types of activities that should be funded. Even though there is an implicit subsidy policy at work through the sector conditional grants, there is no written subsidy policy for sanitation- and hygiene-related activities. These issues should be clarified. 66. Fifth, although delivery of sanitation and hygiene is a cross-sectoral activity and is highly dependent on coordination between relevant sectors, guidance on how 27 coordination should proceed at the national and local levels is not specified in the sanitation memorandum. In 2003 the NSWG was set up as a coordinating mechanism, and its role and function should be clarified in a revised or updated memorandum. 67. Finally, there is no legal basis for implementing the memorandum of understanding. Even though the MOU spells out institutional mandates, there are no clear accountability mechanisms that can be enforced on the basis of a legal framework. Institutional challenges deliver ing on-site sanitation in r ur al ar eas 68. Several institutional and organizational factors underlie difficulties in implementing the Sanitation Memorandum of Understanding in rural areas. Planning and decision making in districts and lower administrative levels 69. In addition to their other responsibilities (such as primary education, primary health care and district hospitals, rural water services, agricultural extension services, provision of district, feeder, and municipal roads), local governments are also responsible for provision of sanitation and for hygiene-related activities, for preparing and enforcing local bylaws, and for imposing penalties (even though that is not formally stated in the Sanitation MOU). In principle, planning at the local government level is supposed to be bottom up. Villages are supposed to prepare community action plans based on local needs and priorities (Francis and James 2003, 331). These are incorporated into parish plans, which in turn are incorporated into subcounty plans. The district technical planning committee then prepares an integrated district plan that is ratified by the district council. Existing research shows, however, that in reality village and lower-level priorities are often not included in district-level plans. In many cases the plans are not of good quality, and they are often based on overoptimistic revenue estimates (Francis and James 2003, 331). Need to support planning and budgeting for sanitation and hygiene services at the district level 70. Despite the relatively high profile accorded sanitation by the MFPED and by sector stakeholders and donors in sector working groups, very few local governments have developed strategies, budgets, and operational plans to meet national targets for sanitation and hygiene. As at the national level, responsibilities for sanitation- and hygiene-related activities are split between district-level technical staff for health, water, and education. The chief administrative office of the district accepts proposals for funding from each of these sectors. Work plans, however, are typically made separately. District departments of health services, which make work plans and draw up budgets, are curatively minded and pay little attention to prevention; other sectors, too, have their particular biases. District-level staff members are not accustomed to planning and competing for budgets. 11 11 To illustrate, district health inspectors, who are the highest-level officials at the district level responsible for hygiene promotion, benefited from donor projects in the 1980s and 1990s that paid for allowances and vehicles for the inspectors and supplemented their low government salaries. The expectation was that the Ugandan government would take over the responsibility for facilitating the fieldworkers, but that has not happened; the NSWG is trying to obtain funds for this purpose. With the end of many of these projects, 28 This is another reason why sanitation has been left behind. In districts such as Rakai, Busia, and Lyantode that prepare joint work plans, delivery of sanitation and hygiene services is much better. It will be important to have a single joint work plan with agreed- on outputs, targets, and deliverables, and there should be accountability for fulfilling these goals. Data collection and monitoring and evaluation at the local government level 71. Collection of data regarding latrines and hand-washing is also a challenge. One source of information is the health inspectors' annual sanitation survey (HIASS). The HIASS collects information on latrines in households and the presence of hand-washing facilities, but not for schools. In some districts, village health teams (VHTs) play a key role in collecting data and monitoring progress in sanitation improvement. Here too, the data collected relate to household sanitation--the presence of latrines, hand-washing facilities, kitchen, drying rack, bath shelter, and animal house and the cleanliness of compounds. For most districts, hand-washing data are based on research conducted in 2006/07. 72. Data collection needs to be improved and carried out in a more coordinated way by all sectors, using common sanitation and hygiene indicators. For instance, the current Health Sector Strategic Plan (Uganda 2005a, 29) identifies two targets for environmental health for 2010: improving safe waste disposal (proxied by latrine coverage) from 57 to 70 percent and increasing from 18 to 100 percent the number of districts implementing water quality surveillance and promotion of safe water consumption. Indicators for hygiene and hand-washing are not included in the annual report. Strengthening and instituting district water and sanitation committees 73. Important organizational structures in approximately 30 percent of the districts are the district water and sanitation coordination committees (interview with UWASNET chair). As shown in Chapter 3, the DWSCCs have proved very useful in involving water, health, education, and community development officers in the preparation of joint plans and in implementing and monitoring sanitation- and hygiene-related tasks. In some districts DWSCCs exist but are not actually operating. They are typically headed by the chief administrative officer, but often that person does not attend committee meetings, indicating a lack of interest in sanitation. Where the committees are active, sanitation is being promoted. Not all districts have embraced the DWSCC concept, and some have shown outright resistance to the formation of a committee. The feeling in those districts is that the district's works committee takes care of issues related to water and sanitation. The center (DWD, EHD, and NSWG) is making efforts to ensure that DWSCCs are formed and active in all districts. front-line bureaucrats have to plan for sanitation and hygiene and compete for budgets, which they are not necessarily trained to do. 29 Difficulties posed by complex system of upward and downward accountability mechanisms 74. To ensure that funds from the conditional grants are being used transparently, it is mandatory that local governments make quarterly reports and account for expenditures. Accordingly, there is heavy emphasis on vertical accountability, often at the cost of accountability to citizens. Reports are submitted to the MFPED through the line ministries--the Ministry of Water and Environment for district water and sanitation conditional grants, the Ministry of Health for primary health care conditional grants, and the Ministry of Education and Sports for school facilities grants. Since district administrative staff is an employee of the district local governments and, in particular, of the chief administrative officer, it is neither answerable to the line ministries nor required to report to them. Line ministries have no power to enforce how the conditional grants are used as long as the suggested guidelines are met. Local governments are accountable to the MFPED and the line ministries for whether funds have been used in accordance with sectoral guidelines; they are not accountable with respect to whether certain sectoral targets have been reached or health outcomes have been achieved. (An exception is the LGDP.) Moreover, the center's capacity and motivation to analyze the reports is low. Existing guidelines for the relevant conditional grants recommend but do not require that local governments spend a certain percentage of any conditional grant on sanitation and hygiene, and there are few incentives for allocating funds for these purposes. 75. The above scenario is illustrated by links between local governments and the Environmental Health Division of the Ministry of Health--the lead agency for environmental health and the secretariat to the NSWG. As is true in general, there is no mandatory reporting by local governments to the EHD on how the funds are being used or the extent to which sectoral conditional grants are being used for sanitation and hygiene promotion. District health inspectors' communications to the EHD are limited to statistical data rather than content. Other than the annual joint sector reviews and the health inspectors' annual conference, there are few forums in which local governments interact with national-level agencies to discuss sanitation and hygiene issues. The inter- district meetings are for inter-district learning rather than a venue for national level­local government interaction. Except by special request, quarterly reports prepared by local governments for the MFPED do not reach the key national coordinating body, the NSWG, through the secretariat, the EHD. This anomaly--that information from districts often does not reach the secretariat to the key sanitation coordinating body--needs to be addressed. Sanitation in ur ban ar eas 76. Uganda is primarily a rural country; only about 15 percent of its population lives in urban areas. Kampala, the largest city, has a population of 1.5 million, with a transient daytime population of up to 2.5 million (Advani 2008). The country has 13 other municipalities (Jinja, Kabale, Lira, Tororo, etc.) and more than 60 town councils. Municipal councils operate at the level of a county and have a number of divisions, equivalent to subcounties; town councils operate at the level of a subcounty. The situation in Kampala, discussed here, illustrates the challenges facing urban areas. 30 Planning for on-site sanitation in Kampala and improving access to sanitation information 77. The mandate for on-site sanitation rests with the Kampala City Council and, in particular, its public health department. The department has numerous health responsibilities and is also responsible for solid waste. It is headed by the chief health inspector, who has responsibility for sanitation within KCC and is aided by health inspectors and health assistants in each of the city's five divisions. In view of the scope of the sanitation issues facing the city, the staffing is very limited. Furthermore, unlike some rural districts, urban areas do not have structures such as district water and sanitation committees or the support of technical support units. Rather, each sector plans on its own. 78. Interviews with KCC officials indicated that urban areas such as Kampala face similar issues as the districts with respect to lack of prioritization for sanitation within the conditional grant structure (see box 2.1). For instance, the health department is made up mainly of medical doctors who are curatively minded and are unwilling to budget sufficient resources for sanitation and hygiene. A major constraint on planning is lack of systematic collection and recording of sanitation statistics such as facilities available, number of people gaining access to public toilet facilities, methods of operation in industrial and commercial facilities, type of operation and maintenance, the role of cesspool emptiers, and NGO involvement. Better information would greatly enhance the city's ability to not merely plan but also to share information with the public and potentially involve them in enforcement. Box 2.1 Sanitation planning illustrated: Nakawa Division, Kampala For Nakawa Division, planning starts at the zone level (local council (LC)1), where ideas for what should be included (for example, garbage collection, construction of communal latrines) in the annual plan are generated. Issues proposed at the LC1 level are presented at the division level without first being prioritized at the ward (LC2) level, but ward level councilors do attend the village-level consultative meetings. The divisional finance officer prepares the division's budget using the indicative planning figures, which are scrutinized by the divisional technical planning committee and finance committee before being presented to the City Council Technical Planning Committee and passed on to the City Council for debate and approval. For health planning, each division constitutes a health subdistrict, and each of the five health subdistricts (divisions) has two health units. Planning for health care, including preventive health, takes place at the subdistrict (LC4) level. In the past, divisional health inspectors played an active role in the planning process, but because of resource constraints this is no longer the case. Consequently, primary health care (PHC) grant funds are not being spent on sanitation activities, even though the guidelines call for 10 percent of the PHC grant to be spent on sanitation and hygiene. The work plan for the KCC (district) level as it relates to sanitation is not a result of the bottom-up approach to planning; rather, it reflects the supportive role of subdistricts to the divisions. Recently, the office of the chief health inspector received 4 million Ugandan shillings in the run-up to the Commonwealth Heads of Government Meeting. The money has been largely spent on inspections of butchershops and enforcement of improvements in these facilities. 31 Issues with servicing toilet facilities in urban areas 79. Given the extremely low capacity of KCC to meet demand by the city's resident and transient populations, both private sector operators and NGOs are active in delivering sanitation services in Kampala. KCC, for instance, has allowed NGOs and schools to build communal latrines throughout the city. A number of public latrines have been constructed through KCC projects such as the Kampala Urban Sanitation Project, by NGOs such as Community Integrated Development Initiatives (CIDI), and through LGDP funding. Nakawa Division alone has 25 such public latrines in various states of repair. For every public latrine constructed, the city council undertakes training of a management committee charged with operation and maintenance of the facility. Over the years, with no support from divisions for monitoring and supervision, and having misused funds derived from user fees, these management committees have become nonoperational. Many latrines have been taken over by the landowners and in some cases have been locked up. Those at markets continue to be managed by the market operators. Although NGOs have helped build toilets, they are not active in providing toilet- emptying services. Even less attention is given to hygiene promotion. Lack of standards for construction of latrines and septic tanks 80. In slums and densely populated areas, latrines are poorly built, overloaded, and badly maintained. The number of people using public toilets is often high; use of communal toilet facilities varies from 8 to 100 families per toilet (Advani 2008). At present, KCC has no specific guidelines for latrine construction. Thus, the latrines constructed do not meet any minimum standards and often fall into disrepair. Lack of latrine construction guidelines and poor enforcement where they do exist--in addition to poor operation and maintenance of public latrines--further limits KCC's ability to enforce and meet minimum public health standards. Need to formalize relationship with the Private Emptiers Association 81. It is estimated that 1.35 million people in residential, institutional, and commercial premises within Kampala District depend on sanitation facilities that have to be serviced by cesspool emptiers. 12 About 478 cubic meters of removable septage are produced by the city's inhabitants every day, another 203 cubic meters are generated by industry, and 116 cubic meters are produced by households in the districts immediately surrounding Kampala, resulting in a total daily septage clearance requirement of 797 cubic meters. KCC owns five cesspool emptiers with a total capacity of about 113 cubic meters that provide septage removal services at subsidized rates. The 27 private cesspool emptiers, members of the Private Emptiers Association (PEA), have a total installed capacity of 120 cubic meters. Because of the centralized system of septage disposal and inefficiencies in the management of cesspool emptiers, the daily combined capacity of KCC and the PEA to handle the septage generated in and around Kampala is estimated at 233 cubic meters, giving a shortfall in supply capacity of 564 cubic meters. 82. The PEA is not registered with KCC's community services department and does not have a formal relationship with KCC, nor does KCC receive licensing fees from private 12 Estimates in this subsection are drawn from Advani (2008). 32 cesspool operators. KCC can play a proactive role in formalizing this relationship and working out a partnership with the PEA, with a mutually agreeable tariff and licensing structure and appropriate accountability mechanisms that will improve the overall sanitation situation. A formal arrangement with the PEA could give its registered members incentives to improve capacity and service delivery in return for a fair market value for their investment (Advani 2008). It would also provide KCC with additional revenues to improve its enforcement capacity. 83. All septage is supposed to be emptied at the Bugolobi Sewage Treatment Works, regardless of where it is collected. Lack of decentralized septage disposal facilities contributes to the costs of the transport and disposal of septage and to illegal dumping. Since supervision of cesspool emptiers is KCC's mandate, NEMA does not license them. Thus, there is very little supervision of the activities of cesspool emptiers by KCC, NEMA, or NWSC. Sewer age infr astr uctur e: Role of the National Water and Sewer age Cor por ation 84. The Water Act (chapter 152 of the laws of Uganda, 2000) was enacted to provide the legal basis for water resources management. One of its objectives is to control pollution and promote safe disposal of wastewater. The Minister of Water and Environment appoints sewerage authorities and enters into performance contracts with each one. These authorities need permits from the Directorate of Water Resources Management to use water, to construct or operate any hydraulic structure, or to discharge treated effluent into water. The DWRM also administers waste discharge regulations (enacted in 1998) on behalf of the Minister. 85. The main authority contracted by the MWE is the NWSC, a public corporation owned by the government. The NWSC is responsible for providing water and sewerage services in 22 urban areas under its jurisdiction. It also has a mandate to treat septage generated by facilities that rely on on-site sanitation, which it does through management of the Bugolobi Sewage Treatment Works. 86. The NWSC was established in 1972 by Decree 34. Its powers were limited, in part because of cumbersome reporting requirements to the minister. It was not allowed to outsource operations management freely, and there were overlaps between the roles of the NWSC and the government. In 1995 NWSC Statute 7, later incorporated into the NWSC Act of 2000, was passed, allowing the corporation to operate on a commercial and financially viable basis (Mugisha and Berg 2006). In addition to revenues collected from user fees, the NWSC receives funding from the Ministry of Water and Environment for provision of water supply and sewerage services. Improvements in water supply, but slow expansion of sewerage connections 87. Since 1998, the NWSC has implemented several reform initiatives that, according to Mugisha and Berg (2006), have had positive impacts. Water network coverage increased by 52 percent (1,300 kilometers of water mains extensions, primarily from internally generated funds). New water connections increased from 3,317 to 23,312 per year, and as a result, total connections have grown from 50,826 to 148,312, or 70 percent of the target population served, out of a population base of 1.7 million people as of 2006. Unaccounted-for water has fallen from 51 to 29 percent (34 percent in Kampala and 15 33 percent in other areas). Metering efficiency (the proportion of metered accounts to total accounts) has increased from 65 to almost 99.6 percent, and connection efficiency (the proportion of active connections to total connections) has grown from 63 to 93.9 percent. The NWSC's annual turnover has risen from about US$11 million to US$34 million, which has contributed to the corporation's becoming a profit-making organization. Despite these successes, the rate of expansion of sewerage connections remains low. 88. The NWSC's board of directors, appointed by the Minister of Water and Environment, is made up of representatives from local governments, the business community, professional bodies, the MFPED, the MWE, the Ministry of Health, and small-scale industries. The NWSC has a head office and also has service providers (operators) in large towns that conduct day-to-day operations management in those towns. Internal incentive contracts have enabled an increase in the managerial autonomy of the service providers. The NWSC is also implementing two sanitation-related projects. 89. Improvement in the provision of sewerage services remains a critical task for the NWSC. As noted earlier, only about 8 percent of Uganda's population has access to sewerage infrastructure. To bolster the number of new sewer connections, the NWSC board approved the implementation of a new sewerage connection policy that became effective in July 2006. According to this policy, all customers whose premises are within 60 meters of NWSC sewer mains are covered; the NWSC provides all materials for installation of sewer lines, and customers are only required to pay the connection fee. The policy was aimed at improving sewerage coverage, the capacity utilization of sewerage treatment ponds and plants, and the promotion of environmental management through encouragement of safe wastewater disposal. During the subsequent year, the growth of sewer connections increased, but not to the level expected when the policy was instituted; in all, 333 sewer connections were installed. The main reason for the low sewer connection rate is limited sewerage network coverage and the reluctance of customers to connect to the sewer system, since most of them already have on-site sanitation facilities. Furthermore, some NWSC areas have no waterborne or piped sewerage services. The NWSC projected, however, in its annual report for 2006/07, that the number of new connections would increase to 500 per year in 2008 (NWSC 2008, 29). 90. In Kampala, poor urban planning and local power relations contribute to the problem. In some areas, such as the Katanga slum area in Makerere, for instance, people have constructed dwellings on top of sewers. As a recent study points out, sewer network expansion or upgrades are difficult, in part, because of interference by local politicians when KCC tries to carry out forced land acquisitions under existing laws (Advani 2008). Need for investments in wastewater treatment 91. Treatment of effluents remains a huge challenge. The Bugolobi wastewater treatment plant receives flows from the sewer network and discharges into Nakivubo Swamp. The entire sewerage network needs major rehabilitation and has not been upgraded since its construction in 1965. Poor monitoring of effluent quality at private wastewater treatment plants, illegal connections to stormwater channels in Kampala, and low capacity at the sewage treatment works all result in emission of effluents that are not suitably treated, leading to contamination of water resources. Cesspool emptiers also dump waste into the environment instead of in designated sewage treatment works or lagoons, to save on 34 access fees. Nakivubo Swamp acts as a natural buffer for the city's wastewater before its discharge into Murchison Bay, Lake Victoria, but the presence of untreated wastewater hampers the swamp's natural filtering ability and affects the quality of water in the bay-- Kampala's main source of water (Advani 2008). 92. In 15 other towns serviced by the NWSC, private cesspool emptiers discharge septage into stabilization ponds or lagoons. Many of these cesspool emptiers are based in Kampala because of low demand in other towns. There are some towns and regions that have no ponds or lagoons. Here septage is dumped in water bodies or open land. The performance of wastewater treatment plants run by the NWSC in all the towns has been consistently poor over the period 2004­06 (Uganda 2007c). 93. At the national level, NEMA and the DWRM are responsible for setting policies and regulations regarding sewerage treatment and for periodic monitoring, but it is municipalities that have to enforce these regulations. Enforcement of wastewater discharge regulations by national and municipal agencies remains weak and needs to be strengthened. Furthermore, although the NWSC endeavors to address the water needs of the urban poor by providing water service through kiosks and public standpipes, the funding allocated to support the provision of sanitation services for urban residents who do not have access to piped sewerage services appears to be limited. These people commonly include the poorest households, in high-population-density areas. A number of NGOs have sanitation programs that attempt to address the sanitation needs of the poor in Kampala. Role of NGOs in sanitation and hygiene in Uganda 94. NGOs are playing a crucial role in the water and sanitation sector in Uganda. About 150 national and international NGOs are registered with the umbrella organization UWASNET, which was formed in 2001. They are represented on key policy forums such as the National Sanitation Working Group. 95. NGOs provide a range of services, including construction of latrines, training, and hygiene promotion (see table 2.5). In some areas, such as household sanitation promotion and implementation, they often perform better than local governments. Their main comparative advantage is skills relating to community mobilization. Local governments as well as donors often work with NGOs to deliver services. For instance, WaterAid, an international NGO, works in five districts in cooperation with local governments and local NGOs. Types of activity include consultation with communities, community mobilization and sensitization concerning water sources, baseline surveys, and hygiene and sanitation promotion. Similarly, Plan International works in several districts, including Tororo and Kamuli, and engages in a range of activities linked with child development, including teaching schoolchildren about hand-washing, funding construction of school latrines, and raising awareness about sanitation and hygiene at the community level. It also works through community-based organizations (CBOs) that train people to construct their own latrines. 96. There is disagreement about whether the shift from project-based support to budget support has adversely affected NGOs. According to the chair of UWASNET, one of the main problems facing NGOs is access to funding. Earlier, funding for water and 35 sanitation activities could be received through projects, but under the current policies NGOs cannot get access to or compete for on-budget funds or certain categories of donor funds that go directly to the districts. To compete for funds, tendering entities must have value added taxation registration and income tax clearance and must be registered as commercial enterprises. NGOs often do not meet these conditions and therefore cannot get Poverty Action Fund resources, although private sector contractors can. Other sector colleagues contest this assessment and argue that the shift to budget support did not affect NGOs, which need to mobilize resources as they have traditionally done. Table 2.5 Examples of NGOs and types of sanitation- and hygiene-related activity Organization Activities Concern Uganda Forms partnerships with local communities and leaders to address water and sanitation issues. Sustainable Sanitation and Is implementing a sanitation project through the social marketing Water Renewal Systems approach. Following up on hygiene education to create demand, households are given opportunities to make informed choices of the type of sanitary facility they wish to have. Under the project, waste is recycled for income generation, integrating sanitation and hygiene with poverty reduction. Community Integrated Under a Citizens Action Project, enables the urban poor to influence water Development Initiatives and sanitation service delivery by participating in advocacy. Action for Slum Health and Helps communities turn garbage into manure for both domestic use and Development, Nakulabye commercial purposes. The organization integrates sanitation and hygiene Parish with HIV/AIDS programs. Role in public sanitary facilities in high- density areas that charge user fees for operation and maintenance has been successful. Kamwokya Community Provides access to safe water facilities and works with communities and Health and Environmental households to improve sanitation and hygiene practices. Protection Association, Kamwokya Division Kisenyi III Community Focuses on environmental sanitation and hygiene improvement and Health Workers Association HIV/AIDS programs. The association is involved in capacity building for community management structures and construction of water and sanitation facilities. Ndeeba Parish Youth Creates awareness and generates community participation in sanitation Association and hygiene improvement activities at both the household and community levels. Community Health Concern, Promotes EcoSan in primary schools; sensitization of communities on Makerere Parish garbage collection, sorting, partial disposal, and drainage cleaning; improvement of latrines through general cleaning and emptying. Source: Uganda Water and Sanitation NGO Network (UWASNET) data. Role of the pr ivate sector in sanitation and hygiene in Uganda 97. The government has undertaken major reforms in the area of privatization. The government's Civil Service Reform Program, endorsed in 1993 and launched in 1997, involved streamlining the civil service and privatizing functions that could be better provided by the private sector (Danert et al. 2003). The emergence of private sector operators and manufacturers has also changed the role of local governments from service providers to enablers, with a greater focus on planning, contract management, supervision 36 of latrine construction and the work of private operators, and software functions such as community mobilization. Nevertheless, local governments continue their earlier role in service provision, and in many cases the relations are not clear. Types of activities undertaken by private sector operators 98. Private sector groups working in the excreta-related sanitation and hygiene sector may be large-scale enterprises manufacturing soap or latrines; one example of this is Mukwano Industries, which holds 90 percent of the bar soap market. But most private businesses are small and medium-size enterprises or small-scale independent providers and entrepreneurs. They are involved in construction of water sources and latrines, soap manufacturing, supply of parts and materials, capacity building, and consultancy services for supervision of construction. Private individuals and companies also provide sanitation-related services ranging from pit digging to production of sanitary facilities such as SanPlats and slabs for pit latrine construction. They include traders who stock sanitary fittings for waterborne toilet facilities and plumbers who install them. In Kampala, private operators also provide cesspool emptying services, as discussed earlier. Challenges facing small and medium-size operators 99. The emergence of private sector operators in the area of sanitation and hygiene is in part a response to local governments' lack of capacity for service provision. Although these operators have come to play a critical role in service delivery, the relations between them tend to be informal. 100. A prevailing perception of government and donors concerning small and medium- size private sector actors is that the private sector is underperforming. Among the limitations of the sector is that many entities have poor management and financial planning skills, lack formal contracts, suffer from shortage of capital, and take on high risks (Danert et al. 2003). A number of other factors pose difficulties for improving the performance of the private sector. Donors and state and local governments heavily emphasize new construction at the expense of maintenance and support of existing physical infrastructure (Danert et al. 2003). Poor maintenance of services is a critical issue for water supply as well as for sanitation and latrines (Baumann, Okuni, and Wandera 2002). Maintenance of the sector's assets is sometimes difficult because of lack of parts and supplies. Contractors find fault with local government planning, contract management rules, procedures and guidelines, and weak technical specifications. 101. There is also documented evidence of corruption in the water and sanitation sector. In interviews carried out by Danert et al. (2003), stakeholders raised the issue of how corruption and abuse of power affect the tendering process, including contract management, approval of completed work, payment, and misuse of positions for personal gain. The firms' success depends on close ties with local government decision makers, including tender boards that are involved in both determining spending priorities and awarding contracts. This connection between firms and state actors in turn affects the transparency of sector and procurement procedures, community ownership of infrastructure, and sustainability. 37 Supporting an enabling environment for private sector operators 102. To foster an enabling environment for private sector operators, public sector institutions can take a number of steps. First, they can support small businesses and private operators by easing access to credit. Second, they can take a stronger role in making the process of contracting private sector operators much more transparent and accountable. Third, improvement in recordkeeping by contractors and easier access by the public to information regarding contracts can enable greater public scrutiny and improve accountability. 103. Fourth, the public sector can provide capacity building and incentives to small businesses to form associations that enable these enterprises to learn about and share knowledge about innovative practices and upgrade their technical skills relevant to construction of latrines and other sanitation hardware. Such associations can play an important role in providing information to members about market demand and supply and helping them gain market access. 104. Fifth, local governments can provide incentives to large firms to devise innovative means of engaging in social marketing. For example, the private firm Crestanks, which distributes water and sanitation products in Uganda, employs behavior change communication to encourage hygiene and greater use of the company's products. Crestanks has linked up with faith-based organizations and opinion leaders to accelerate demand. As a result of these measures, more than 10,000 units have been sold in the past three years in Uganda, and sales currently exceed 1,000 units per month (Uganda 2006e). Finally, the public sector needs to support research and development to provide stakeholders with affordable and reliable technologies. Role of development par tner s 105. Through the introduction of SWAPs, as discussed earlier, there has been considerable coordination among donors in the water and sanitation, health, and education sectors. 13 For example, in 2003, as part of the current funding modality for the water and sanitation sector, a joint partnership fund (JPF) arrangement was set up, initially with the government of Uganda, the Danish International Development Agency (DANIDA), the Swedish International Development Cooperation Authority (Sida), and the U.K. Department for International Development (DFID). Austria and the German Agency for Technical Cooperation (Deutsche Gesellschaft für Technische Zusammenarbeit, GTZ) joined later. 106. The JPF ended in June 2008. To replace it, since 2008 a Joint Water and Sanitation Sector Program Support (JWSSPS) has been initiated along the same principles. The JPF/JWSSPS is a pooled, project-like funding mechanism that represents a transitory solution. It reduces transaction costs because the funders share a single committee, work plan, and reporting and review mechanism. In addition to general budget support and mechanisms such as the JPF, a number of donors are actively supporting investment 13 According to the MFPED, development assistance is provided in line with the following hierarchy: general budget support, sector and Poverty Action Fund budget support, pooled funding, and individual projects. 38 projects in the areas of excreta-related sanitation and hygiene outside general budget support. These are implemented through line ministries or with local governments. 107. Despite donor coordination and consolidation of funds through budget support, the need for more targeted project-level funding is clearly still felt in the sector. For instance, DFID support to the EHD through the Water and Sanitation Program over a period of about five years facilitated several activities at the national level, particularly National Sanitation Working Group activities. 14 A flexible funding mechanism of this kind is needed at the center to respond to new needs and support innovative activities. Conclusion 108. The analysis in this chapter highlights the institutional issues, low funding, and limited prioritization of sanitation and hygiene at the national and local government levels. These issues explain why implementation of the Sanitation MOU has been limited and why it has been difficult to improve sanitation and hygiene and related health indicators in Uganda despite the numerous efforts by the government in the past 10 years. The Sanitation MOU in its present form needs to be revised by further clarifying institutional mandates and specifying clear funding mechanisms, as discussed later in this report. 14 The activities included finalization of environmental health policy, improvement of the environmental health information system, and key studies on, for example, strengthening the budget framework, the 10- year financing strategy, and documentation of three best practices. 39 3. Lessons fr om Good-Pr actice Examples: Two Pr omising Cases 109. Even though aggregate indicators linked with sanitation, hygiene, and related health outcomes have been slow to improve, several districts and municipalities have shown significant improvement in one or more of these indicators, with some villages reaching 100 percent latrine coverage status. This chapter provides a snapshot of selected cases and highlights the factors underlying success. The examples of Luwero town and Rakai District were chosen because they illustrate different mechanisms for improvement and provide the contrast of the challenges facing rural and urban areas. The case of Rakai Distr ict: Scaling up model villages 110. Rakai District located in the southwestern part of Uganda has witnessed significant advances in sanitation coverage, from 66 percent in 2006 to 76 percent in 2007 (Uganda 2007c) and an estimated 83 percent in April 2008 (Rakai District data). Some villages have attained 100 percent household latrine coverage and as high as 95 percent coverage for hand-washing facilities. Villages such as Nsumba and Botera that were among the first to achieve improvements in sanitation and hygiene are now classified as national centers for sanitation learning. A history of women's activism 111. In Rakai, the impetus for improving sanitation came from women's groups, dating back to the 1990s (Rugasira, Abaru, and Winberg 2002), that organized themselves with the objectives of carrying out home improvement, supporting household income through revolving funds, helping the disabled and orphans, and providing support for income- generating activities. A key feature of these groups or clubs was the need by members to adhere to group bylaws that also included sanitary provisions. The objectives and bylaws of the groups varied, but they tended to include a membership fee, fines for late payment, a requirement for an improved homestead (for example, latrine, drying rack, and in some cases energy-saving cookstoves), and the like. 112. An example of such a group is the Nsumba Salaam Club, formed in 2001 by six women. Its aims include improving household sanitation, eradicating illiteracy, combating HIV/AIDS, reducing child mortality, and improving maternal health. It has an executive committee and a monitoring committee that checks households each month to ensure that they are following the bylaws. Once basic sanitary facilities are present, the club donates U Sh 200,000 to the household for income-generating activities. Services provided by the club include training in sanitation and hygiene promotion. Spillover from associations to the village level 113. The hygiene promotion activities carried out by the Nsumba Salaam Club had a spillover effect because many neighboring parishes and subcounties received training in sanitation improvement. The club was recognized by Innovations (a program based at Makerere University) and was given rewards that were used to help upgrade the whole village through road improvement, construction of a resource center, and the like. This example spurred the formation of other clubs, such as the Nsumba Twegatte Health Club, that worked to enhance sanitation promotion among low-income households. 40 Promoting model villages through public recognition and rewards 114. In recognition of these efforts, in 2004 the Rakai District local government launched a home improvement campaign in sanitation and hygiene. Villages that could act as role models for total behavior change pertaining to sanitation and hygiene were emphasized. In a review meeting after one year, Nsumba model village had done very well in sanitation and hygiene, and it was decided to scale up the concept by establishing two model villages in each subcounty. The best model villages are given public recognition and awards through the office of the district health inspector in a prize ceremony. The model village approach to sanitation improvement is recognized as one of the best operational practices in the sector in Uganda. Role of district governments 115. In order to support and scale up the village-level initiatives, district government officials took a number of steps. First, a meeting was organized by the district (LC5) chairman in August 2006 for heads of departments, subcounty (LC3) chairpersons, extension staff, and NGO managers to discuss and share the best practices of Nsumba village. The main implementation strategy included an integrated approach toward hygiene and sanitation promotion, a standard communication strategy, competition among health staff and rewards for the best-performing staff, home improvement competitions, exchange visits to other model villages, use of the available resources, and coordination with NGOs. 116. Next, staff members were recruited. Currently, there is a health inspector for each county and for every town council and a health assistant for each of the 18 subcounties. At the district level is a district health inspector and a deputy district health inspector. A health information management officer based in the office of the district health officer was hired to manage health-related information, including information on sanitation. Under the integrated approach, nurses and health assistants were briefed on the standard communication strategy to be used as a guide during community sensitization sessions. The health inspector in charge was given a motorcycle and a monthly allowance of U Sh 20,000; that officer was expected to integrate sanitation with other community health activities. 117. In 2006 the chief administrative officer brought together all departments and NGOs involved in delivery of water and sanitation services in the district, and Rakai District instituted a district water and sanitation coordination committee. This is chaired by the CAO and consists of political leaders, including the secretaries for works and technical services and for health, education, and social services; the heads of relevant district departments and offices--water, planning, community-based services, finance, health services, and education; and NGOs in the water and sanitation sector. The committee has provided a platform for coordinating and overseeing activities in the water and sanitation sector. It reviews progress and charts a way forward for sector activities in the district. 118. In addition, the district passed an ordinance that targeted sanitation improvement. The ordinance spelled out sanitation requirements and penalties for those convicted of violations. As a result of the high level of sensitization, law enforcement is rarely applied except in urban areas. The ordinance is enforced by the town council law enforcement 41 authorities in collaboration with the office of the town health inspector. Fines are levied if individuals do not comply after repeated warnings. Finally, through mobilization of political leadership to support the model village approach, all political leaders at the LC1 level, district councilors, and church and opinion leaders participated in visits to Nsumba village to promote the concept of model villages. Innovations in funding, coordination, monitoring, and technology 119. A typical problem with improving latrine coverage is access to funds. In the case of Rakai District, an innovative feature was revolving funds that women could get access to through membership in groups. Where women did not have access to funds to build latrines, other women pooled resources or donated labor for the purpose, reducing the costs of latrine construction. Since formation of groups is at the core of the model village idea, group formation in other villages is being encouraged as a way to scale up sanitation and hygiene. Twezimbe Muzaganda Group in Bottela village (Kirumba Subcounty) and Mitondo village (Lwakoni Subcounty) are examples of sharing resources within group settings for construction of latrines. Households also innovated by using local materials for building pit latrines. Cement and sand are being used to smooth the squat hole instead of using a SanPlat, and the step-on tippy-tap allows the use of the foot to remove or replace the cover to the squat hole, avoiding use of the hands. 120. The main sources of public funds are district water and sanitation conditional grants and primary health care grants. Release of funds for sanitation activities takes place according to the work plan and often depends on other expenditures under the grant. Public funds are used primarily for supporting "software" activities such as raising awareness about sanitation and hand-washing, support to staff, and rewards. The district education department claimed lack of funds but is willing to make contributions toward school latrine construction. Monitoring was carried out at two levels: by group members themselves (as in Nsumba village) and by district officials prior to giving awards. Public recognition and rewards set up competition between villages and helped improve sanitation. Role of NGOs and donors 121. A number of NGOs carry out sanitation promotion activities in Rakai District. For example, Community Welfare Services (COWESER) is involved in promotion of sanitation and has provided key facilitation in the establishment of new model villages, as in Bottela. COWESER is being supported by the nonprofit NETWAS Uganda in conducting sanitation promotion in areas where they are constructing rainwater- harvesting tanks. In contrast to other cases, the role of international donors in Rakai in improving sanitation and hygiene has not been very significant, although they have helped support Sanitation Week activities. Where additional funding is needed, resources are pooled from various sources that include the district water office, the health office, and NGOs. There is high-level coordination and collaboration between NGOs and other development partners such as National Agricultural Advisory Services. 42 Factors underlying success 122. A number of factors contributed to high sanitation and hygiene coverage in Rakai District: A key ingredient was the formation of women's groups that aimed to improve sanitation and hygiene within a broader set of development objectives. The public sector played a crucial role, in that politicians and bureaucrats lent strong support to the scaling up of a village-level initiative. Rakai's new district health officer, who joined the department in 2004, took a personal interest and exercised initiative in mobilizing available existing resources such as public health care funds and funds for tuberculosis, reproductive health, and HIV/AIDS programs to facilitate hygiene and sanitation promotion activities. In addition, there was collaboration between front-line officials at the district and subcounty levels (for example, the district health officer and the district and subcounty health inspectorate staff). Extension workers took advantage of opportunities to integrate sanitation into other field-based programs, whether in the health sector or in other sectors. This is particularly important given the district's meager tax base and low revenue collection. Rakai's planning process seems more participatory than elsewhere. For example, model villages hold village council meetings relatively frequently, giving communities the opportunity to make known their views. Furthermore, where documentation of indicators and report writing are good (as is the case with many women's clubs), information moves from the subcounties to the district. Finally, through the initiative of the district information officer, a Rakai newsletter is published that disseminates information about various initiatives and success stories, providing further incentives for scaling up. The case of Luwer o town: Rapid impr ovements in sanitation indicators 123. The town of Luwero in Luwero District is an urban area that in recent years has seen a dramatic increase in sanitation coverage, from 57 percent in 2005 to 86 percent in March 2008. In the context of a national average increase in sanitation coverage of 1 percent per year for the last three years, Luwero's increase of 29 percent in three years is a significant achievement. 124. Nevertheless, this case has many imperfections. It is estimated that only 4 percent of the town's population washes hands after visiting a latrine. Furthermore, although household latrine coverage has risen, insufficient attention has been paid to public and school sanitation. A study carried out in 2006 showed that 80 percent of the latrines were traditional pit latrines without a vent pipe and 20 percent were VIP latrines; a few waterborne toilets (less than 1 percent) were connected to septic tanks. Households that lacked pit latrines shared toilets with neighbors, while other used polyethylene bags ("flying toilets") that they dumped in convenient refuse bunkers and drainage channels. There were eight public latrines, of which three were VIP latrines. Three of the eight public latrines were managed by caretakers on behalf of and under the supervision of the Luwero Town Council's public health department. Inspections revealed that most of the public latrines were not being properly managed, while others had major structural 43 damage and needed immediate repair. A piped water distribution system, constructed in 2001 under the Small Towns Water and Sanitation Project funded by the World Bank and the government of Uganda, serves a population of roughly 10,000 through about 852 household connections. Other residents rely on five water kiosks or use community- managed, handpump-equipped boreholes and springs. 125. Despite the limitations in addressing broader water, sanitation, and hygiene targets, the case of Luwero is an important example of efforts by local officials to scale up latrine coverage rapidly, and so it has been chosen as a case study here. Role of the town technical staff and administrative leadership 126. A key factor in Luwero town's initial success is the initiative of the town's new health inspector, who took office in 2005, and of a supportive town clerk. At that time, the Luwero Town Council was entering into a partnership with the German Development Service (Deutscher Entwicklungsdienst, DED), to improve planning of the water supply and sanitation systems and its waste management system. With the assistance of the DED, a master plan for water supply and sanitation was drawn up to be used as a tool for the development of a three-year rollover town development plan. The DED provided a technical adviser to the council. 127. Public health department funding has represented, on average, 8 percent of total town council expenditure. Most of these funds were spent for solid waste purposes (equipment for refuse bunkers and for refuse handling). No separate budget was earmarked for on-site sanitation activities. In fiscal 2006/07 the public health department applied for U Sh 600,000 for home hygiene and sanitation improvement, but the money was never released. With technical assistance from the DED, the Luwero Town Council undertook a number of activities, largely with its own funding. First, on the initiative of the DED technical adviser, a town water and sanitation working group was formed whose membership included the town clerk, the town health inspector, the community development officer, the town engineer, the law enforcement officer, and the DED technical adviser. Its initial task was to conduct a baseline survey and develop a water supply and sanitation master plan. The working group meets every quarter to review the master plan and related activities and to identify problems and solutions. 128. Second, the town council, led by the town health inspector, conducted a series of sanitation workshops that targeted political and opinion leaders at the town council level and lower levels. The workshops aimed at building commitment and motivation for improving sanitation and hygiene, a task that entailed enforcing the town's bylaws. Town agents were encouraged to compile lists of households without access to latrines. 129. Third, the town council held several village-level community mobilization and hygiene education meetings and encouraged construction and improvement of latrines. At the village meetings, communities were made aware of the provisions of the Public Health Act and Luwero Town Council bylaws related to sanitation and excreta disposal. 44 Formation of village health teams 130. On the initiative of the town health inspector, villages were asked to elect village health teams. 15 The teams' responsibilities included sanitation and hygiene education, the larger public health care components (for example, immunization, nutrition, and HIV/AIDS education), and monitoring of the state of sanitation in the village. VHTs are largely volunteers, but there is a proposal to pay them a monthly allowance of U Sh 2,000 with funds from the town council. These village health teams have played an important role in keeping records of new sanitation developments in their areas and sharing information, particularly related to infringement of bylaws, and they form a crucial link between the community and the town leadership. Enforcement of sanitation bylaws 131. Following the village-level meetings, the environmental health staff, VHTs, and law enforcement personnel conducted home visiting, moving from house to house and village to village to educate and encourage people and, at the same time, enforce the law. Villagers who responded positively by constructing or improving latrines were rewarded by the town health inspectorate staff with presents while heads of households that did not have access to latrine facilities were served with nuisance notices. The noncompliant household heads were to sign an agreement specifying a period within which the household or owner of the premises would comply--typically three months, to allow for the construction of a new pit latrine. Failure to comply was followed by arrests and prosecution. Latrines in a dangerous state of repair, or dilapidated superstructures, were demolished, and the town health inspector gave the owners three months to construct new ones. In the ordinance, the council designated the first Thursday of each month as a day for town clean-up, and all residents were expected to participate. 132. Most of the achievements in improving access to latrine coverage hinged on law enforcement, mainly under the Public Health Act; the Luwero Town Council bylaws adopted in 2000 are silent on the subject of human excreta disposal. The bylaws do set a fine of U Sh 40,000 for failure to comply with the act. This stipulation is used to enforce a wide range of public health provisions. At the time of the study 200 copies of the provisions on protection of drains had been printed in English, with a Luganda (local- language) translation, and were on display not only on public notice boards but on private business premises as well. Law enforcement is applied as a last resort when education and persuasion fail. Even so, fear of the law has been a major factor in improving sanitation, particularly latrine coverage. 133. There are bylaws on latrine construction, but there are no regulations about hand- washing, which may be more dependent on promotional activities and behavior change. The town council intends to develop sanitation-specific bylaws that address not just latrine construction but other aspects of total sanitation as well. 15 Even though they are part of the town, the lower administrative levels are still referred to as villages rather than wards. 45 Lack of support from senior-level political leadership 134. Political support at the town council level has been inadequate. Some political leaders have attempted to caution the health office on law enforcement and the associated occasional arrests and court charges. The Kampala Declaration on Sanitation and the provisions of the Public Health Act are used by the technical team to defend their use of law enforcement. Political leadership at the ward level has been more helpful in its support of the village health teams. The message of exemplary leadership has been well accepted by community-level leaders and all those involved in law enforcement: if authorities are to require the construction of latrines, they must have latrines themselves. Strong coordination between technical officers at the town council 135. A key factor in the scaling up of sanitation in Luwero town has been strong coordination between the public health and community services departments and the law enforcement section. Within the town council, the public health department (PHD) has the overall responsibility for excreta-related sanitation and hygiene promotion activities. On an ongoing basis, the PHD coordinates with the community services department (CSD), which is headed by a senior community development officer. The CSD is responsible for generating planning ideas from communities through village-level consultative meetings, and ideas so generated are incorporated into the sanitation and hygiene improvement action plans and budgets. Most important, the law enforcement section in the office of the town clerk has had a significant role in enforcing the Public Health Act and the Luwero Town Council bylaws. Warnings, arrests, demolition of poor latrines, and delivery of nuisance citations are carried out under close collaboration between the PHD and the law enforcement section. Coordination with the department of technical services has also been good. It is headed by a senior assistant engineering officer who participates in the town water and sanitation working group, advises on the structural plans for on-site sanitation facilities, and enforces building standards. Importance of participatory planning and budgeting 136. In Luwero, planning for sanitation and budgeting is done systematically through the sanitation and hygiene promotion three-year rolling annual work plans derived from the master plan for water supply and sanitation. The work plans are updated annually, taking into account the views of the community. Initially, the community development officer conducts consultative meetings at the village level to collect views and concerns and proposes activities to be undertaken in the upcoming financial year. It is at these consultative meetings that communities have a chance to express their demands for sanitation improvements. Views from the village-level meetings are presented and prioritized at parish-level meetings. At the parish level, planning suggestions from communities are integrated and harmonized with the existing water and sanitation master plan. The public health department's action plan and budget are then drawn up and presented at a technical planning committee meeting that integrates all departmental plans into a proposed plan of action to be presented to the town council. 137. In addition to the selection and training of VHTs, a large part of the sanitation activity plans has to do with mobilization of households for latrine construction. The 46 council has been more concerned with improving access to sanitary excreta disposal facilities than with promoting a particular type of latrine. Innovations in funding, technology, and monitoring 138. The council offers no form of subsidy for latrine construction for households; people use their own household savings. Town council funds expended for sanitation promotion are derived largely from the council's revenues from markets, licensing of trade premises, and property taxes and are used to pay staff allowances. It was not possible to gather detailed information on innovations in credit and technology for this study. The DED is planning to support an EcoSan toilet project through the training of local artisans. Limitations of the case 139. Offsetting the successes in scaling up household latrine coverage is the status of public latrines and school sanitation. The latter situation, especially in private schools, is very poor. Some schools have no functional hand-washing facilities. Moreover, little has been done to promote hand-washing, which remains at 4 percent in the town. One explanation given was that the officials wanted to sequence latrine coverage and hand- washing, which require different forms of behavior change. Lessons fr om pr omising stor ies 140. The two cases offer a number of lessons for improving sanitation and hygiene in Uganda. In both, the local government played an important role in scaling up sanitation, but in different ways. In Rakai the district technical staff supported a homegrown concept of a "model village"; in Luwero the initiative came from district health officials, the town clerk, and other technical staff. The two cases also point to the importance of mechanisms such as the district-level water and sanitation committee (or group) and the importance of systematic planning, budgeting, and monitoring in scaling up sanitation. Both cases highlight the need to forge strong links between public officials and community members. This was done in Luwero through the monitoring role of the village health teams and in Rakai though women's clubs. 141. No success in collective action, however limited, is sustainable without appropriate incentives and monitoring mechanisms. In Rakai these included monitoring by women's groups to ensure that households had latrines and, in some cases, enforcement by district officials. In Luwero strong monitoring and enforcement of local bylaws by health and law enforcement officials was important. The presentation of rewards at a public ceremony in Rakai set in motion a competition between villages that helped scale up sanitation and hygiene. 142. Interestingly, in neither case were household latrines subsidized by the public sector. Public funds were used to facilitate district and subcounty extension workers and for promotional activities. Nor did the national line ministries provide significant technical support. The case of Rakai shows that communities and local governments can improve sanitation without significant help from donors. 47 Conclusion 143. The cases of Luwero and Rakai exemplify many factors often associated with good governance: participatory and bottom-up planning, support from enlightened bureaucrats, strong collaboration between technical departments in the town council, links between communities and the town council, and appropriate incentives and enforcement mechanisms. Nevertheless, both examples raise important questions. Rakai District has the potential to achieve more than 86 percent latrine coverage--but it has not done so. One important factor is that the focus in the model village concept was on 100 percent household latrine coverage and not on villages free of open defecation. Even villages that did achieve 100 percent latrine coverage were not open-defecation-free because many of the schools did not have enough latrines. In Luwero, even though the latrine coverage indicator has improved, hand-washing is extremely rare. 144. These insights have important implications for policy makers at the national level: Many districts and municipalities are not giving sufficient priority to sanitation and hygiene activities in their conditional grants and do not have the benefit of benevolent technical staff and supportive politicians. It is likely that a dedicated conditional grant would help give sanitation and hygiene a needed additional financial boost. The cases show that funds for addressing health issues linked with excreta-related sanitation may be used not for hardware activities but to support software activities such as hygiene and sanitation promotion. Furthermore, funds can be used to institute awards at the district level and not just at the village and household levels. In Luwero there was little focus on improving hygiene. Here too, more systematic technical guidance from line ministries can help raise awareness about the sanitation, hygiene, and health linkages needed to attain potential health benefits. Finally, it needs to be recognized that shifting from open defecation to an open- defecation-free environment is an important first behavioral step in moving up the sanitation ladder to more hygienic basic sanitation facilities. As the experience of Rakai shows, the importance of this behavioral step cannot be overemphasized. 48 4. Establishing a Dedicated Budget Line for Sanitation and Hygiene 145. As noted in Chapter 2, one of the main constraints in improving sanitation and hygiene has been failure to give these issues sufficient priority in sector conditional grants. Although the limitations of the Sanitation Memorandum of Understanding are recognized, there is an informal but broad consensus among sector colleagues that the best way to ensure sufficient funding is to introduce a dedicated budget line for sanitation and hygiene. Accordingly, the 2006 joint sector review for water and sanitation requested guidance on how such an integrated budget line should be instituted and implemented. In response, this chapter proposes four different mechanisms for creating an integrated budget line, discusses trade-offs, and recommends one of the options. 16 It does not prioritize areas for funding or make suggestions regarding funding amounts or distribution between possible sources of funds, which needs to be done as part of follow- up work. 146. It should be noted that the issue of an integrated budget line has arisen in other developing countries as well. For instance, at the 2008 AfricaSan meeting in Durban, the ministers pledged to create separate budget lines for sanitation and hygiene in their countries, to commit at least 0.5 percent of GDP to sanitation and hygiene, and to take the necessary steps to ensure that national sanitation programs will meet the MDG goals. Options for tr ansfer r ing ear mar ked funds to distr icts 147. Given the cross-sectoral character of sanitation and hygiene, there is no single natural organizational home where a dedicated budget line can be housed. Four viable options for implementing a dedicated budget line are the following: An earmarked supplement to one or more existing sector conditional grants. This option envisages a dedicated budget line within an existing grant--the DWSCG, SFG, PHCCG, or CDCG. This is the least attractive option. A cross-ministerial sector conditional grant--a new grant, with the budget split in accordance with line ministry mandates. The disbursements would be made by each of the participating line ministries but would be reported jointly under one sector conditional grant. This option is ranked here as third best. An anchor line ministry sector conditional grant, which involves a new grant housed in a single line ministry--the Ministry of Water and Environment; the Ministry of Health; the Ministry of Education and Sports; or the Ministry of Gender, Labour, and Social Development. Some administrative collaboration mechanism has to be established to cover the cross-sectoral aspects of sanitation and hygiene promotion. This option is regarded as second best. A sanitation and hygiene top-up to the local government development program grant. 17 This would be a subsector-specific top-up to the LGDP grant provided by the MFPED and supervised by the Ministry of Local Government. The 16 This chapter does not undertake a comprehensive analysis of available financing or financing needs for the sector, which has already been done (Uganda 2006e). 17 The LGDP grants are funds set aside for infrastructure development projects derived from a participatory mechanism for identifying community and subcounty priorities. 49 administrative responsibility would rest with the Ministry of Local Government and the technical responsibility with the Ministries of Water and Environment; Health; Education and Sports; and Gender, Labour, and Social Development. This is the preferred option. 148. Each option is discussed and elaborated in this section. All require that the various line ministries work together to develop guidelines for the use of the dedicated budget line and that they agree on relevant performance indicators and accountability mechanisms. Mechanism 1: Earmarking within existing sector conditional grants 149. The first mechanism builds on the existing sector conditional grant framework; sanitation and hygiene will be supported through the DWSCG, the PHCCG, and the SFG (see figure 4.1). Each grant would have a separate budget line with an amount earmarked for sanitation and hygiene. Consequently, the funds would be made available under the line ministries' sector ceiling and would be counted against their respective allocations. The funds for sanitation and hygiene would be tracked through the respective sector conditional grants, making it possible to trace the released funds directly to the activities. 150. Because the model builds on mechanisms that are already well established and running, there would be limited requirements for additional technical and administrative capacity development. It would, however, be necessary to be more specific about sanitation and hygiene activities in the existing sector conditional grant guidelines, and so some work would be required. Local government would continue to be the driver in priority setting and planning. Existing reporting formats and monitoring and evaluation practices could be used with some modifications to better reflect sanitation and hygiene issues. The annual sector performance report would be compiled as is currently done for the water and sanitation sector. Consequently, it is anticipated that sanitation and hygiene information would be extracted from the respective sector conditional grant reports. Trade-offs: Risks of continued fragmentation and lack of prioritization within conditional grants 151. The introduction of an earmarked budget might make more funds available, but this might happen at the cost of funds already provided in existing grants. Thus, one downside of this mechanism is that the net funds available might be less than the amount of new funds. In addition, it is not evident that the respective line ministries will devote more attention to sanitation and hygiene. Finally, the use of existing grants is not likely to reduce the fragmentation from which the subsector is currently suffering, as sanitation and hygiene will continue to be secondary to other major responsibilities in the respective line ministries. 50 Figure 4.1 Responsibilities and flows using earmarking within existing sector conditional grants MWE = DWSCG MH = PHCCG and release requests Sector ceiling/vote MES = SFG National Advises Sanitation Line ministry Working Group (MWE, MH, MFPED MES) Sector conditional grant Sector conditional grant work guidelines plans and budgets Funds Administrative support, Sector conditional grant standards, and supervision progress and financial reports Capacity development Sector conditional grant audit reports Local government MWE = DWSCG = DWO MH = PHCCG = DDHS MES = SFG = DEO Planning Implementation Reporting Accountability Coordination Source: Authors' construction. Note: DDHS, district director of health services; DEO, district education officer; DWO, district water officer; DWSCG, district water and sanitation conditional grant; MES, Ministry of Education and Sports; MFPED, Ministry of Finance, Planning, and Economic Development; MGLSD, Ministry of Gender, Labour, and Social Development; MH, Ministry of Health; MWE, Ministry of Water and Environment; PHCCG, primary health care conditional grant; SFG, school facilities grant. 152. The administrative issues surrounding earmarking within a sector conditional grant also have to be considered. Generally, earmarking within a grant is not recommended, but it is accepted for a single budget line. For the PHCCG this applies to drugs and medical supplies, which must account for at least 50 percent of the funds spent. In the DWSCG, 70 percent is earmarked for water supplies (although the earmarking is not mandatory). Introducing yet another earmarking is likely to be out of harmony with the fiscal decentralization framework, which is based on the principle of local prioritization. 51 Mechanism 2: Cross-ministerial sector conditional grant 153. This second option envisions a new sanitation and hygiene sector conditional grant, with responsibility shared among the Ministries of Water and Environment; Health; Education and Sports; and Gender, Labour, and Social Development (see figure 4.2). The funds would fall under the respective sector ceilings, and each ministry would be accountable for the funds in accordance with its sanitation and hygiene responsibilities. Consequently, the second mechanism would not require material changes to the existing sector ceilings. Figure 4.2 Responsibilities and flows under a cross-ministerial sector conditional grant MH Sanitation and and release requests hygiene sector Sector ceiling/vote MES National conditional grant PAF account Sanitation Working MWE Advises MFPED Group MGLSD Respective sector reports Interministerial with specific sanitation and working group hygiene indicators included for later extraction Sector conditional grant Sector conditional grant work guidelines plans and budgets Funds Administrative support and Sector conditional grant supervision progress and financial reports Capacity development Sector conditional grant audit reports support, and supervison MH Technical guidance, Performance reports MES Local government MWE Anchor ministry's branch under CAO (advised by DWSCC) responsible for MGLSD Planning Implementation Reporting Accountability Coordination Source: Authors' construction. Note: CAO, chief administrative officer; DWSCC, district water and sanitation coordination committee; MES, Ministry of Education and Sports; MFPED, Ministry of Finance, Planning, and Economic Development; MGLSD, Ministry of Gender, Labour, and Social Development; MH, Ministry of Health; MWE, Ministry of Water and Environment; PAF, Poverty Action Fund. 52 154. The design entails the creation of an interministerial working group (IMWG) that would be responsible for administrative coordination, drafting guidelines and performance indicators, and for monitoring. The National Sanitation Working Group would be the partner in policy dialogue and could advise the IMWG during the drafting process. 155. The IMWG would also be responsible for preparing the sector performance report. Information and indicators would be extracted from various quarterly reports prepared in connection with existing sector conditional grants. Consequently, dedicated reporting formats and structures and additional monitoring and evaluation routines at the district or municipality level would not be necessary. Establishment of a dedicated grant would make it possible to track the funds from disbursement to expenditure point. There might be a need for capacity development at the central and district levels because capacity varies in the line ministries. The guidelines would be issued jointly by the responsible line ministries. The districts and municipalities would subsequently set priorities and plans in accordance with the guidelines. They would report through existing channels, although one or more line ministries might add indicators to reflect the guidelines. Trade-offs: Possible higher profile for sanitation, but continued fragmentation within sector conditional grants 156. One advantage of this mechanism is that it does not entail material adjustments or reductions of sector ceilings. In addition, provision of a separate grant is likely to heighten the profile of sanitation and hygiene. Yet serious challenges are embedded in the collaborative approach. The coordination envisaged in the 2001 MOU through the conditional grant structure has not been adequate (as discussed in Chapter 2), and there are no immediate suggestions that a new grant will improve the situation. Consequently, the grant does not fully solve the problem of fragmentation in the subsector. The grant might address the marginalization of sanitation and hygiene by providing dedicated funds, but there is an implied risk that funds for sanitation and hygiene activities will be extracted from the existing sector conditional grants. 157. Furthermore, there would be an increased need to coordinate capacity development at central as well as local government levels. Transaction costs at the district and municipality levels are likely to increase, as the provision of a grant through several channels (line ministries) implies a risk of duplication and necessitates increased coordination efforts at the local level. Administratively, coordination could consist of four different departments reporting on, fundamentally, the same grant, or of some district departments planning or carrying out identical activities. Since the separate grant does not imply reductions in sector ceilings, it is likely to attract greater support from line ministries, but given the continued fragmentation and cumbersome administrative procedures it would involve, it is a second-best option. Mechanism 3: Anchor line ministry sector conditional grant 158. The third design follows the standard procedures for a sector conditional grant by anchoring it in a specific line ministry that would be held responsible for the whole grant. The line ministry would require technical support from other line ministries in accordance with their respective sanitation mandates (see figure 4.3). Fundamentally, 53 there are four ministries that might be able to house the grant, but none can claim to represent the entire subsector. Figure 4.3 Responsibilities and flows under an anchor line ministry sector conditional grant MH National Sanitation Advises MES Working Group Sanitation and hygiene sector MWE and release requests conditional grant approves guidelines Sector ceiling/vote PAF account Develops and and reports MGLSD Anchor line ministry MFPED Interministerial IMWG chair working group Sector conditional grant Sector conditional grant work guidelines plans and budgets Funds Administrative support and Sector conditional grant supervision progress and financial reports Capacity development Sector conditional grant audit reports support, and supervison MH Technical guidance, Performance reports MES Local government MWE Anchor ministry's branch under CAO (advised by DWSCC) responsible for: MGLSD Planning Implementation Reporting Accountability Coordination Source: Authors' construction. Note: CAO, chief administrative officer; DWSCC, district water and sanitation coordination committee; MES, Ministry of Education and Sports; MFPED, Ministry of Finance, Planning, and Economic Development; MGLSD, Ministry of Gender, Labour, and Social Development; MH, Ministry of Health; MWE, Ministry of Water and Environment; PAF, Poverty Action Fund. 159. The Ministry of Water and Environment is responsible for sanitation around water sources. The ministry has experience with handling the DWSCG. The operation of the grant has been good, with safeguards in the form of value for money and tracking 54 studies. 18 The ministry also has experience collaborating with other ministries in producing the annual performance report for the water and sanitation sector. Based on past performance, the MWE has the infrastructure to handle the grant, although its sanitation mandate is marginal in the context of the overall sanitation and hygiene subsector. Technical support units (TSUs) set up by the ministry provide administrative and technical support for district implementation of the DWSCG and a strong link with local governments. 160. The Ministry of Education and Sports, which is responsible for overseeing school sanitation and hygiene, has experience administering the school facilities grants, which are targeted toward the construction of new schools and thus new latrines. The grants do not include funds for promotion, operation, maintenance, or replacement of toilets and pits. The MES seems a marginal locus for a sanitation and hygiene conditional grant, although it does affect children (more than 8.2 million children are in primary school alone). 19 161. The Ministry of Health, through its Environmental Health Division, is responsible for household sanitation and hygiene, which is integrated into the PHCCG. The ministry encounters excessive demands for resources for its prime objective, curative health, and this leaves sanitation and hygiene in a secondary position. The MH administers several conditional grants and hospital-delegated resources. It thus has considerable experience with operating grants, but it has had difficulties in obtaining annual reports from districts and municipalities (personal communication, Dr. Grace Mulindwa, Ministry of Health). At the district level the health arm of the districts and municipalities is commonly charged with the coordination of planning and implementation of sanitation and hygiene issues. 162. On the basis of its experience with handling conditional grants, its organization, and its strong promotional mandate at the local government level, the Ministry of Health seems the logical choice as the anchor ministry. However, officers interviewed in the MWE, MGLSD, and MES voiced concerns that curative priorities would always receive the prime attention from the Ministry of Health even if a sector conditional grant targeting sanitation and hygiene were introduced. 163. The Ministry of Gender, Labour, and Social Development is responsible for advocacy and sensitization at the community level. Historically, other ministries have also used community development workers in their household-targeted activities. The MGLSD's work is highly dependent on development partners or efforts under the stewardship of other departments at the local level. The choice of the MGLSD as the anchor ministry would offer an opportunity to raise the profile of women and other 18 There is agreement on carrying out an annual value for money/technical audit of rural and small-town water facilities to review the outcomes of the grant, with assistance from Joint Water and Sanitation Sector Program Support and the government of Uganda. The value for money audit is supplemented by a tracking study to follow up on the findings of the audit. In 2005 the tracking study focused on the procurement processes relating to the DWSCG and the operations and maintenance grant. The audit is carried out in sample districts (10, in 2005) to enable better understanding of why performance varies across districts and what factors need to be addressed in order to improve cost-efficiency, quality, and equity. 19 Uganda Ministry of Education and Sports, "Education Sector Fact File II 2007." http://www.education.go.ug/fact%20file%202007%202.pdf. 55 vulnerable groups in promoting better sanitation and hygiene. The ministry administers the community development conditional grant and has developed a social development sector strategic investment plan for 2003­08. It handles some projects, but because of limited information it was not possible to ascertain its capacity for taking on another sector conditional grant. 164. Guidelines for the use of the sector conditional grant and the performance indicators would have to be developed and subsequently issued by the anchor line ministry. The guidelines should include what is fundable from the grant and what may fall outside the funding priorities, as well as a breakdown by budget line. The line ministries with a sanitation and hygiene promotion mandate should undertake a joint effort to develop the guidelines. The design also implies the establishment of an IMWG. The sector conditional grant may use reporting formats agreed to by the IMWG. The monitoring and evaluation framework could build on the existing sector frameworks, thus reducing transaction costs at the local government level. The annual sanitation and hygiene performance report would, ideally, be synthesized by the IMWG under the leadership of the anchor line ministry. The report could form an integral part of the performance report for the water and sanitation sector, as well as the health sector. 165. In the context of this mechanism, local governments should be responsible for setting priorities and planning. The guidelines accompanying this mechanism would respect the principles of the Fiscal Dectralization Strategy but could include ring fencing--for example, of one budget line for promotion at the household level by community development workers. Trade-offs: Dependence on political support from line ministries 166. The main advantage of mechanism 3 is that it gives a single ministry the responsibility for administering the budget line. It could thus be easier to administer and could remedy the fragmentation in the existing conditional grant structure. But it, too, carries a number of risks. One is that the introduction of a single sector conditional grant will, no matter what anchor line ministry is chosen, put a stress on the sector ceiling of that ministry and crowd out other priority activities. In other words, the introduction of a sector conditional grant might work to the detriment of other national priorities. 167. Furthermore, political-economy issues arise in terms of gaining support for this mechanism from ministries that do not house the budget line, and the effectiveness of the IMWG would depend on which ministry chaired the group. Based on interviews, there seem to be important issues between the line ministries, and the lack of progress since the signing of the 2001 Memorandum of Understanding indicates that significant challenges would surface once additional resources were provided. The duration of the grant would also have a considerable impact, as new ways of working add transaction costs in the short run. 168. Further capacity development at the central as well as the local level might be necessary to implement this financing mechanism. The choice of anchor line ministry might face challenges, however, because of line of command; that is, one line ministry could not command officers reporting to a different ministry. There may be a need for a new support structure (such as the TSUs) if the responsibility is given to the Ministry of 56 Health, the Ministry of Education and Sports, or the Ministry of Gender, Labour, and Social Development. 169. The choice of anchor line ministry could have serious drawbacks because confusion might arise when funds were disbursed through a ministry without a technical mandate in one or more of the supported areas. This issue would require considerable collaboration and administrative and political coordination at the central level. A possible consequence could be that sanitation and hygiene would be further marginalized in one or more of the existing sector conditional grants. Some ministries might also find a reason not to allocate funds to their technical responsibilities because those funds would be perceived as being under another line ministry. In a worst-case scenario, this would deepen fragmentation in the subsector. Mechanism 4: Integrated budget line as a supplement to the Local Government Development Program (LGDP) grant 170. The fourth mechanism involves administering the budget line as a top-up or supplement to the LGDP grant. The first and second phases of the LGDP included a local development grant, responsibility for which has been taken over by the government of Uganda. The budget for the grant is now under the Economic and Social Services Department of the MFPED but is actively managed by the Ministry of Local Government. Consequently, the LGDP has no implications for sector ceilings. Figure 4.4 shows the setup for mechanism 4. 171. The Fiscal Dectralization Strategy recommends that development partners align with the LGDP within the Development Transfer System. It states: Similarly the Development Transfer System seeks to provide the degree of conditionality which donors currently require to enable continued sector budget support. There are more important implications relating to support which donors target to individual districts/municipalities for the provision of infrastructure. Government will promote the use of the channeling of investment support through national systems. Therefore: Donors with existing support to local governments will be requested to align their modalities for providing investment support with the LGDP modalities. Where possible, existing support should be routed through the LGDP. For new local government support programs, donors will be requested to make local government investment financing congruent with national systems. This will involve channeling nonsectoral investment support via the LGDP. Donors will be requested, if possible, not to earmark this support to specific districts/municipalities, as this may result in inequitable distribution of resources countrywide (Uganda 2002, 50). 172. This passage highlights the government's preference for channeling additional fund as envisaged in option 4, although special requirements would have to be met to create an inclusive mechanism. The mechanism has to respect the various line ministries' mandates and ensure that sanitation and hygiene activities are prioritized as part of the LGDP by issuing specific guidelines. Historically, sanitation and hygiene do not appear to have been local priorities under the LGDP; Thomson (2004) estimated that in fiscal 2002/03 sanitation accounted for only 0.001 percent of the funds available. 57 Figure 4.4 Responsibilities and flows under an LGDP hygiene and sanitation top-up/grant MH National Advises Sanitation Working MES Group Sanitation and guidelines and reports hygiene sector Develop and approve MWE LGDP budget line Release requests MGLSD MLG (PCU?) MFPED Interministerial Chair of IMWG working group hygiene indicators included for later extraction for Respective sector reports with specific sanitation and Sanitation and hygiene LGDP work plans and budgets guidelines use by interministerial working group LGDP progress and financial Funds Administrative support and reports supervision Local government audit Administrative capacity reports development Technical guidance, support, supervision, and capacity MH development MES Local government MWE Planning Department under CAO (advised by DWSCC) responsible for: Planning MGLSD Implementation Reporting Accountability Reporting Coordination The respective local government branches implement according to LGDP work plan and budget. Source: Authors' construction. Note: CAO, chief administrative officer; DWSCC, district water and sanitation coordination committee; LGDP, Local Government Development Program; MES, Ministry of Education and Sports; MFPED, Ministry of Finance, Planning, and Economic Development; MGLSD, Ministry of Gender, Labour, and Social Development; MH, Ministry of Health; MLG, Ministry of Local Government; MWE, Ministry of Water and Environment; PCU, project coordination unit. 173. LGDP grants are made available on a matching basis; local governments have to contribute 10 percent of the activity costs. At least 80 percent of LGDP funds has to be used for activities within any of the five Poverty Action Fund priority areas: water and sanitation, access roads, primary education, primary health, and agricultural extension. The remaining 20 percent may be used toward other priorities except for activities on a negative list issued by the Ministry of Local Government. Dedicated sanitation and 58 hygiene funds could be provided as a top-up to the LGDP. The releases should be captured in a separate budget line so that local governments will know the exact amount allocated for sanitation and hygiene. Advantages and risks 174. An advantage of mechanism 4 is that because the LGDP comes under the Economic and Social Services Department of the MFPED, there are no implications for the respective sector ceilings. Thus, funds could be provided over and above existing DWSCG and PHCCG activities. There is, however, a risk that sanitation and hygiene activities will be removed from the other sector conditional grants once the new targeted mechanism is operational. 175. The funds have to follow the same planning, implementation, reporting, and monitoring and evaluation principles as apply to the LGDP. It would, however, be necessary to add a conditionality requiring that annual expenditure on sanitation and hygiene match the amount allocated or, more realistically, equal a percentage of the approved work plans and budgets. This would ensure that all top-up funds are used for sanitation and hygiene activities, as it is not possible to track funds to an exact activity and expenditure. 176. The Ministry of Local Government would be responsible for supervising and monitoring in accordance with its mandate under the Local Government Act. Technical support could be provided by the respective line ministries under their mandates in sanitation and hygiene. Guidelines for the use of the top-up and the performance indicators would have to be developed and subsequently issued by the Ministry of Local Government. The guidelines should include a positive and a negative list and a breakdown by budget line. 177. Because of the cross-cutting nature of sanitation and hygiene, the development of the guidelines has to be a joint effort, which could take place in an interministerial working group under the chairmanship of the Ministry of Local Government. The IMWG is envisaged as the tool for administrative coordination, whereas the National Sanitation Working Group is the partner in policy dialogue. Local governments would be responsible for planning and prioritization and for operating the LGDP/top-up; thus, the procedures for identifying, planning, delivering, and managing the grant would be mainstreamed within existing local government systems. Progress reports and financial reporting would be embedded in the existing LGDP reporting structure through amendments, if necessary. This reporting would be supplemented by the reporting being done under the DWSCG, the PHCCG, and the SFG. Mechanism 4 could use the existing monitoring framework. Thus, it would work to reduce transaction costs at the local government level. 178. Option 4 contains a built-in dilemma caused by the seeming contradiction between the discretionary character of the LGDP grant and the conditionality of a sanitation and hygiene top-up. Whereas local governments have full discretion over the LGDP grant, a sector-specific top-up would limit the scope to hygiene and sanitation, which might work against the flexibility of the LGDP. This problem could be solved by using the LGDP grant as a vehicle for transfer and reporting only. Funds budgeted under a separate budget line would be released together with LGDP funds and then split into a separate subledger 59 once they are received by the district or municipality. This procedure would ensure tracking and, at the same time, ring-fence the funds for sanitation and hygiene. This may be done without adding transaction costs, but it demands political attention and decisions with respect to precedence. 179. Another risk with mechanism 4 is that opening the LGDP for one special arrangement might open it for others, thus undermining the concept behind the LGDP. Here, the Ministry of Local Government and the MFPED, working in concert, could facilitate a positive dialogue and deliberation. Summary of Four Mechanisms 180. The advantages and disadvantages of the four financing mechanisms are summarized in table 4.1. 181. In the context of the government's Fiscal Dectralization Strategy, the LGDP top- up/grant is the best option because it delegates priority setting to local governments and can be implemented without implications for sector ceilings. The setup taps into the existing administrative framework and can be phased out at any time without significant administrative implications. Activities to be funded by the new financing mechanism 182. The integrated budget line should be accompanied by clear guidelines on the types of activity that can be funded. The government of Uganda, with the support of the National Sanitation Working Group, has recently commissioned and approved a 10-year financing strategy that focuses on a three-pronged strategy: a demand-creation program, a supply improvement program, and support for an enabling environment (Uganda 2006e). The strategy outlines various activities under each pillar, identifies responsible actors, and discusses cost implications. Relevant policy targets include 91 percent latrine coverage in rural areas, 98 percent toilet coverage in urban areas, 88 percent latrine coverage in areas without waterborne sewerage, 10 percent coverage for waterborne sewerage in towns, 100 percent coverage in schools, and a pupil-stance ratio of 40:1 by 2015. The costs of implementing the activities have also been estimated by the study (see table 4.2). 60 Table 4.1 Trade-offs between options for structuring the integrated budget line Mechanism Main features Advantages Disadvantages Earmarking Earmarking within an Uses existing setup Earmarking within a sector within existing existing grant (that is, for grant reporting, conditional grant is in the FDS sector within the SFG, auditing, etc. gray area conditional DWSCG, or PHCCG) Falls within line Does not address fragmentation grants ministries' existing of mandates between line mandates and does ministries not affect sector ceilings Cross- New sector Respects line Requires a new administrative ministerial conditional grant with ministries' existing setup sector responsibility shared mandates Does not address fragmentation conditional by multiple line Does not materially Requires considerable grant ministries; possible affect sector ceilings administrative coordination consolidation of Capacity development aspects sanitation and hygiene are uncertain elements in the SFG, Risk of duplication at district or DWSCG, and PHCCG municipal level Anchor line New mechanism with Addresses Requires a new administrative ministry sector responsibility held by fragmentation, as setup conditional one line ministry; one line ministry Could limit sanitation and grant possible consolidation holds the hygiene mainstreaming at the of sanitation and responsibility central and local levels hygiene elements in Potential for conflicts between the SFG, DWSCG, line ministries' mandates and and PHCCG funding Capacity development requirements are uncertain LGDP New mechanism with Fully compliant with By earmarking funds for sanitation and responsibility held by the FDS sanitation and hygiene, hygiene top- local governments; Promotes local mechanism temporarily goes up/grant funds provided against priority setting against the spirit of the FDS and the vote of the Utilizes the existing the discretionary character of the MFPED's Economic administrative LGDP and Social Services framework Requires the working of an Department; possible Does not affect IMWG and thus some sort of consolidation of sector ceilings or line coordination mechanism sanitation and hygiene ministries' existing between sectors elements in the SFG, mandates DWSCG, and PHCCG Possibly complementary to activities in the SFG, PHCCG, and DWSCG Source: Authors' compilation. Note: DWSCG, district water and sanitation conditional grant; FDS, Fiscal Dectralization Strategy; IMWG, interministerial working group; LGDP, Local Government Development Program; MFPED, Ministry of Finance, Planning, and Economic Development; PHCCG, primary health care conditional grant; SFG, school facilities grant. 61 Table 4.2 Summary of costs of sanitation and hygiene promotion financing strategy, by implementing agency Estimated 10-year cost (million Ugandan shillings) Percent of Area of expenditure and implementing agency Recurrent Development Total total Public sector, decentralized Rural districts 1,680 2,956 4,636 Urban districts 459 948 1,407 Schools 289 355 644 All public sector, decentralized 6,688 17 Public sector, central IDPs 4,590 0 4,590 EHD 88 673 760 DWD 0 4,690 4,690 MES 52 10 62 All public sector, central 10,102 26 Civil society NGOs 366 0 366 Private sector Formal private sector 175 22,159 22,334 All private sector 22,334 57 Total 7,699 31,791 39,491 100 Source: Uganda 2006e. Note: DWD, Directorate of Water Development: EHD, Environmental Health Division; IDP, internally displaced person; MES, Ministry of Education and Sports; NGO, nongovernmental organization. 183. The existing conditional grants support activities listed in box 4.1. This is also the subsidy policy supported by the integrated sanitation and hygiene 10-year financing strategy. A similar approach to funding activities could continue under the dedicated budget line. In Uganda, as in many other countries (for example, Bangladesh, Benin, Burkina Faso, and India), household latrine facilities are regarded as an area for private investment and are not funded through on-budget funds. Public latrines, school latrines, and initial construction of sewerage in Uganda are fully subsidized within the conditional grant structure. In addition to "hardware" subsidies, there are subsidies for the "software" aspects of sanitation and hygiene, including promotion of hygienic behaviors such as hand-washing with soap, stimulation of demand for sanitation (for example, through social marketing), staff training, and community mobilization.20 20 The 10-year sanitation and hygiene promotion strategy (Uganda 2006e) takes both hardware and software costs into account. 62 Box 4.1 Areas subsidized by conditional grants under Uganda's existing subsidy policy 100 percent subsidy of public latrines (in marketplaces and at bus stops--usually in urban centers or rural growth centers) 100 percent subsidy for school latrines Subsidy on initial construction of sewerage networks, with the idea that tariffs should later recover at least the operation and maintenance costs Subsidy of promotion of integrated sanitation and hygiene at the central, local, community, and household levels 100 percent subsidy of latrines in camps for internally displaced persons No subsidy for household latrines (although these had been subsidized by past projects and are sometimes supported by ongoing NGO projects) No subsidy for private sector activities Source: Uganda 2006e. 184. The justification for the use of public funds for sanitation-related activities is mainly based on the positive externalities of adequate sanitation at the communal level in helping to reduce the occurrence of diarrheal diseases and epidemics. Despite broad support for public funding for sanitation, there is considerable debate on where and how subsidies should be provided (Trémolet, Perez, and Kolsky 2007)--for instance, how to fund latrines for poor people. Some countries, such as Senegal and South Africa, fully subsidize facilities for the poor; others, such as Ethiopia, only fund sanitation promotion. Another debate concerns whether subsidies should be extended for hardware, whether public funding should be reserved for software activities, and whether funding should include support for microcredit, training, and other technical assistance. There is also disagreement as to whether the public sector should provide assistance for household sanitation facilities and in what form. In urban areas, where network-based solutions are more common, it is suggested that households should pay for the various components of a service provided through sewerage connections. This, however, creates difficulties for poorer households that may not even have access to the service. As in Kampala, even middle-income households may be reluctant to connect to sewerage lines if the costs of connection are greater than alternate means of emptying pit latrines (Advani 2008). 185. International experience with community-led total sanitation (CLTS) provides important lessons (Kar 2003; Sanan and Moulik 2007) on what should be financed and by whom and on the role of different actors. CLTS started in South Asia (for example, Bangladesh and India) and has been successful in Indonesia and other countries, particularly in rural areas. It moves away from supply-driven subsidies for latrines toward promotion of demand for their use and awareness of fecal-oral links. Instead of focusing on targets and indicators such as number of latrines constructed, the approach uses open- defecation-free villages as an indicator of success. While the CLTS approach as practiced in different countries varies as to the types of incentives used, at its core is a shift away from government supply-driven hardware subsidies toward a bottom-up, community-led approach focusing on long-term behavioral change. Plan Uganda is piloting the CLTS 63 approach in two villages in Tororo and Luwero Districts. The sanitation challenges facing municipalities, with their high population densities and scarcity of space, are more complex than in rural areas, and a CLTS-type approach may or may not work. More innovative solutions are needed. 186. The types of activity for which an integrated budget line may be used will need to be considered in the context of the issues facing each municipality. There are many activities to fund--excreta-related sanitation, sewage treatment, drainage, and so on. Which activities can be funded will need to be considered in the context of the municipality's overall planning and budgeting. To keep things simple and less complicated at the outset, the first phase of the dedicated budget line should focus on excreta-related sanitation and hygiene promotion activities. This would heighten awareness of integrated sanitation and hygiene and work toward the immediate target of improving the national disease burden by addressing the high incidence of diarrheal disease and the lack of progress in infant and child mortality and morbidity (see table 2.1, in Chapter 2). For both rural and urban areas, the activity mix will have to be determined and described in the guidelines for the use of the integrated budget line. Accounting and exter nal audit 187. In implementing an integrated budget line, the existing government system will be used. All accounting entities will apply best financial management practices in accordance with Ugandan legislation and in observation of the government procedures laid down in the Fiscal Dectralization Strategy (2002) and other relevant laws and regulations. Separate financial management guidelines might be developed with respect to a basket for capacity development, should such be required. The Office of the Auditor General (OAG) ensures that an external audit of expenditures and financial statements is carried out in accordance with international auditing standards. The OAG will be responsible for undertaking appropriate and timely follow-up on possible audit issues. The annual audit might be supplemented by value for money/technical audits. Tracking studies and rotational audits could also be instituted. Timing 188. The planning process is consultative, involving all levels of government. The budget framework is established in the form of the medium-term expenditure framework (MTEF), as shown in figure 4.5. Indicative planning figures are released in October of a given year, with the aim of preparing budget framework papers by the following January. This implies that local governments have three or four months to undertake a consultative planning process that involves the subcounty level. Ideally, the indicative plan/MTEF is submitted to parliament on April 1 for approval by May 15. Subsequently, the line ministries prepare detailed budget estimates. The MFPED finalizes the budget allocations, and the cabinet approves the final budget before its submission to parliament in early June, with the objective of completing the budget by the end of June. 64 Figure 4.5 National schedule for financial planning Source: Handout received from Dr Britaa Oltmann, Director Special Programmes, Uganda & Tanzania, German Development Bank. Note: APIR, annual PEAP/PRSP implementation and review; BFP, budget framework paper; MFPED, Ministry of Finance, Planning, and Economic Development; MTEF, medium-term expenditure framework; PER, public expenditure review; SWG, sector working group. 189. The implication is that guidelines for a sanitation and hygiene sector conditional grant or top-up would have to be issued by December 2009, at the very latest, to be operational in fiscal 2010/11. To achieve a full work plan, the indicative planning figures would have to be released earlier so that local governments could make some basic preparations before the guidelines were issued. Allocation mechanisms and financing sour ces 190. In addition to the choice of financing mechanism, a few additional issues need to be considered. These include the criteria for allocating funds through the conditional grant to local governments, financing sources for the budget line, and the impact of the budget line on sector ceilings. Each issue is discussed briefly here; specific amounts for the budget line and distribution among possible sources of funding are outside the terms of reference for this study and thus not suggested. Criteria for allocating funds to local governments 191. The choice of determining the transfer modality is relatively simple. One or more of the following approaches can be used. 192. The universal approach applies the Local Government Finance Commission distribution formula for determining transfers to local governments. The size of the transfer is calculated as a mix of population size and land area: 85 percent for population 65 and 15 percent for land. Because this method uses existing principles, there are no transaction costs, and the formula is fully transparent and objective. There is, however, no consideration of poverty, local specifics, or existing indicators. 193. The discretionary approach might take various forms. The sector might develop a formula that takes into account coverage, poverty levels, health indicators, and the like, or it might use the universal approach with a top-up. This approach allows the targeting of support toward the poorest areas or areas with low coverage. 194. The performance-related approach is typically attached to one of the first two models. It could use the existing LGDP performance framework, in which a 20 percent increase is provided in coming years if certain transparent and objective benchmarks are met. Should performance fall short of previously agreed benchmarks, 20 percent is withheld from the district or municipality in subsequent years. At the same time, the Ministry of Local Government provides capacity building to ensure that the slide does not continue in successive years. The model rewards good performers and thus ensures impact from the onset. It might have a bias against local governments with a weak human resource base and thus would benefit stronger local governments. In addition to building on performance, it could contain an element of rewarding local governments by matching transfers with a certain percentage of locally generated revenue or unconditional grants. 195. The eventual choice of criteria for allocating funds to districts sends a strong signal about central government priorities. The sanitation and hygiene indicators vary significantly across the country, so using a discretionary approach to render the criteria pro-poor could be beneficial. Districts and municipalities that give greater priority to integrated sanitation and hygiene and that meet performance benchmarks should be rewarded for doing so, as the impact would be seen in other sectors, notably health. Financing sources 196. The MFPED has the final decision about the source of new or existing government funds. It is assumed that the development partners will allocate their support in line with government priorities. The funds for setting up a new financing mechanism may come from any of the following three sources: Existing funds. Funds may be drawn from one or more existing grants--the DWSCG, the PHCCG, or the SFG. Technically, it would be possible to extract sanitation and hygiene funds from the existing grants and consolidate them as part of a new grant. New funds. These may come from the national budget, or development partners, or both. A combination of existing and new funds. Conclusions and r ecommendations 197. The analysis presented here considers four options and recommends that the budget line be introduced as a subsector-specific supplement to the LGDP grant, provided through the Ministry of Local Government but under the MFPED's budget. This 66 mechanism has near-unanimous support from representatives of key line ministries. 21 Introducing an integrated budget line as an LGDP top-up/grant can be a useful measure for prioritizing sanitation and hygiene, which have historically been marginalized. The mechanism can be phased in through piloting in a select number of districts and municipalities. The accountant general in the MFPED has already established administrative procedures for setting up an integrated budget line for sanitation. The use of these procedures awaits major decisions with respect to sector ceilings and how the budget line should be implemented. These decisions rest with the MFPED. 198. Establishing the budget line cannot, by itself, be regarded as a panacea for improving sanitation and hygiene and the associated health indicators. It is crucial that this step be linked with a clarification of institutional mandates and accountability structures through reform of the Sanitation Memorandum of Understanding. 21 This statement is based on extensive consultations with line ministries, the MLG, and the MFPED on the four possible mechanisms. 67 5. Solid Waste and Dr ainage Management in Ur ban Uganda 199. In Kampala and other urban areas, disposal of excreta-related waste is linked with solid waste and drainage management, since it often finds its way into garbage heaps and drainage channels. The National Health Policy defines environmental sanitation broadly to include solid waste management and drainage (Uganda 2005c). However, these issues are not addressed in the Sanitation MOU of 2001. One of the requests from the 2006 joint sector review and the Ministry of Water and Environment was to provide guidance on whether the sanitation memorandum should be revised to include solid waste and drainage. This chapter responds to that request. Its objective is to analyze the institutional mandates linked with solid waste management and drainage and provide recommendations on the revision of the Sanitation MOU. The focus is mainly on Kampala, for reasons of time and budget, but that city can be considered illustrative of other municipalities as well. Solid waste and dr ainage in ur ban Uganda: The scope of the pr oblem 200. Although Uganda is predominantly a rural country, with only 15 percent of its population in urban areas, urban population growth has been accelerating since 1980, and the population of urban centers almost doubled in each of the last two census periods (see table 5.1). Table 5.1 Urban centers in Uganda, 1969 to 2002 Indicator Census year 1969 1980 1991 2002 Population of Kampala City 330,700 458,503 774,241 1,189,142 Total population of other urban centers with more than 47,872 45,060 401,322 1,041,344 30,000 people Number of towns, other than Kampala, with population 1 1 9 19 greater than 30,000 Urban population as percent of total population 6.2 6.6 9.9 12.3 Urban population (million) 0.592 0.831 1.647 2.981 National population (million) 9.561 12.636 16.671 24.227 Source: UBOS 2002, 2006. 201. Solid waste management and drainage are local government responsibilities. Solid waste management is primarily an urban issue and is concentrated in 15 of the major urban centers (defined as urban areas with more than 30,000 people), including Kampala. These urban centers have a combined population of 2.5 million, or 83 percent of the country's urban population, and they account for 58 percent of all urban waste generated in the country. Kampala alone produces an estimated 1,500 metric tons of solid waste per day, or about 39­40 percent of the solid waste generated in urban centers in Uganda (see table 5.2). Most urban centers were planned by the central government during colonial times as formal urban settlements. Kampala has a network of natural drains and built drains constructed as part of roads. There are eight natural drainage systems, which include primary, secondary, and tertiary drains. Development of drainage infrastructure has not kept pace with the physical growth of urban centers, which are now dominated by 68 informal settlements. According to the Kampala drainage master plan, only 22 percent of the city has a drainage system. During heavy rains, most residents are affected by flooding, which also has adverse effects on the environment and on environmental health. Table 5.2 Solid waste and drainage in major urban centers, 2007 Population Solid waste generated City (million) (metric tons per day) Kampala 1.50 1,500 Jinja/Njeru 0.15 136 Gulu 0.15 118 Lira 0.12 96 Mbarara 0.08 55 Mbale 0.08 53 Kasese 0.07 45 Masaka 0.07 46 Entebbe 0.06 40 Arua 0.06 33 Kabale 0.05 26 Tororo 0.05 24 Fort Portal 0.04 17 Soroty 0.04 17 Bushenyi 0.03 10 Total 2.53 2,216 Kampala collection rate, 40 percent; Kampala drainage system coverage, 22 percent Source: Population projection based on UBOS census; solid waste projections based on discussion with Kampala City Council. Growth rate of solid waste outpacing urban population growth and economic growth 202. The rate of waste generation is increasing rapidly, posing enormous challenges for KCC. In 1985 an estimated 281,907 metric tons of waste were generated, but by 2007 the figure was approximately 1.4 million tons, implying a rate of growth of 157 percent (see table 5.3). This more-than-proportional growth in solid waste generation can be explained by economic growth; between 1985 and 2002, economic activity in urban areas, mostly in Kampala, grew 555 percent. It is expected that populations and economic activity in urban areas will increase in the coming years, exacerbating the solid waste management challenges. 69 Table 5.3 Population, economic growth, and generation of solid waste, 1985 to 2007 Change, 1985­ 1985 1995 2007 2007 (percent) Solid waste generated in all urban areas (metric tons per year)a 281,907 585,508 1,325,532 370 Total urban population 1,287,244 2,291,615 4,035,105 213 Population of Kampala 575,880 904,987 1,439,831 150 Population of other urban centers 711,364 1,386,627 2,595,274 265 Index of nonagricultural GDP 100 247 655 555 Urban population as percent of national population 8.3 11 14 n.a. a. Figures for solid waste generation refer to the national urban population. Estimates of solid waste assume 0.6 kilogram of waste per person per day in 1985, 0.7 kilogram per person per day in 1995, and 0.9 kilogram per person per day in 2007. Source: For population, UBOS census data; for GDP index, World Bank, World Development Report (various years). Note: n.a., not applicable. Types of waste 203. Municipal solid waste is the bulk of the waste produced (see table 5.4). About 70­80 percent of the waste generated is organic. Dealing with it requires sophisticated organization and management of activities related to solid waste collection, transport, and disposal. For example, landfill planning, development, and operation have to comply with environmental regulations, as do collection and transport of waste. Handling various types of solid waste (municipal waste, medical waste, hazardous waste, and nonhazardous industrial waste) requires specific technical and managerial skills, special- purpose equipment, and investments that are frequently beyond the reach of those responsible for dealing with waste. Table 5.4 Types, sources, and amounts of solid waste and collection and disposal rates Industrial Industrial Community Municipal Medical solid nonhazardous hazardous hazardous solid waste waste waste waste waste Sources Households, National and Food industry, Energy, metal, Automotive hotels, office local hospitals, fish-processing petroleum stations and business private clinics plants, wood industries gas stations industry Quantity 1,325,532 1,415 195,642 57,475 49,264 (metric tons per year) Collection and 26 percent Poor collection Poor collection Poor or Uncontrolled disposal collected; poor and disposal and disposal uncontrolled collection and disposal practices practices disposal disposal practices Source: Estimation of solid waste based on data from the National Environment Management Authority and the Kampala City Council and on Uganda (2005b). 70 Low collection rates for solid waste and poor handling practices 204. By 2002, only 26 percent of all solid waste generated by households in all urban centers was being regularly collected (see table 5.5). Estimates for Kampala vary, but about 40­43 percent of the waste generated was collected there. In other major urban areas, the figure was about 15 percent. Households handle the remaining wastes in various ways, including open dumping into street heaps--a method used by 15 percent of households in Kampala and 23 percent in the other urban centers. Urban households (all centers combined) also get rid of solid waste by burning (13 percent), depositing waste in nearby pits (28 percent), throwing it into their household gardens (12 percent), and other methods (1 percent). 205. Large amounts of solid waste remain in the streets uncollected, and environmental and environmental health regulations are not respected. The Ministry of Health found that health centers handle their wastes with no coordination or control from national or district authorities; they dispose of medical wastes using a combination of methods, including open pits, open-air burning, burial, incineration, discharge into the wastewater system, and dumping into urban authority waste skips (Uganda 2005b). Table 5.5 Household solid waste disposal methods in urban centers, 2002 (percent) Street Method Skip bin Burning Pit heap Garden Other Kampala 43 19 16 15 6 1 Urban centers other than Kampala 15 9 36 23 16 1 City (combined) All urban centers combined 26 13 28 20 12 1 Source: KCC 2002; UBOS 2002, 2006. Methods of waste collection and transport in Kampala 206. In Kampala, collection of municipal solid waste involves KCC, private contractors, and NGOs and takes place in two main ways: through the central collection system or house to house (Mugagga 2006). In the central system, KCC provides containers (for example, in market areas) in the form of secondary storage facilities and bears the costs of transport to the landfill. There is considerable excess dumping around the containers, and collections are irregular, so the containers often overflow, making the surroundings filthy. In the house-to-house system, households pay a fee to a private contractor. Garbage is left outside the house on specific days, and the customer is billed. The fee varies from U Sh 5,000 to U Sh 20,000 a month, depending on the size of the garbage bin and the frequency of collection. Of the areas that receive solid waste collection services, 70 percent use the central collection system and 30 percent (mostly in well-to-do areas) have the house-to-house system (Mugagga 2006). In slum settlements and poorer neighborhoods, residents bring garbage to a truck three times a week. Money is collected by local leaders and brought to private contractors, who take away the garbage. 207. Following the approval of the Kampala solid waste ordinance of 2000 (discussed below), KCC decentralized collection of solid waste to its five divisions--Central, Kawempe, Rubaga, Makindye, and Nakawa. Of these Central is the richest and Kawempe 71 is the poorest. In Makindye Division two private companies are involved. The divisional public health and environment department collects waste from markets, and the private companies collect waste from households. The company provides people with low- density polyethylene bags, and in some areas it goes house to house to collect the waste. (Typically, higher-income households enjoy this service.) In other areas household waste is left at a transfer point for pickup by the collection crew. This is more often the case in low-income areas or where streets are too narrow for trucks. The cleanest division is Central. NGOs such as the Kasubi Community Development Association (KACODA) are also involved in waste collection, particularly in low-income areas (Mugagga 2006). Institutions and factories work with private contractors to dispose of waste by paying a fee. Operating practices at Kiteezi landfill 208. At present, only one landfill--the Kiteezi landfill, in Wakiso District--serves Kampala and the surrounding areas, and its capacity will soon be exhausted. Kiteezi is the only landfill in the country that is planned and implemented according to minimum acceptable environmental standards. The landfill opened in April 1996, and it operates every day of the year, 24 hours a day. Its operation has been contracted out to a private contractor, OTADA Ltd., with funding and supervision by KCC. Liquid effluent from the leachate treatment plant is apparently monitored. The release of gases from the landfill is not monitored because appropriate technology is lacking. According to NEMA, during the past several years various environmental parameters of the landfill's operation have exceeded approved national thresholds; as a result, NEMA has been reluctant to issue an operating license for the facility. KCC officials consider NEMA's unwillingness to issue the license unfair because they understand that Kiteezi is one of the best-managed landfills in East Africa. 209. Outside of Kampala, all other urban areas dispose of solid waste in dumpsites without complying with environmental regulations. Various environmental and health risks are associated with dumpsites: for example, leachate from decomposition of solid waste can contaminate underground water sources, and vermin-spread diseases can easily emerge when solid waste is not covered promptly. Current environmental regulations for sitting, constructing, and operating sanitary landfills in Uganda have been in place since the late 1990s. Most dumpsites and the Kampala sanitary landfill were established before such environmental regulations were in place. Failure to invest sufficiently in urban drainage 210. Because of the country's many pressing social demands, investments in drainage systems have not been specified as part of sanitation projects, and a residual approach has been taken. For example, the Small Towns Water and Sanitation credit from the World Bank's International Development Association (IDA), which was approved in 1994 and closed in 2003, included pit latrines but not drainage. Only when local governments were unable to use the funds for pit latrines did the project reallocate funding to drainage facilities in Luwero, Busia, Mabala, Ntungamo, and Kyotera. After closure of the IDA credit, the African Development Bank appraised (2004) and approved its own small-town water and sanitation project, which included drainage development as an integral 72 component of sanitation infrastructure. Current assistance from the German Development Service for the development of master plans for urban development in small towns takes an integrative approach to sanitation that includes solid waste and drainage infrastructure. Need for major investments in Kampala's drainage systems 211. Kampala presents the most salient case of drainage infrastructure underdevelopment in Uganda. As a consequence, major flooding paralyzes urban populations and business during heavy rains, and precarious and informally developed drainage systems have become carriers of solid waste and toilet (pit latrine) effluents in poor urban areas. Such effluents lead to massive environmental degradation in the city. To control some of these problems, a new project, the Kampala Infrastructure and Institutional Development Project (also supported by IDA and recently approved), will fund priority investments in the master plan with the aim of improving drainage coverage to 31 percent of Kampala's current needs. The work will include the expansion and lining of 3.6 kilometers of mains and 4 kilometers of secondary channels, as well as remedial work on four tertiary drainage "black spots." Intrusion of solid waste into Kampala's drainage systems 212. Uncollected solid waste in periurban areas is said to be contaminated with human fecal matter, as many people in poor periurban areas have no option but to use "flying toilets" or pots during the night. Fecal matter in turn finds its way into the heaps of solid waste, particularly those close to tertiary and secondary drainage facilities (Kulabako, Nalubega, and Roger 2004). 22 Public drains also receive inadequately disposed excreta from pit latrines, especially elevated pit latrines installed on the sides of the drains. In Kampala's Central Division, partially treated sewage and the contents of septic tanks from the National Water and Sewerage Corporation, the water utility, are discharged continuously into the public drains. The NWSC sewerage system in Kampala serves about 8.5 percent of its population. Another 20 percent of the residents discharge the contents of their septic tanks into the NWSC's overloaded sewage treatment plant, from which it is dumped into the open public drainage system (Nakivubu main drain). KCC has been facing persistent financial deficits and has not been able to allocate the necessary budget or workforce to maintain the drainage system, so siltation occurs in addition to solid waste accumulations. Contamination of Murchison Bay 213. Drainage systems in urban centers carry contaminants such as highly concentrated nutrients and thermotolerant coliform (TTC) bacteria from piles of solid waste, pit latrines, and the sewerage system. It is estimated that each year the drainage system in Kampala receives 471 metric tons of nitrogen and 85 metric tons of phosphorus from solid waste along with 2,141 metric tons of nitrogen, 364 metric tons of phosphorus, and 1.04 × 1023 colony-forming units (cfu) of TTC bacteria from pit latrines (see table 5.6). High levels of nitrogen and phosphorus discharged into rivers or lakes help cause 22 Kulabako, Nalubega, and Roger (2004) argue that elderly persons and children are unable to use high pit latrines, increasing the likelihood that human fecal matter will go directly into solid waste heaps. 73 eutrophication, and high levels of TTC bacteria contribute greatly to outbreaks of diseases such as cholera, diarrhea, and dysentery. Table 5.6 Nitrogen, phosphorus, and thermotolerant coliform bacteria in drainage systems in Kampala Phosphorus Nitrogen (kilograms per TTC bacteria (kilograms per year) year) (1023 cfu per year) Solid waste 471,224 85,829 - Pit latrines 2,141,084 364,751 1.04 Total 2,612,308 450,581 1.04 Source: Authors' estimates, derived using methodology employed by Kulabako, Nalubega, and Roger (2004) to estimate anthropogenic pollution in Kawampe Division, Kampala. Note: cfu, colony-forming units. Vicious circle of environmental degradation and threats to environmental health 214. Various vicious circles with respect to environmental health appear to originate in Kampala's drainage systems. For example, highly contaminated wastewater in drains intrudes into empty pipes in the water supply system (especially during days of rationing) and is then carried to households. People who drink contaminated water may acquire diarrhea, cholera, or other diseases, and their illness leads to their becoming poorer and continuing to practice unsafe disposal of solid waste and excreta. This waste ends up in public drains, the contaminated water intrudes into the water system, and the cycle continues. 215. Another vicious circle concerns the degradation of the wetlands, which receive highly contaminated drain water. Encroachment by people who build houses and pursue farming activities has reduced the natural filtration capacity of the wetlands, and the drain water makes its way into Lake Victoria. Direct discharge of heavily polluted water into the lake contributes to the intense eutrophication currently observed and causes TTC bacteria to accumulate in the lake's standing waters, close to and around NWSC intakes. As a consequence, the cost of treating water for human consumption rises, posing the risk of a reduction in quality because the NWSC may not be able to allocate more funds for treatment. To avoid lowering the quality of water for human consumption, the NWSC can reduce budget allocations for treating effluents (sewage) that discharge into the public drains and flow to Lake Victoria, but this measure would further increase the cost of treatment of water for human consumption. Fr amework for addr essing solid waste and dr ainage at the national level 216. Box 5.1 lists the relevant acts and regulations governing solid waste management in Uganda. The National Environmental Management Policy, issued in 1994, establishes the general environmental policy framework, which includes guidance for handling and disposal of solid waste and for drainage. (The framework is sponsored by the World Bank through the formulation of national environmental action plans.) The legal instrument for implementing the policy is the National Environmental Management Act, issued in May 1995. The National Environment Management Authority, created under this law, is the key national environmental regulatory agency. The Waste Management 74 Regulations issued in October 1999 set forth a special-purpose legal ruling on handling and disposal of all kinds of waste within Ugandan territory. The Waste Management Regulations include modern principles for financing solid waste management, including the polluter pays principle and personal responsibility for solid waste generated by individuals. Box 5.1 Evolution of the policy, institutional, and legal framework for solid waste management and drainage 1990­94 National Environmental Action Plan 1994 National Environmental Management Policy 1995 National Environmental Management Act 1995 Creation of National Environment Management Authority under the Ministry of Natural Resources 1995 Water Act, under which the Directorate of Water Development was created 1995 New constitution, establishing decentralized government functions 1997 Local Government Act, establishing local government mandates 1998 Ministry of Local Government, created to support local government development 1998 Local Government Development Program, including promotion of private sector participation 1999 Waste Management Regulations (Statutory Instruments) 2000 Kampala City Council's Solid Waste Management Ordinance 2000 Public Health Act (updated) 2001 Memorandum of Understanding among the Ministries of Health; Water, Lands, and Environment; and Education and Sports 2005 National Environmental Health Policy Source: Authors' compilation. 217. With respect to solid waste, NEMA's functions include licensing waste management service providers to undertake collection, storage, and transport and to operate landfills, along with approving sites for municipal landfills. It also has a policy-making, oversight, and monitoring role in the solid waste sector. 75 Figure 5.1 Institutional framework for solid waste management Source: Authors' construction. Note: EIA, environmental impact assessment; NEMA, National Environment Management Authority; SW, solid waste. 218. At the national level, in addition to NEMA, a number of other agencies have policy and regulatory responsibilities related to solid waste management and drainage, as illustrated in figure 5.1. These include a quality of effluents regulator, the Directorate of Water Resources Management in the Ministry of Water and Environment and an environmental health regulator, the Environmental Health Division in the Ministry of Health. The DWRM has a mandate to set water quality standards for effluents discharged into urban drainage systems and elsewhere. It is also responsible for monitoring and periodically assessing effluents from landfills and the quality of water in drainage systems. Drainage falls under the Ministry of Water and Environment because drainage systems are infrastructure that carry rainwater (and wastewater). It is unclear whether the Directorate of Water Development or the DWRM has a policy-making mandate at the national level. 219. The Public Health Act of 1964 mandates the Ministry of Health to ensure that solid waste management services are delivered in such a way that the health of the population is protected. The Ministry of Local Government is charged with setting broader policies related to strengthening local governments' capacity to provide local public services, including drainage and solid waste management services. With respect to solid waste, although in principle the legal mandates of the relevant institutional agents at the national level do not overlap, in practice implementation of these functions is weak. Line ministries currently give local governments little strategic guidance on either solid waste or drainage. KCC and solid waste and dr ainage management in Kampala 220. Local governments have policy and legislative autonomy within their jurisdictions; they are expected to develop master plans for solid waste and drainage management and to issue ordinances that regulate the delivery of these services. Such local laws have to be consistent with national laws. 76 221. In Kampala, civil servants in charge of solid waste and drainage management report to the city or town clerk, the equivalent of the chief administrative officer in districts. The clerk, in turn, reports to the Kampala City Council. Solid waste and drainage services are located within two directorates: the Directorate of Health, Hygiene, and Environment and the Directorate of Works and Urban Planning respectively (see figure 5.2). At the operational level, the solid waste engineer is responsible for making sure that solid waste is collected, transported, and disposed of according to environmental regulations, and the principal health inspector ensures that solid waste services are delivered according to environmental health regulations. The drainage engineer is responsible for drainage management services, and the physical planning department is in charge of investments and monitoring of operations. Due to resource and capacity issues, the effectiveness of these officers in providing services and enforcing regulations is limited. Figure 5.2 Organizational arrangements for solid waste management and drainage, Kampala Source: Authors' construction. Note: MFPED, Ministry of Finance, Planning, and Economic Development; MH, Ministry of Health; MLG, Ministry of Local Government; MLHUD, Ministry of Land, Housing, and Urban Development; MWE, Ministry of Water and Environment; NEMA, National Environment Management Authority. 222. In practice, management of solid waste and drainage is devolved to the five divisions that make up Kampala. KCC headquarters is primarily involved with disposal-- that is, supervision of the management of the Kiteezi landfill, which, as noted earlier, has been contracted out to OTADA Ltd. The five divisions are primarily responsible for collection and transport. Each has a solid waste engineer. In addition, they hire contractors to carry out tasks at the divisional level. The division-level solid waste engineers are part of the divisional department of public health. Funding for the services provided by the division comes from a variety of local taxes, such as ground rent, business licenses, and property taxes. Divisions collect taxes and keep 50 percent of the proceeds; the other half goes to KCC to support its activities, but 30 percent of that portion is returned to the divisions.23 23 The KCC has other sources of revenue, including central transfers and income from various licenses and fees. 77 223. For drainage management as well, responsibilities are split between KCC headquarters and the five divisions. KCC is responsible for management of the main drains and surfaced road drains, and the divisions are responsible for the secondary and tertiary natural drains and unsurfaced road drains. A drainage engineer is supposed to address drainage-related issues at KCC but had been assigned to another project activity when field research was carried out for this report. 224. Recordkeeping for solid waste­related issues and drainage is not systematically performed at KCC or its divisions, and there is no systematic mechanism for explaining to the public the roles and mandates of the various government levels or for receiving feedback from the public. For instance, when a drain becomes clogged, citizens typically lodge complaints with the community development staff or the divisional health assistant, who is in contact with communities, rather than with the drainage engineer. 225. Line ministries with mandates relating to solid waste and drainage are supposed to play a regulatory/advisory role toward KCC and other local governments. With the exception of the Ministry of Health and its Health Inspectorate, however, institutions that have to do with solid waste and drainage management at the national and municipal levels have existed for about 10 years and are thus quite young. The civil service officers in these institutions at the central and local government levels are still building their capacity. Weak institutional capacity is partly to blame for the governance problems in the solid waste and drainage management sector. 226. KCC issued its Solid Waste Management Ordinance in 2000. The ordinance regulates the control, storage, collection, transport, processing, and disposal of solid waste in Kampala and describes the roles of different stakeholders--local authorities, private sector operators, and communities. It provides for the establishment of solid waste disposal facilities and regulation of the construction, maintenance, and operation of such facilities. Through the enactment of this ordinance, KCC has devolved responsibility for management of solid waste to its five divisional councils. An important limitation of the ordinance is that it does not recognize the role of informal sector workers. For someone to collect, transport, or dispose of waste for a fee without a valid license is an offence under the ordinance. Fieldwork shows that many residents are unaware of the solid waste ordinance and what their role is in terms of management of household waste (Mugagga 2006). Kampala has no bylaws covering drainage. This is one reason that management of drains tends to be a neglected area. 227. Strategic planning and budgeting for solid waste and drainage are among the biggest challenges involved in turning around service provision in these areas. In 2002 KCC prepared a solid waste management strategy. It also commissioned a solid waste strategy for 2007­16 that proposes an action plan and provides cost estimates for different activities. It appears that the strategy is being selectively implemented and funded mainly by donor agencies. Neither solid waste nor drainage (both among the council's key mandates) is given priority in funding, as is shown below. This is true in other urban areas as well. Planning for solid waste management and drainage is also hindered by poor data collection in these areas. 228. Budgetary constraints are an important challenge for KCC and for other local governments. For instance, KCC's annual budget of expenditures is U Sh 39 billion, or 78 1.4 percent of the national budget of U Sh 2,880 billion. 24 Of this amount, U Sh 12 billion is paid by the central government as salaries to health workers and teachers, leaving about U Sh 27 billion. Out of this, 93 percent (U Sh 25 billion) is allocated for salaries (city council salaries, about U Sh 5 billion; staff salaries, U Sh 18.6 billion) and financial costs (U Sh 1.6 billion). Very little is left to cover the recurrent costs of any service, and none to finance capital costs. Decision making on capital investment is therefore influenced by the central government and by donor agencies. 229. Recent measures passed by the central government have further weakened the capacity of local governments to deliver services. A case in point is the elimination in 2004 of the graduated tax and of property taxes on non-business properties. Before its elimination, the graduated tax contributed about 50 percent of local governments' total own revenues. According to the 2004 annual report presented to parliament by the Local Government Finance Commission, local governments' own revenues were by then already exhibiting a declining trend, as seen in panel A of figure 5.3 (see also Appendix D). (Note that declining figures are in current market prices; if they were expressed in constant market prices terms the declining trend would be even worse.) Panel B of figure 5.3 shows a decline in own revenues as a share of sources of finance for local governments' annual budgets, from 34 percent in fiscal 1999/2000 to 13 percent in fiscal 2003/04, just before the elimination of the graduated tax. After that, the share of local governments' own revenues in financing the total budget fell to an estimated 6 percent. Thus, local governments in Uganda have become financially very weak and increasingly rely on transfers from the central government for most of their recurrent and development budgets. The problem is compounded by the formation of new district and urban local governments. 230. The government of Uganda has sought to improve governance at the local level by introducing sound principles for budgeting and planning (through the medium-term expenditure framework) and improved systems for public financial management and procurement practice. The government has also tried to strengthen existing oversight institutions (for example, the Office of the Auditor General), but improvement at the local level has so far been elusive. Local governments have been given mandates for service but do not have sufficient financial resources. As noted earlier, only 30 percent of the total national budget is transferred to local governments, and 80 percent of that is constrained by conditional grants. Moreover, because governments' ability to generate resources locally has been reduced, they are heavily dependent on central government transfers. Another explanation is that policies and strategies for turning around local governments failed to take fully into account the specific conditions of those governments. Perhaps transfer of responsibilities should have been carried out more gradually so that local governments could have built their capacity to plan and budget and to raise and account for local tax revenue and other sources of income. 24 City Council of Kampala, District Annual Budget Speech 2007/08. 79 Figure 5.3 Trends in local government revenues, 1999­2005 (current prices) Source: Local Government Finance Commission data. Note: One U.S. dollar equals 1,500 Ugandan shillings (2006 exchange rate). 231. Local government reform in Uganda has been conceived of as a vehicle for improving governance through participatory decision making. The popular belief is that local government officials do not necessarily act to promote the public good and good governance by improving the delivery of various services and complying with relevant regulations. Thus, one reason cited for the poor construction of drains is corruption in road construction, and local officials are said to interfere with local government procurement processes in collusion with civil servants (see box 5.2). If the thesis that local elected officials are part of the problem is correct, and assuming that solid waste 80 and drainage services will continue to be local government mandates, alternative options for improving governance in solid waste and drainage management will need to be found. Box 5.2 Political corruption in local government From a report by Transparency Uganda and the Centre for Basic Research: "It was unanimously agreed by respondents that politicians were engrossed in corruption and that they exhibited it most through their interference with the local government procurement processes, and in particular the award of tenders in connivance with civil servants. The other forms included diversion of resources, favoring supporters for contracts and jobs, presenting bogus allowance claims, collusion with civil servants to embezzle, bribery and extortion, protection of corrupt officials, and use of public resources for personal work. "While all politicians were reported to be corrupt, the office of the district chairperson was reportedly rated as more corrupt. Respondents noted that district chairpersons wield so much power that they had virtually assumed the roles of the district boards and commissions including those of civil servants. . . . 42 percent of the respondents reported LC 5 [district] chairman as the political office with increasing political corruption followed by the district councilors (23 percent), and LC 3 [subcounty] chairman (16 percent)." Source: Transparency Uganda and CBR 2005. 232. KCC's annual expenditure budget has been about U Sh 37 billion per year for the last three years, and its internally generated funds averaged U Sh 24 billion per year. The national government provided KCC with about U Sh 13 billion per year (see table 5.7). During the same period, the council would have needed to allocate between U Sh 10.8 billion and U Sh 11.7 billion for solid waste management, but it did not do so. Thus, rather than KCC paying private contractors, the bulk of financing for solid waste management came from households themselves, who paid the contractors directly. Because not all households can pay, solid waste collection covers only about 40 percent of the population. The limited KCC allocation went for fuel for the divisions' trucks, for topping up contracts with private contractors to collect and transport solid waste, and for the operation of the Kiteezi landfill; these expenses totaled U Sh 1.56 billion during fiscal 2005/06. (Note that these numbers are in constant market prices; if the numbers were in current market prices the budget figures would appear to have increased about 5 percent per year, the same as the rate of inflation in Uganda during these years.) 81 Table 5.7 Kampala City budget and financing, by fiscal year (billion Ugandan shillings at 2006 constant prices) 2003/04 2004/05 2005/06 Total KCC budget 37.57 36.96 37.39 Financing Own revenue 23.75 25.49 22.25 From national government 13.83 11.47 15.14 Memorandum Needed for solid waste managementa 10.83 11.26 11.71 Allocated to solid waste management - - 1.56 a. Estimated at US$15 per metric ton of solid waste in Uganda, including collection and disposal. Source: Kampala City Council, District Annual Budget Speech 2007/08. 233. A decline in local government revenues is expected to have an adverse impact on the quality of service delivery. As table 5.8 shows, however, even when local governments had more revenues, the allocation for solid waste management was very low compared with what was needed to keep the main urban centers clean. The reason may be high allocations for council and staff salaries, as was the case in Kampala. It is estimated that during fiscal 1999/2000, U Sh 10 billion was needed for handling solid waste in all main urban centers, while the budget allocation for solid waste management for that year was only about U Sh 0.25 billion. If local governments had had to finance solid waste management out of their own revenues, it would have taken 9.9 percent of their total revenues during fiscal 1999/2000 and about 35 percent in fiscal 2004/5. These figures reveal difficult times in the solid waste sector, as during the whole period local governments as a group never allocated more than 2.5 percent of what they needed for this purpose. (Note that the analysis of local government finances is done at current market prices; if constant market prices were used, the financial situation of all local governments combined would appear even worse.) Table 5.8 Local government revenues and solid waste financing allocations and amounts needed, by fiscal year (million Ugandan shillings, current prices) 1999/2000 2000/01 2001/02 2002/03 2003/04 2004/05 Local government revenues 110,748 109,388 104,812 99,571 94,393 47,792 Needed for solid waste 10,962 13,152 13,667 14,630 16,214 16,755 management As percent of total revenue 9.9 12.0 13.0 14.7 17.2 35.1 Allocated for solid waste 250 250 250 250 250 250 management As percent of amount 2.3 1.9 1.8 1.7 1.5 1.5 needed Source: For local government revenues, Local Government Finance Commission. Note: Funds needed for solid waste management are estimated by the authors at US$15 per metric ton for collection and transport; the amount allocated for solid waste management is from the Water and Sanitation Program rapid assessment (Uganda 2005d). 82 Solid waste collection and tr ansport by the pr ivate sector in Kampala 234. Given KCC's inability to deliver solid waste collection services, businesses and affluent residents in Kampala have turned to private sector providers. Accurate data regarding the number of private contractors involved in refuse collection and transport are not available. According to one estimate, about 20­30 private contractors operate in the city. KCC started promoting private sector participation in the collection and disposal of solid waste under the World Bank­supported KCC strategic framework for reform. 25 Two types of partnership arrangements with private contractors for solid waste collection and transport emerged. In one case private operators received a license to provide a service and were paid by KCC. In the other arrangement, KCC provided a license to service providers who were paid by consumers willing to buy the service. A number of private sector operators have also been working informally outside these types of arrangement and have no formal contracts with KCC. 235. Lack of formal contracts has created difficulties for KCC's division staff and for the private sector and consumers. First, KCC's five divisions are mainly responsible for supervision of the contractors, and it is very difficult for divisional solid waste staff to monitor or regulate their activities. Second, without formal contracts it is difficult for officials to hold contractors accountable for the quality of service. For instance, one private contractor may collect waste from households for a fee and, to save on fuel costs, may dump it illegally in an area where a different operator may be working. This creates problems for the transport and eventual disposal of the waste. Third, since the contractors are operating informally, they do not pay taxes on their income from households' fees, and the city loses an important source of revenue. 236. Many private sector operators are unable to comply with NEMA regulations for obtaining a license to run their trucks, and so many are functioning illegally. In March 2004 KCC, with the support of the Ministry of Local Government, tendered a formal contract with Nabugabu-Updeal Joint Venture (N-UP), one of the biggest solid waste management companies in Kampala. 26 Yet even after the contract was signed, N-UP remained informal; NEMA could not issue a license because most of the company's trucks were not suitable for environmentally safe transport of solid waste. The same is true of the other private contractors' trucks. NEMA's explanation for the widespread informality in the private solid waste truck fleet is that even though the trucks cannot comply with the environmental regulations, if the trucks were not circulating the streets of Kampala the environmental damage would be even worse. 237. On the economic regulation side, at least in Kampala most private service providers, including those that have secured contracts with the local government, are providing the service for a fee determined by market competition. Thus an unregulated polluter pays principle is being applied in the solid waste sector, and 40 percent of solid waste is being collected on this basis. The financing of solid waste management that is missing in table 5.8 is in fact contributed by business units and individual households. 25 The framework has three broad areas: changing the administrative structure of the KCC and downsizing it, liberalizing service delivery to allow private sector participation, and improving budget and expenditure procedures. 26 Technical assistance for preparing and tendering the contracts was provided by the World Bank­ supported Local Government Development Program. 83 238. One implication of private sector participation, however informal, is that KCC has not expanded or renovated its solid waste truck fleet since 1995. At the divisional level the trucks are being used to provide services in critical areas, on a firefighting basis, especially where private companies have no incentive to serve. Thus as the private sector has begun to play a role in municipal solid waste management, KCC has decreased its capital and recurrent budget allocations for solid waste management (except that it pays a private operator to manage the Kiteezi sanitary landfill). Local government councils in other main urban areas are also starting to use the private sector for collection and transport of solid waste. For example, in Jinja the municipal council is outsourcing collection of solid waste to private contractors (who nevertheless use the council trucks and are paid by the municipal government). 239. A second implication of privatization in solid waste collection is that the role of KCC and its divisions with respect to solid waste has evolved to include contract management and timely assessment of the contractor's work. Because of lack of formal contracts for collection and transport, however, divisional staff do not know what to supervise and enforce and are not able to play their oversight role effectively. Role of NGOs in mitigating lack of ser vice to poor ur ban ar eas 240. Some NGOs have taken up the challenge of serving poor urban dwellers who cannot pay for services provided by private operators. A case in point is the Kasubi Community Development Association, which has sought official recognition as a solid waste collection and recycling NGO. KACODA's per ton cost is about US$5. KACODA integrated collection and recycling activities to lower its collection costs. It is currently partnering with private providers to facilitate access by the poor to solid waste collection services. Youth groups are also engaged in waste collection. NGOs are typically not involved in collection and transport, as they lack the necessary infrastructure. 241. Some NGOs are involved in innovative activities linked with waste collection and income generation. For example, the Urban Community Development Association (UCDA) works with households in low-income areas to promote organic waste composting. The UCDA gives households bags for sorting different types of waste and gives them free compost in exchange for waste. It also carries out various activities such as making and selling compost. Proceeds from sales contribute to a revolving loan fund from which members can borrow money for small businesses and improve their incomes (see also Mugagga 2006). Community Integrated Development Initiatives also engages in solid waste activities, including sensitizing ragpickers to collect, sort, and sell recyclable items. There is a group doing this in Mengo and selling items to plastics companies. CIDI is also exploring ways of using items such as rotten wood, banana peels, and paper to manufacture briquettes. 242. It is unclear how many NGOs are working on solid waste issues in Kampala; no information was available at KCC headquarters or at the divisions. One option is for KCC, particularly the public health department, to explore ways of entering into collaborative relationships with NGOs in areas where the latter have a comparative advantage, particularly since they serve poor or low-income residents and have innovative ways of combining recycling with income generation. 84 Impor tance of info rmal secto r wo rker s in waste disposal 243. As in many other cities in developing countries, numerous poor people are involved in various types of activities associated with solid waste collection. Accurate estimates are unavailable. Their work is not recognized under the KCC solid waste ordinance, and so they work outside the formal sector and are subject to harassment by the authorities. At Kiteezi landfill, informal ragpickers sort solid waste as soon as it is dumped and sell the recyclable materials (paper, plastics, and metal products). Discussions with KCC staff who have worked at the landfill suggest that at present approximately 150 informal sector workers are active there. Although the ragpickers at Kiteezi are not formally organized, they do have an informal structure and an informal leader who influences entry into recycling, sorting, and collecting activities at landfills, and they have developed self- policing mechanisms. Many of the ragpickers are internally displaced people or belong to the Batooro ethnic group. 244. Ragpickers collect and sort various items, such as paper, scrap metal, cardboard, and plastics, which they sell to middlemen, traders, or local plastics companies (Mugagga 2006). An estimated metric ton of waste is removed by the ragpickers. Some of the recycled items are apparently taken to Nairobi and sold to large paper-recycling plants. KCC can consider entering into partnership arrangements with informal workers, as has been done in other countries (see box 5.3). Box 5.3 Collaborating rather than competing with the informal sector In the early 1990s two municipalities in Brazil (Porto Alegre and Belo Horizonte) established partnerships between municipal governments and pickers' associations in an early example of an integrated approach to solid waste management. Under the initial leadership of UNICEF, the strategy was to eradicate open dumps while building social inclusion. A precondition for funding solid waste activities was compliance with social criteria--that is, addressing pickers' issues in solid waste management plans. Between 2000 and 2002 the Brazilian federal government invested US$188 million in solid waste management, and in 2003 the Ministry of Environment opened a special line of funding of US$2.6 million for pickers' cooperatives (Dias 2007). In Egypt, as in many developing countries, the informal sector plays a leading role in waste collection by usually charging a user fee. A municipality in Egypt recently contracted solid waste management activities to international companies. The results were mixed; one contractor failed because of unofficial competition with informal operators, but another decided to cooperate with the informal sector. After intense negotiations, informal waste collectors were hired under a subcontract to collect household waste and sort out recyclables, reducing the waste taken to the landfill and lowering costs. This example shows how developing countries can build on rather than replace existing informal recycling systems. Such measures protect livelihoods while improving the efficiency and working conditions of those involved (Zhu et al. 2007). 85 Local gover nments' financial difficulties and the CDM 245. Local urban governments in Uganda have started to envisage potential benefits from implementing environmentally friendly solid waste disposal practices. KCC and nine other municipal governments are actively committed to taking advantage of the international Clean Development Mechanism (CDM). 27 KCC is supporting a system for capturing and flaring methane gas at the Kiteezi landfill. NEMA is assisting nine municipalities in improving their landfill facilities so they can undertake composting. If successful, local governments would have in place a self-enforcing mechanism for keeping urban centers clean because the main material used to produce emission reduction credits is solid waste. Excessive projections of solid waste volumes? 246. Most municipal governments planning to establish composting facilities to benefit from the CDM have projected unusually high volumes for solid waste for their jurisdictions. With the exception of Mbale, towns participating in the composting program have estimated amounts of between 1.7 and 2.4 kilograms per capita (see table 5.9). These numbers contrast markedly with the 1 kilogram or less per capita for most urban centers in developing countries (World Bank 1999, 7). Reliance on high estimates of waste generated, when in reality the amount is half the estimated figure, could lead to overspending on composting facilities and equipment, making the project financially nonviable. Table 5.9 Estimates of solid waste generated in municipalities with composting projects Fort Jinja Lira Mbarara Mbale Kasese Kabale Portal Soroty Population (million) 0.15 0.12 0.08 0.08 0.07 0.05 0.04 0.04 Solid waste per day 250 200 171 80 167 92 89 96 (metric tons) Kilograms per person-day 1.7 1.7 2.1 1.0 2.4 1.8 2.2 2.4 Source: For projection of solid waste generation, NEMA data. Projection of solid waste generation in urban centers 247. In making projections of solid waste generation, it is assumed that, on average, urban centers will continue growing at an annual rate of about 5 percent up to 2015 and then slow slightly. In line with population census figures for 1980, 1991, and 2002, it is assumed that Kampala will grow less rapidly than other urban centers. Based on these population projections, Kampala's solid waste generation as a percentage of total solid waste generated in urban centers will go from 40 percent in 2007 to 32 percent in 2020 (see table 5.10) because solid waste generated in other urban centers will grow at a faster rate than in Kampala. Solid waste management in other urban centers will be as challenging as in Kampala, or even more so. 27 See Hopwood and Cohen [1998]; CDM website, http://unfccc.int/kyoto_protocol/mechanisms/clean_development_mechanism/items/2718.php. 86 Table 5.10 Estimates of generation of solid waste in urban centers, 2007 to 2020 (metric tons per year) 2007 2010 2015 2020 Kampala 525,538 646,531 806,665 953,445 Other urban centers 799,994 1,009,661 1,480,158 2,040,877 All urban centers 1,325,532 1,656,192 2,286,822 2,994,322 Kampala as percent of all urban 40 39 35 32 Annual growth of solid waste in 7.2 4.5 3.4 Kampala (percent) Annual growth of solid waste in all 8.1 8.0 6.6 other urban centers (percent) Source: Authors' estimates. Role of the Wor ld Bank and other donors 248. A number of donors are involved in solid waste and drainage in Kampala. The first World Bank urban project for Uganda, approved in 1991, focused on investment in infrastructure in Kampala, with very limited attention to human resources and institutional capacity development. In 1994 the Bank approved a second project designed to fund urban infrastructure, Small Towns Water and Sanitation, with considerable emphasis on pit latrine sanitation and, by default, drainage infrastructure. Both projects were handled by the central government. By 1996 KCC had formulated its strategic framework for reform and had solicited assistance from the World Bank. 249. The Bank's Local Government Development Program was approved in 2000. It emphasized capacity and institutional development in local governments and helped reforms designed to involve the private sector as the main agent for improving the performance of local governments and service delivery. A sanitary landfill for Kampala was established under this project. Parallel to the LGDP, the Bank approved and implemented the Nakivubu Channel Rehabilitation Project, which included the preparation of the Kampala Drainage Master Plan. Currently, two ongoing projects involve solid waste management, and one of these includes drainage. Both projects will support local governments' endeavors to take advantage of the Clean Development Mechanism. 250. Other donors are also involved. For instance, the German Development Service will assist the building of local government institutions by supporting planning and capacity- building activities that include solid waste, drainage, and water and sanitation. The African Development Bank has recently approved a project to support urban local governments in planning and financing infrastructure investments, including drainage and solid waste management. Conclusion 251. Improvements in solid waste management and drainage in Kampala and other municipalities require substantial efforts to strengthen the capacity of municipal 87 governments, the partnerships between local governments, the private sector, and NGOs, and innovative financing for all these activities. Given the relative neglect of excreta- related sanitation in rural and in urban areas and the distinct set of institutional constraints involved, it makes sense to not include solid waste and drainage in the Sanitation Memorandum of Understanding. 88 6. Conclusions and Recommendations 252. This study highlights the institutional factors that underlie the relative marginalization of sanitation at the national and local government levels in Uganda. It also illustrates some of the reasons why sanitation has not been given priority within the existing conditional grant structure, thus hindering the implementation of the Sanitation Memorandum of Understanding. Local governments face tremendous challenges in delivering services. They are caught in the dilemma of being mandated to deliver crucial services as part of broader decentralization reforms but with little discretion over funding because of constraints imposed by the conditional grant structure. In a context of weak human resource and planning capacity, improvements in sanitation and hygiene have been slow. 253. Yet in the midst of this bleak scenario, some districts and municipalities have succeeded in rapidly improving sanitation and hygiene. These local-level initiatives can be supported by national initiatives. An important instrument that has been proposed for encouraging prioritization of sanitation and hygiene is the introduction of an integrated budget line for sanitation and hygiene. The study examines four possible mechanisms for doing this, discusses the trade-offs, and recommends administering such a budget line as a top-up or supplement to the LGDP grant. Recommendations for excr eta-r elated sanitation and hygiene 254. Given that both rural and urban local governments in Uganda face significant institutional and governance constraints, what options do they have for dealing with excreta-related sanitation and hygiene and improving health outcomes? On the basis of the analysis carried out in this report, the following recommendations are made (and are summarized in table 6.1). Table 6.1 Recommendations for excreta-related sanitation and hygiene Issue Recommendation Responsible agencies Weak prioritization of sanitation Implement integrated budget line as a top- Ministry of Finance, and hygiene at national and local up to the Local Government Development Planning, and government levels Program (LGDP) grant, with clear Economic performance standards, reporting Development guidelines, and accountability mechanisms (MFPED); Ministry of Local Government (MLG) Slow improvement of sanitation Clarify mandates and reform the MOU and MLG; IMWG and hygiene targets and lagging link this with implementation of the budget implementation of Sanitation line in both urban and rural areas as Memorandum of Understanding appropriate; establish an interministerial working group (IMWG) Lack of incentives for local Promote campaigns and competitions and Line ministries and governments to prioritize establish reward mechanism, especially at MLG through IMWG sanitation and hygiene local government level Weak planning and budgeting Establish district and town water and Local governments capacity for sanitation and sanitation coordination committees; hygiene at the local government strengthen capacity of committees and level relevant staff 89 Need for technical support for Strengthen technical support units to Directorate of Water local governments and improved support local governments Development coordination between line (DWD), Ministry of ministries and local governments Water and Environment; other line ministries Shortage of health inspectorate Fill vacant posts of health inspectorates in Local governments; staff both urban and rural areas MFPED; MLG Weak enforcement of sanitation Establish, disseminate, and enforce local Local governments; bylaws; lack of bylaws on bylaws on sanitation and hygiene; enforce Environmental sanitation and hygiene in some laws to hold leaders accountable (in office) Health Division localities (EHD), Ministry of Health Inadequate political will, lack of Establish mechanisms for public MLG; IMWG exemplary leadership, and recognition of local government leaders limited support for enforcement who champion sanitation and hygiene and at local government level support enforcement of the Public Health Act and sanitation bylaws Neglect of promotion of hand- Promote advocacy at all levels; sensitize Local governments; washing with soap, although the local leaders to be advocates for sanitation nongovernmental practice can reduce diarrheal and hygiene; always combine promotion of organizations; disease among children by sanitation with promotion of hand-washing community-based nearly 47 percent and acute with soap, especially at critical times (after organizations respiratory infections by about visiting a toilet, before eating food, and 30 percent before feeding a baby) Lack of guidelines for latrine Have municipal governments/KCC Kampala City construction in Kampala, leading establish clear latrine construction Council to failure to follow minimum guidelines guidelines for construction and tendency for latrines to fall into disrepair Stronger link between planning Strengthen leadership role of the EHD; Ministry of Health; and budgeting for sanitation and provide technical assistance to relevant line line ministries hygiene needed at the EHD and ministries to strengthen capacity in other agencies at the national sanitation and hygiene level Data collection on key sanitation Review indicators; improve collection and Line ministries; local and hygiene indicators not utilization of data on sanitation and hygiene governments systematic indicators; build capacity Source: Authors' compilation. Note: Most of the recommended actions can be implemented with the relevant agencies' own resources. Implement the budget line for sanitation 255. It is recommended that a budget line be established through a sanitation and hygiene top-up to the Local Government Development Program grant. This subsector-specific top-up would be provided by the MFPED and supervised by the Ministry of Local Government. Because sanitation and hygiene are cross-sectoral issues, it is necessary that representatives from different ministries work together. Accordingly, an interministerial working group with representatives from the Ministries of Health; Water and Environment; Education and Sports; Local Government; and Gender, Labour, and Social Development should be formed to develop guidelines for the use of the dedicated budget line and to agree on relevant performance indicators and accountability mechanisms. The IMWG would be led by the Ministry of Local Government under the guidance of the 90 National Sanitation Working Group. Administrative responsibility for the budget line would rest with the Ministry of Local Government and the technical responsibility would rest with the four sectoral ministries. 256. This option is consistent with Uganda's Fiscal Dectralization Strategy. It also supports local government discretion over how funds are spent on sanitation and hygiene, since the funds go directly to local governments. The mechanism uses existing administrative frameworks, does not affect existing sector ceilings or line ministries' existing mandates, and complements activities under the existing conditional sector grants, the DWSCG, PHCCG, and SFG. Reform the Sanitation Memorandum of Understanding as part of a package of guidelines for implementing the integrated budget line 257. The integrated budget line is an important mechanism for earmarking funds for sanitation and hygiene but by itself it will not be sufficient to improve sanitation and hygiene indicators. Underlying institutional and organizational issues will also have to be addressed. Accordingly, it is recommended that the implementation of the integrated budget line be combined with reform of the Sanitation MOU. In addition to the ministries identified in the existing memorandum, the Ministry of Local Government; the Ministry of Gender, Labour, and Social Development; and local governments should be signatories to the revised memorandum, and their mandates should be clarified. 258. The allocation of funds to local governments should be accompanied by explicit performance agreements. For instance, local governments should be given incentives to put in place sanitation bylaws that contain clear guidelines for latrine construction and hygiene promotion. Contractual agreements between local governments should include specific high-impact interventions to encourage results-oriented behavior so that local government officials will deliver on agreed-on targets. Establish a system of rewards and incentives at the national level 259. Good-practice examples of accelerated sanitation coverage in Uganda and in other countries such as Bangladesh, Ethiopia, and India highlight the importance of introducing financial rewards and incentives at every government level. 28 Public finance should be used to create awareness, promote exchange visits and hygiene education, encourage sustainable technologies such as ecological sanitation, and build the capacity of stakeholders. Public resources should be made available for incentives, rewards, awareness creation, promotion of better technologies, social marketing, and capacity building. Offer incentives to form district and town water, sanitation, and hygiene committees 260. A consistent factor in the better-performing districts and towns in Uganda is the presence of a water and sanitation coordinating body. A committee of this kind promotes integrated planning and budgeting, improves synergies (and therefore leads to better use of resources), and facilitates involvement of NGOs and, where possible, the private sector. It also provides a forum in which community development officers, health 28 See Bibby and Knapp 2007; Swayam Shikshan Prayog 2005. 91 inspectors, and water and sanitation officers can work together. It is recommended that local governments establish and strengthen district and town water and sanitation coordination committees. Access to funds from the integrated budget line should be linked to formation of these bodies. Provide technical support to urban and rural local governments 261. Experience in Uganda suggests that technical support units in the water and sanitation sector are important in building the capacity of local governments, assisting with budgeting and planning, and providing technical advice on construction and maintenance. TSUs also form an important link between the Directorate of Water Development and local governments through national-level coordination provided by the central TSU secretariat, and they should be strengthened. It is also recommended that measures be devised to provide technical support to local governments in both rural and urban areas with respect to planning, budgeting for, and implementing sanitation and hygiene activities. 262. In some of the cases reviewed for this report, donors such as the German Development Service in Luwero town provided technical support to towns for sanitation planning and budgeting. Instead of working in an ad hoc, piecemeal way, donors can collaborate to provide such support to local governments. It is suggested that the Ministry of Local Government, supported by donors in a collaborative and coordinated manner, provide such assistance to local governments. Improve staffing of and support for the health inspectorate 263. The case studies of Rakai District and the town of Luwero demonstrate that a key ingredient of better sanitation is to fill all positions on the health inspectorate staff and give staff members adequate allowances and transportation. The sense of achievement from improvements in sanitation coverage is an important motivating factor for the health inspectorate staff in Rakai, but this altruistic kind of motivation is not sufficient and sustainable. In the mid-1970s, Kampala, with a population of about 400,000, had 33 well- facilitated health inspectors. Now it has a daytime population of over 2.5 million and only 12 health inspectorate staff, and they receive only poor support. This understaffing contributes to poor sanitary conditions in the city. It is recommended that health inspectorate positions at local government levels in both towns and districts be filled and that the officers be adequately facilitated. Enforce the Public Health Act and sanitation bylaws 264. Some local governments have not passed sanitation ordinances and bylaws; others may have them but often do not enforce them. It is recommended that all local governments enact sanitation bylaws that contain clear requirements for construction of latrines, specification of roles and mandates, enumeration of activities affecting public health that are legal or illegal, and clearly articulated fines and penalties. The better- performing areas are marked by strong enforcement by communities and district and town staffs. Having updated laws in place is a first step in the process. 92 Establish mechanisms for public recognition of local government leaders 265. An important lesson from the better-performing districts and municipalities is that active involvement of leaders at all levels, including opinion leaders, is vital for the allocation of budgets to hygiene and sanitation and the enforcement of local sanitation bylaws. An annual public recognition system should be instituted to honor local leaders who support enforcement of the laws. At the 2007 Health Assembly, local government leaders committed themselves to achieving 100 percent sanitation coverage and enforcing the Public Health Act and relevant regulations and bylaws. Such efforts should be supported by line ministries. Leaders should explain the benefits of good sanitation and hygiene at every opportunity. The relevant ministries should be encouraged to fulfill their roles and responsibilities, and follow-up should be undertaken to ensure that budgets are mainstreamed or increased, especially at the local government level. Combine latrine coverage with promotion of hand-washing with soap 266. Hand-washing is one of the most effective means of preventing diarrheal disease, along with safe stool disposal and safe household water treatment. Evidence indicates that improved hand-washing, in particular with soap, can have a major impact on public health in any country and can significantly reduce two leading causes of childhood mortality: diarrheal disease and acute respiratory infection (ARI). Washing hands with soap at the right times can reduce instances of diarrhea by 35­50 percent, and evidence also suggests that hand-washing with soap can significantly reduce ARI (Rabie and Curtis 2006). Hand-washing may be a better option for disease prevention than any single vaccine, yet it is often neglected. In Luwero, for example, latrine coverage increased rapidly, but the prevalence of hand-washing was only 4 percent. 267. It is recommended that programs of latrine coverage should, at a minimum, be combined with promotion of hand-washing with soap, especially at critical times--after visiting the latrine, before eating, and before feeding a baby. Support should be provided to the national hand-washing campaign launched in 2009. Improve accountability of local governments in meeting targets 268. A core issue underlying weak fulfillment of targets at the local government level is lack of accountability mechanisms. Better monitoring and enforcement by relevant line ministries, especially the Ministry of Local Government, of agreed-on sanitation and hygiene targets is needed, and incentives should be provided. Emphasize importance of open-defecation-free status 269. Examination of good-practice districts in Uganda shows that even villages that have reached 100 percent latrine coverage are not necessarily free of open defecation. Shifting from open defecation to open-defecation-free is an important behavioral step in moving up the sanitation ladder to hygienic facilities and should be emphasized. Support collection of information and dissemination to the public 270. An important bottleneck in local governments is lack of systematically collected information concerning excreta-related sanitation and hygiene. Even in Kampala, it was 93 difficult to find accurate information about the number of pit latrines, the percentages of the population with different types of latrine, the number of private sector operators, and so on. It was also unclear whether the information was supposed to be collected at the divisional level or by KCC headquarters. The case of Kampala is illustrative of weak data collection in other localities. It is recommended that systematic collection of information about sanitation and hygiene, as well as solid waste and drainage, be pursued by all local governments. Such information can help improve planning and budgeting for environmental sanitation in general, and sharing this information with the public can strengthen citizen involvement and thus promote accountability of the public sector for service delivery. Recommendations for solid waste management and dr ainage 271. The analysis of solid waste management and drainage undertaken in this report goes beyond an assessment of mandates to show how--in a context of limited resources and weak local government planning and budgeting capacity--other actors (mainly private sector entities and nongovernmental organizations (NGOs) have entered into solid waste collection and transport and are reshaping service delivery. The main recommendations linked with solid waste management and drainage follow (and summarized in table 6.2). Prepare a national solid waste management strategy and financing strategy 272. Given Uganda's rapid urbanization, the challenges linked with solid waste management are likely to increase. At present, municipalities are devising ad hoc mechanisms for dealing with various aspects of the issue. It is recommended that Uganda develop a national solid waste management strategy, with principles for sustainable financing for the sector based on international best practice. Such a strategy could be useful in providing guidance to municipalities on how to develop their solid waste management frameworks. A national strategy would need to be articulated by NEMA, the national policy maker for solid waste management. A similar function is performed in the United States by the Environmental Protection Agency, which is responsible for designing a national strategy, policies, and laws, with state and local governments in charge of implementation. 273. A national solid waste management strategy should clarify the roles of all key actors, including local governments, the private sector, NGOs, and informal sector workers. It should provide guidance on various aspects of solid waste management, such as separation at source, collection, transport, recycling, reuse, and disposal. It should also include provisions for the consolidation of private sector participation as a practical instrument for improving governance and financing in the solid waste management sector. 274. Solid waste management not to be included in the revised Sanitation MOU. In response to the query from the 2006 Joint Sector Review for Water and Sanitation, it is recommended that solid waste not be included in the revised Memorandum of Understanding. The mandates for solid waste at the national level are relatively clear and rest primarily with the National Environment Management Authority, with other bodies such as the Directorate of Water Development playing a regulatory role. At the national level, what needs to be improved is these agencies' regulatory and monitoring roles. 94 Table 6.2 Recommendations for solid waste management and drainage Implementing Issue Recommendation agencies Instruments Mandates for solid Prepare national solid waste management National Technical waste at the national strategy and financing strategy Environment assistance level are clear, but the Management through existing approach to Authority (NEMA); projects or solid waste Ministry of Local trust funds management in urban Government areas is ad hoc (MLG); Ministry of Water and Environment (MWE) Leadership on drainage MWE should take the lead on policy making and DWRM; NEMA; MWE to is lacking at the national strategy development with respect to drainage; NWSC; MWE; identify level Directorate of Water Resources Management MLG resources (DWRM) might assume this role; a working group on drainage should be formed, to include the DWRM, NEMA, the National Water and Sewerage Corporation (NWSC), and the MLG, to collaborate on and develop a joint strategy to support local governments in the management, upgrading, and maintenance of drainage Shortage of staffing for Increase staff capacity for addressing solid waste Urban Urban environmental and drainage authorities/KCC authorities/ sanitation exists in the KCC own Kampala City Council budget (KCC) and other urban settings Informality in Strengthen regulation; formalize contracts KCC and other KCC/urban contracting constrains between KCC and private operators for the urban authorities authorities' monitoring and collection and transport of waste; provide own budget supervision of private licenses to operators linked with realistic sector operators, performance indicators creating inefficiencies in service delivery Work of informal sector Revise the KCC solid waste ordinance KCC KCC own workers is not legally provisions on informal sector workers and budget recognized facilitate the organization of these workers into cooperatives Regulation on landfill Introduce regulation of landfill gases at the NEMA NEMA gases is not in place national level budget Enforcement of Improve enforcement; stronger political KCC and divisional KCC own Kampala solid waste leadership is needed to support enforcement of staff budget ordinance is poor bylaws and ordinances Monitoring of effluents Strengthen the regulatory role of NEMA and the NEMA; DWRM Own released into drains and MWE resources water bodies is poor Source: Authors' compilation. Note: Many of the recommendations that emerged from the Kampala case study are applicable to other municipalities as well. 95 275. Integrated budget line not to include solid waste. The inclusion of solid waste in the dedicated sanitation budget line would risk, once again, neglect of excreta-related sanitation and hygiene. Other funding mechanisms can be harnessed. Current World Bank projects are already supporting revenue generation from waste through the Clean Development Mechanism, and others are in preparation. Other options include taxes, user fees, and establishment of a municipal trust fund, as has been done elsewhere. 29 276. Drainage a possibility for the integrated budget line. Whether drainage should be included in the budget line needs to be further discussed. Poor drainage is closely linked with the water and health sectors. In Kampala, for example, urban drains carry effluents from pit latrines and the sewerage system, and the drainage eventually gets into Lake Victoria, where it degrades water quality and poses significant health risks for the surrounding population. Planning for drainage at the local government level has been greatly neglected. One reason for including drainage in the sanitation budget line (and in associated guidelines) would be to enable coordinated planning and budgeting for both excreta-related sanitation and drainage management at the local level. The risk of including drainage in the budget line is that it may cut into funding for excreta-related sanitation and hygiene. Clarify responsibility for drainage and establish a working group responsible for drainage at the national level 277. The policy-making function for drainage at the national level belongs to the Ministry of Water and Environment, but it is unclear which agency within the ministry has the lead role. The ministry should clarify this mandate and establish a working group, to include the Directorate of Water Resources Management; the National Environment Management Authority; the National Water and Sewerage Corporation; the Ministry of Works, which has a policy-making role in road construction; and the Ministry of Local Government, in view of its mandate to strengthen the capacity of local governments. The task of the working group would be to develop strategic guidance on drainage for municipalities and local governments. Build KCC and local government capacity for solid waste and drainage mandates 278. A major issue with the Kampala City Council is its limited human resource capacity for addressing mandates for solid waste and drainage. For instance, the sole staff member assigned to work on drainage was seconded to work on a separate project. Capacity in this area needs to be increased. Formalize relations with private sector stakeholders involved in the collection and transport of solid waste 279. Private sector operators play a significant role in solid waste collection and transport in Kampala, but many do not have formal contracts with the municipality. This makes it difficult for division-level staff who have the prime responsibility for collection and transport to supervise the work of private contractors, and it contributes to poor service delivery. Developing a framework for the private sector participation, formalizing these 29 See Becker 2007; Zhu et al. 2007. 96 contracts, and supporting greater transparency in access to the terms of the contracts by KCC and divisional staff would not only promote accountability but would also add to the city's revenue base because the contractors would then be paying taxes. 280. Consolidation of private sector participation should be part of a program for the commercialization of solid waste management service provision. A fully commercialized service would have several benefits: accounts related to solid waste management would be fully separated from local government, and value for money and accountability would thus improve; financing policy would be implemented according to explicit milestones in the improvement of services; private operators would be accountable to the contract management unit under well-defined contracts that included specific obligations; political interference would be minimized, as the commercial institution would be answerable to its board; and the arrangement would be better suited for handling contracts for projects for municipal composting and capture of landfill gases. Revise the KCC solid waste ordinance provisions on informal sector workers and facilitate organization of these workers into cooperatives 281. Although there is support among KCC and divisional staff for the Kampala solid waste ordinance, it has important shortcomings that need to be addressed. The ordinance should be revised to acknowledge the important contributions of informal sector workers. 282. Informal waste collection and recycling workers typically constitute 2 percent of the population of developing-country cities, yet in Kampala their vital services are often not recognized or adequately rewarded. KCC should support the formation of cooperatives of these workers so that they can have access to loans, health care, and training. Introduce regulation on landfill gases at the national level 283. At present, there is no regulation on exploitation of landfill gases. One should be put in place; here, too, NEMA can take a lead role. Improve enforcement of Kampala's solid waste ordinance 284. KCC's solid waste ordinance provides the legal basis for proper storage, collection, and disposal of waste. Nevertheless, because of lack of enforcement by KCC officials, there is rampant illegal dumping of garbage in nondesignated areas of the city. Stronger political leadership for enforcing the ordinance is needed. The city could hire day and night patrols to improve monitoring and enforcement, and divisional staff could help form community teams to assist enforcement. Strengthen the regulatory roles of NEMA and the DWRM 285. A critical issue is the monitoring of effluents released into major drainage systems. Given that NEMA and the DWRM have the primary responsibility for monitoring, their regulatory roles need to be strengthened. NEMA should be more active in coordinating the activities of the various donors involved in solid waste management. 97 Appendix A. Sanitation Memor andum of Under standing Uganda has one of the lowest access coverages for sanitation in the world, and the government has decided to address this embarrassing situation by setting targets and putting in place plans and strategies to rectify this situation. In order for the existing and new programs to be implemented successfully and meet the set targets, there is need for a clear institutional arrangement. Since the early 1980s, DWD/MWLE [Directorate of Water Development/Ministry of Water, Lands and Environment], in collaboration with EHD/MH [Environmental Health Division/Ministry of Health] and donors, have incorporated water-related sanitation activities as an integrated part of rural water and sanitation programs. The Water Sector Reform, undertaken by MWLE/DWD in collaboration with line ministries and local governments with support from donors, has prepared a 15-year strategy and investment plan for rural water supply and sanitation, where aspects of sanitation related to water supply provision are covered. The urban water reform proposal is that the water and sanitation services in the towns be integrated and managed together. At the moment there are unclear institutional arrangements for sanitation at the central level that hamper service delivery by the local governments. The approach in handling sanitation issues is not well defined, the water sector addresses some aspects and health sector addresses others. The issues even reached the cabinet level and it was agreed that the institutional responsibility for sanitation be clarified between Ministry of Health and Ministry of Water, Lands and Environment. In 2000, two meetings were held between the two ministries (MWLE/MH) at policy level (ministers) and technical level (permanent secretary and directors), but were not conclusive and the issue was referred to MFPED [Ministry of Finance, Planning and Economic Development] to organize another meeting. MFPED chaired meeting held on 23rd March 2001, attended by officials from MH, MWLE, MES [Ministry of Education and Sports], MGLSD [Ministry of Gender, Labour and Social Development] and MLG [Ministry of Local Government], that agreed on a common stand and way forward. The three ministries (MH, MWLE and MES) initiated efforts to resolve the issue and each of the 3 ministries prepared issue papers on sanitation that were presented at the First Joint Government of Uganda/Development Partners Review of Water and Sanitation sector in September 2001. There was consensus and recommendation that sanitation and hygiene promotion be given higher priority and that: Benefits from the investments in rural and urban water supply will not be fully realized if the health benefits are not obtained. More emphasis is needed on hygiene promotion for household sanitation, sanitation in schools and the special challenges of urban sanitation. Furthermore, it was agreed that the concerned ministries should formally certify the institutional anchorages and responsibilities, including prioritization of resources, for sanitation and hygiene promotion. The lead central level institutions for defining strategies and plans in specific areas of sanitation and hygiene promotion would be: MWLE for planning investments in sewerage services and public facilities in towns and rural growth centers; 98 MH for household hygiene and sanitation; and MES for school latrine construction and hygiene education. The mechanisms for cooperation and integration among line ministries need strengthening and elaboration. The undersigned certify their agreement to the above and agree to finalize putting in place institutional arrangements, including co-operation mechanisms and resources prioritization before 31st December 2001 (one of the undertakings from the Joint Government of Uganda/Donor Review). Signed: Permanent Secretary Permanent Secretary Permanent Secretary Ministry of Water, Lands Ministry of Health Ministry of Education and Environment and Sports Note: This appendix is an edited version of the Sanitation Memorandum of Understanding. 99 Appendix B. List of Stakeholder s Consulted and Inter viewed Name Title Organization Government Dr. Kenya Mugisha Director General of Health Ministry of Health (MH) Services Paul Luyima Assistant Commissioner, MH Environmental Health Sam Ahimbisibwe Health Educator MH Juliana Kyomhangi Senior Principal Health Inspector MH Justin Otai Senior Health Environmentalist MH Robert Odongo Senior Health Environmentalist MH Dr. Grace Mulindwa Planning MH Eng. Richard Cong Assistant Commissioner, Water Directorate of Water Development Liaison Unit (DWD) Eng. Aaron Kabirizi Assistant Commissioner, Rural DWD Water Benneth Hulterstrom Swedish International DWD Development Cooperation Authority (Sida) Adviser Mugeiga Kato Technical Support DWD Eng. Ian Arebahona Principal Engineer DWD Oketcho Pokomol Program Officer DWD Firmina Acuba Social Scientist DWD Malinne Blomberg Financial Management Adviser DWD Gilbert Kimanzi Principal Engineer DWD Paul Bisoborwa Sociologist DWD Christopher Tumusiime Acting Assistant Commissioner, DWD Planning and Development-- Urban Water Collins Amanya Social Economist DWD Daudi Mukama Technical Support DWD Julia Kamaraa Social Scientist DWD Stanley Watenga Focal Point Person, Technical DWD Service Unit (TSU) 5 David Mukama Public Health Specialist, TSU 7 DWD Jennifa Aanyu Public Health Specialist, TSU 3 DWD Kalinaki Shaban Public Health Specialist, TSU 4 DWD Santa Ojok Senior Education Officer Ministry of Education and Sports (MES) Martin H. M. Mugoya Assistant Commissioner, Primary MES Education Emmanuel Araali Kusemererwa Principal Education Officer MES Eng. Andrew Kizza Assistant Commissioner, Ministry of Local Government Inspection Department (MLG) Eng. Paul Kasule Mukasa Local Government Development MLG Program (LGDP) Program Coordinator Adam Babale Principal Economist Local Government Finance Commission Gerald Sawula Deputy Executive Director National Environment Management Authority (NEMA) 100 Lydia Biribonwa Senior Environmental Inspector NEMA Persis Basemera Environmental Education Officer NEMA Margret Lwanga District Support Coordinator NEMA Mohammed Kirumira Chief Health Inspector Kampala City Council (KCC) David Kiggundu Tamale Project Coordinator Kampala Institutional and Infrastructure Development Program, KCC Eng. Maurice Kairaniya Solid Waste Engineer KCC Eng. Michael Mudanya Solid Waste Engineer KCC Phoebe Gubya Environment Officer KCC Samuel Ali World Bank Project Accountant KCC Edward Mukalazi Project Engineer, Drainage KCC Jerry Garvey Technical Adviser, Kampala KCC Integrated Environmental Planning and Management Project (KIEMP) Helen Obuya Community Development KCC Specialist, KIEMP Namuteesa Suzan Health Inspector, Nakawa KCC Division Stephen Gwojolonga Assistant Solid Waste Engineer KCC, Central Division Ernest Nabihamba Principal Production and Jinja Municipal Council Environmental Officer Eng. P. Twesigye Project Manager, Planning and National Water and Sewerage Capital Development Dept. Corporation (NWSC) Emudong Silver Manager, NWSC, Soroti NWSC Dorothy Kobel Principal Engineer NWSC Hon. Syda N. M. Bumba Minister Ministry of Gender, Labour, and Social Development (MGLSD) Stephen Kasaija Assistant Commissioner, MGLSD Planning Elizabeth Kyasiimire Commissioner, Social MGLSD Development Osinde Owor Acting Assistant Commissioner, MGLSD Community Development Department Yosa Manasa Kazimoto District Health Inspector Ministry of Health, Mukono District Kato Semugera District Health Inspector Ministry of Health, Wakiso District Dr. Robert Mayanja District Health Officer Rakai District Local Government Kaddu Lubega District Health Inspector Rakai District Local Government Bamuloba Mizamiru Deputy District Health Inspector Rakai District Local Government Tumusiime Janal Member, Sanitation Group, Rakai District Local Government Botela Teddy TerNalukwata Member, Sanitation Group, Rakai District Local Government Botela John Musisi Member, Sanitation Group, Rakai District Local Government Botela Lwanga Member, Sanitation Group, Rakai District Local Government Botela Molly Namagembe Secretary for Community Lyantonde District Local Govt. Development Violet Namara Deputy Speaker Lyantonde District Local Govt. 101 G. Igga Assistant Chief Administrative Lyantonde District Local Officer Government Dr. G. Katumba. District Health Officer Lyantonde District Local Government Francis Kiwanuka District Water Officer Lyantonde District Local Government E. Karashote District Health Inspector Lyantonde District Local Government Ifraim Kamugisha Member, Buyanja Sanitation Lyantonde District Local Group Government Jane Namatovu Member, Buyanja Sanitation Lyantonde District Local Group Government Edwin Baijuka Member, Buyanja Sanitation Lyantonde District Local Group Government Joseph Kisakye Town Health Inspector Luwero Town Council Isaac Kakooza Acting Manager, Luwero Water Luwero Town Council Supply Authority Jan Michael Mock Technical Adviser, German Luwero Town Council Development Service (DED) Kakande Musa Health Assistant Luwero Town Council Sendagire Gitta Examiner of Accounts Luwero Town Council P. Mukasa Community Member, Luwero Luwero Town Council Central G. Lutwama Community Member, Luwero Luwero Town Council Central Grace Kimuli Community Member, Kakookolo Luwero Town Council Village Agnes Nantongo Community Member, Kakookolo Luwero Town Council Village Ruth Nanteza Community Member, Kakookolo Luwero Town Council Village F. Drokede Principal Medical Officer Soroti Municipal Council Christopher Okiror Principal Health Inspector Soroti Municipal Council Stephen Eron Principal Education Officer Soroti Municipal Council Prossy Nanyolo Health Inspector Soroti Municipal Council C. Elongot Environment Officer Soroti Municipal Council Osidak E Aporu Head Teacher, Pioneer Primary Soroti Municipal Council School Peter Okoboi Community Member, Cell I Soroti Municipal Council Stephen Okias Community Member, Cell I Soroti Municipal Council Nathan Opolot Community Member, Cell I Soroti Municipal Council Akiteg Annet Community Member, Cell I Soroti Municipal Council Christine Apio Community Member, Cell I Soroti Municipal Council Chris Nsubuga National Coordinator National Hand-Washing Campaign George Serunjogi Principal Finance Officer Ministry of Finance, Planning, and Economic Development (MFPED) Gustavio O. Lujwero-Bwoch Accountant General MFPED Ishmael Magona Commissioner, Infrastructure and MFPED Social Development Margaret Kobusingye Desk Officer, Water and MFPED Sanitation John F. S. Muwanga Auditor General Office of the Auditor General Aloysius Mayanja Director of Audit Office of the Auditor General 102 Joel Kiwanuka Senior Social Scientist Ministry of Water and Environment Samuel Mabala Acting Commissioner, Urban Ministry of Land, Housing and Development. Urban Development (MLHUD) Abubaker Muhammad Moki Head of Policy Analysis Unit MLHUD Henry Harrison Irumba Senior Policy Analyst MLHUD Katsigaire Savino Acting Commissioner, Physical MLHUD Planning Tom Wanyakala Personal Assistant to Minister MLHUD Abby Iga Assistant Commissioner, District Ministry of Local Government Urban Authority Development partners Robert Burtscher Program Officer, Water and Embassy of Austria Sanitation P. Kamuhangire Water and Sanitation Expert African Development Bank Adam Babale Consultant African Development Bank P. Oketcho Social Specialist African Development Bank Grace Waako Katuramu Program Officer Danish International Development Agency Patrick Okuni Program Officer UNICEF John Byarugaba Executive Director Uganda Water and Sanitation NGO Network (UWASNET) Alex Muhumuza Mbaguta Program Officer UWASNET J. Smet Senior Program Officer International Water and Sanitation Research Centre James Gibson Program Support Manager PLAN International John Odolon Senior Urban Officer PLAN International Yunia Musaazi Head of Advocacy and WaterAid Communication Yiga Baker Matovu Program Officer WaterAid Abe Ssonko Director and Project Manager Nabugabu-Updeal Joint Venture Ina Jurga Technical Adviser EcoSan German Development Service Terry Lawrence Consultant U.K. Department for International Development (DFID) Capacity Assessment Bank Robert Atkins Consultant DFID Capacity Assessment Bank Archana Patkar Consultant DFID Capacity Assessment Bank Brendan Doyle Consultant DFID Capacity Assessment Bank Bea Parkes Governance Adviser DFID Anthony Waterkeyn Consultant DFID Fred Nuwagaba Program Officer German Agency for Technical Cooperation--Reform of the Urban Water Sector Julian Kyomuhangi Senior Principal Environmental Water, Sanitation, Hygiene Health Officer Campaign Fulgensio Jjuuko Executive Director Community Integrated Development Initiatives Mohammed Kawere Director Urban Community Development Association Anna Kristina Mayr Technical Assistant, Water Sector John Kisiga Program Coordinator Kasubi Community Development Association World Bank Maria Jacobson Associate Expert Water and Sanitation Program-- 103 Africa, World Bank Martin Onyach-Olaa Urban Specialist World Bank Patrick Umah Tete Senior Financial Management World Bank Specialist 104 Appendix C. Guidelines for Sector Conditional Gr ants Appendix table C.1 Conditional grants and main features of implementation guidelines Conditional grant Key features of the implementation guidelines Universal The district education officer should agree with schools on the expenditure of the primary UPE grant budget on the following components: education Extra-instructional/scholastic materials (UPE)a Co-curriculum development School management Administration. Schools have discretion to keep up to 20 percent of the money for contingency expenditures. The other expenditures must focus on the teaching and learning process. District In accordance with the Decentralization Statute of 2000, 65 percent of all grant water and funds must be allocated to subcounty local government. This is to enable investment sanitation decisions at the district level to be driven by investment priorities, including low- conditional cost technology options, at the subcounty level. grant (DWSCG)b The DWSCG may be allocated as follows: Rural water supply facilities: not less than 70 percent Software activities for rural water supply and sanitation: up to 12 percent Rehabilitation of boreholes and piped water schemes: up to 8 percent Construction of sanitation facilities: up to 6 percent Supervision, monitoring, and district water office operational costs: up to 4 percent. Software activities for rural water supply and sanitation: local governments may use up to 12 percent of the total budget for software activities, including hygiene education. The steps consist of four phases: general planning and advocacy; preconstruction mobilization and training; construction; and postconstruction support. Details of these activities are set out in the document "Steps in Implementation of Water and Sanitation Software Activities," issued by the Ministry of Water and Environment, Directorate of Water Development, in 2005. Construction of sanitation facilities: Districts are advised to budget up to 6 percent of the DWSCG for the planning and provision of sanitation and hygiene facilities in rural growth centers and public places. Primary Guidelines for allocation: health care Procurement of drugs and other supplies for health centers II, III, and IV: 50 conditional percent grant Operation of the district health office: 9 percent (nonwage)c Operation of health subdistrict and health centers: 41 percent. The detailed allocation of the 41 percent is at the discretion of the district health team. Activities to be undertaken are as follows: Health subdistrict level: support supervision, planning and budgeting, preparation of reports and budgets, and liaison with the district director's office Health center level: outreach, transport (fuel and maintenance of vehicles), facility and property costs (maintenance of buildings and minor repairs, compound, utilities, stationery, maintenance of equipment, purchase of charcoal and kerosene). a. Ministry of Education and Sports, "Universal Primary Education (UPE) Capitation Grant: Planning and Implementation Guidelines for District and Urban Councils; May 2007," 5. The UPE replaces the school facilities grant (SFG). b. Ministry of Water and Environment, "Water and Sanitation Sector: Sectoral Schedules/Guidelines 2007/8, December 2006," 9. c. Ministry of Health, "Financial Year 2007/08 District Transfers for Health Services," July 2007, 1. 106 Appendix D. Revenues of Local Gover nments Appendix table D.1 Main sources of own revenue for local governments, by fiscal year Revenue source 1999/2000 2000/01 2001/02 2002/03 2003/04 2004/05 Amount (million Ugandan shillings, current prices) Graduated tax 71,056 68,009 54,504 51,779 46,601 0 Property tax 10,264 6,586 14,266 13,552 13,552 13,552 User fees and charges 16,239 11,868 19,401 18,431 18,431 18,431 Licenses 3,342 1,949 3,729 3,542 3,542 3,542 Other revenue 9,846 20,975 12,912 12,267 12,267 12,267 Total 110,748 109,388 104,812 99,571 94,393 47,792 Percent of total revenue Graduated tax 64.2 62.2 52.0 52.0 49.4 0.0 Property tax 9.3 6.0 13. 13.6 14.4 28.4 User fees and charges 14.7 10.8 18.5 18.5 19.5 38.6 Licenses 3.0 1.8 3.6 3.6 3.8 7.4 Other revenue 8.9 19.2 12.3 12.3 13.0 25.7 Total 100. 100 100 100 100 100 Amount (million U.S. dollars) Graduated tax 44.7 38.2 31.5 29.9 26.0 0.0 Property tax 6.5 3.7 8.2 7.8 7.6 7.8 User fees and charges 10.2 6.7 11.2 10.7 10.3 10.7 Licenses 2.1 1.1 2.2 2.0 2.0 2.0 Other revenue 6.2 11.8 7.5 7.1 6.8 7.1 Total 69.7 61.4 60.6 57.6 52.7 27.6 Source: Local Government Financing Commission, own estimates for 2003/04­2004/05. Note: U.S. dollar amounts are at the rate of exchange for the given year: 2000 2001 2002 2003 2004 2005 U Sh/US$ 1,590 1,782 1,730 1,730 1,791 1,729 107 Appendix table D.2 Central government and own sources of funding of local governments, by fiscal year Central government transfers Local government Fiscal Total own Total year Unconditional Equalization Conditional transfers funding funding Million Ugandan shillings 1999/2000 66,620 2,000 261,481 330,100 110,748 440,848 2000/01 79,138 4,000 418,842 501,980 109,388 611,368 2001/02 73,343 4,400 537,257 615,000 104,812 719,812 2002/03 77,436 4,334 588,178 669,949 99,571 769,520 2003/04 82,797 3,534 655,136 741,467 94,393 835,861 2004/05 87,530 3,535 714,483 805,547 47,792 853,340 Percent of total 1999/2000 15.1 0.5 59.3 74.9 25.1 100.0 2000/01 12.9 0.7 68.5 82.1 17.9 100.0 2001/02 10.2 0.6 74.6 85.4 14.6 100.0 2002/03 10.1 0.6 76.4 87.1 12.9 100.0 2003/04 9.9 0.4 78.4 88.7 11.3 100.0 2004/05 10.3 0.4 83.7 94.4 5.6 100.0 Million U.S. dollars 1999/2000 41.9 1.3 164.5 207.6 69.7 277.3 2000/01 44.4 2.2 235.0 281.7 61.4 343.1 2001/02 42.4 2.5 310.6 355.5 60.6 416.1 2002/03 44.8 2.5 340.0 387.3 57.6 444.8 2003/04 46.2 2.0 365.8 414.0 52.7 466.7 2004/05 50.6 2.0 413.2 465.9 27.6 493.5 Source: Local Government Financing Commission, fiscal databank. Appendix table D.3 Allocation of sanitation budget, by subsector and by fiscal year (million Ugandan shillings) Total, 1998/99 1999/2000 2000/01 2001/02 2002/03 2003/04 2004/05 2000/05 Piped sewerage 2,356 2,517 2,569 2,042 2,209 2,147 2,663 11,630 School latrines 2,850 4,666 8,862 4,622 4,045 4,045 4,045 25,619 Other latrines 5,633 4,410 4,571 5,114 1,939 1,713 1,669 15,006 Hygiene promotion 3,245 3,180 3,870 3,343 3,096 3,774 4,782 18,865 Institutional support 251 241 665 438 1,193 888 889 4,073 Solid waste and drainage 250 250 250 250 250 250 250 1,250 Total estimated expenditure 14,585 15,264 20,787 15,809 12,732 12,817 14,298 76,443 Source: Uganda 2005d. 108 Appendix table D.4 Sanitation budget, by institution and by fiscal year (million Ugandan shillings) Total, 1998/99 1999/2000 2000/01 2001/02 2002/03 2003/04 2004/05 2000/05 Directorate of Water 7,464 6,808 11,091 5,585 1,753 1,193 1,663 21,285 Development Ministry of Health 1,727 1,717 2,141 1,914 2,341 3,048 3,544 12,988 Ministry of Education and 975 2158 2912 4185 4345 4345 4345 20,132 Sports National Water and Sewerage 2,356 2,517 2,559 2,022 2,189 2,127 2,643 11,540 Corporation Local Government Development 0 0 20 40 40 40 40 180 Program Local governments 250 250 250 250 250 250 250 1,250 Nongovernmental 1,814 1,814 1,814 1,814 1,814 1,814 1,814 9,070 organizations Total estimated 14,586 15,264 20,787 15,810 12,732 12,817 14,299 76,445 expenditure Source: Based on Uganda 2005d. 109 Bibliogr aphy Advani, R. 2008. 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