Integrating Hygiene and Basic Sanitation into Conditional Cash Transfer Programs

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The seminar will examine the widely neglected and underestimated adverse nutritional impact of lack of safe water, sanitation and hygiene (WASH). It makes apparent how governments struggling to feed their citizens can make a substantial contribution to food and nutrition security by making WASH investments. Reducing faecal infections through sanitation and hygienic behaviour is a major means for reducing the undernutrition of children, enhancing the wellbeing of children, women and men, and achieving the MDGs. Approaches for scaling-up WASH like Conditional Cash Transfers (CCT) as well as approaches to improve food and nutrition security through productive sanitation will be presented using regional case studies. Together with the participants the potentials and challenges of these approaches will be discussed in rotating discussion groups facilitated by distinguished sector experts. The goal is to get an in-depth understanding of this neglected link and to provide constructive impulses for promising ways forward to strengthen this nexus at scale and push towards fulfilment of the human right to water and sanitation. This seminar was part of World Water Week, 2012.

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Integrating Hygiene and Basic Sanitation into Conditional Cash Transfer Programs

  1. 1. Integrating Hygiene and Basic Sanitation intoConditional Cash Transfer ProgramsJuan Costain and Almud WeitzWSPStockholm World Water Week, August 29 2012
  2. 2. Conditional Cash Transfers – Concept• Cash incentives for the poor• To remove demand-side constraints• Education: transport, uniforms• Health and Nutrition: transport, food• Supply available, or can be induced throughdemand side• Long-term interventions• Dual objective:• Alleviate current poverty• Induce behavior change
  3. 3. CCT Design: Key Questions• What are key constraints fordesired results by target group?• What are private costs forcomplying?• What subsidy amount would‘make a difference’?• How can conditions be monitoredand at what cost?Two basic CCT systems:• Targeting households/families(most common)• Targeting communities
  4. 4. Why Do We Care About CCT Programs?• Traditional financing not sufficient in advancingsanitation• Help align incentives in sanitation markets and fostermore efficient and equitable service delivery• Can foster better poverty targeting• Potential to reinforce impact on malnutrition/stunting:• impact evaluations: overall level of consumptionand composition of consumption positivelyaffected• evidence that hygiene and sanitation goodpractice could increase nutritional impact/reducestunting further
  5. 5. CCTs Spread Rapidly Over Past Decade
  6. 6. CCTs Spread Rapidly over Past DecadeOver 30 countries with CCT programs
  7. 7. Country Example 1: Peru• Rural chronic malnutrition has not improved in linewith poverty rates and access to sanitation (10%versus 15-17%)• Suggesting that either the infrastructure investmentin sanitation is not the right one (latrine) nor it isused by the people servedPopulation: 30 millionUrbanization: 76%Economic growth: 6.9%Poverty rate: 31%, rural: 56%GDP/capita: $5,463
  8. 8. Household CCT Program: JUNTOS in Peru• Annual budget: USD 400 million(0.23% of Perus GDP)• Coverage: 700 district in 14regions (out of 25)• 500,000 beneficiaries• 1.7% of total population• 27% of extremely poor• Impact evaluation• chronic malnutrition reduced from28.5% in 2007 to 23.2% in 2010
  9. 9. Entry Points for Sanitation in JUNTOS ProgramCCT TargetHouseholdsMinistry ofDevelopment andSocial InclusionSanitation providersMinistry ofHousing andSanitationRegionalMulti-stakeholderPlatformsResources for co-financing sanitationfacilitiesLocalGovernmentComplianceverificationof householdsbehaviors andprovidersperformanceJUNTOSCCT ProgramResources for householdsincentivesDelivery of non-transferable couponto purchase certifiedsanitation facilityaccording to demandexpressionPost installationcash incentiveconditional to goodpractices (hygiene,use and maintenanceof services)Strengthening demand creation andpost installation behaviorsPrivate sanitation supply throughexisting public programsAgreement collaborativework on key issues
  10. 10. DemandSanitation promotionCommunity mobilizationInformation & counselingNon-transferable couponto purchase certifiedsanitation facilityPost installation cashincentive conditional togood practicesIndividualSanitation and hygieneawarenessHouseholdWillingness to demand /purchaseCommunityLocal leader trainedIndividualUse of sanitationfacilityHand washing withsoapHouseholdClean sanitationfacilityHouse defecationfree (clean floor)CommunityOpen defecationfreeChronicMalnutritionHeight-for-agein 0-24 monthschildrenWhere Are We? Strategic ApproachIntervention strategy Intermediate results Behavior results Health impactSupplyTraining and certificationby Ministry of SanitationBusiness model forsanitation (package ofgoods and services)Sanitation providerOffers catalogue of certifiedsanitation facilitiesLocal GovernmentCapacity for complianceverificationDemandedsanitationInstalledsanitationBottlenecks at local levelAssure articulated intervention in a localityLocal prioritiesAssure complemented interventions (solid waste)
  11. 11. Population: 240 millionUrbanization: 54%Economic growth: 6.1%Poverty rate: 13.3%GDP/capita: $2,945Access to Sanitation: 130 millionUrban: 73% Rural: 39%Open Defecation: 63 millionUrban: 18% Rural: 40%Stunting under five: 35.6%Country Example 2: Indonesia
  12. 12. • Annual budget: USD 55.5 million• Coverage: 3, 755 villages in 370 sub-districtsof 8 provinces• 12 education (4) and health (8) indicators• Impact evaluation:• Main long-term impact decrease in childmalnutrition (10% from baseline)• More pronounced in areas with lowbaseline indicators• Making grants conditional uponperformance improves programeffectiveness in health• e.g. , 19.2% decline in severe stunting in NTTprovince in Eastern IndonesiaCommunity CCT Program:“Healthy and Smart Generation” in Indonesia
  13. 13. Improve growth and reduce stuntingInterventionsWhat can be done to prevent stunting ?Poor MaternalNutrition & LBW0-6 mos: PoorBreastfeeding7-24 mos: PoorWeaning, Morbidity,Micronut. DeficiencyHygiene &SanitationSERVICE PROVISION:complete pre-natalcare– 4 visits– nutrition counseling– Fetal & maternalgrowth monitoring– Micronutrientsupplements–Full immunizationCOMMUNITY ACTIVITIES– Awareness raising– Increased participationand use of MCHservices– Removal of barriers toservice use– Parental education– Supplementary feedingfor insecure regionsSERVICE PROVISION– Growth promotion(height and weight)– Immunizations– Counseling formothers; hygiene– Training for serviceproviders on-site– Standardized protocolto manage growthCOMMUNITY ACTIVITIES– Awareness raising– Increased use of MCHservices– Removal of barriers toservice use– Parental education(family planning, earlychildhood educationpractices)SERVICE PROVISIONGrowth promotion(height and weight)– Immunizations– Provision of micronut.– Counseling for mothers– Training for serviceproviders on-site– Standardized protocolto manage growth– Treatment protocol– DewormingCOMMUNITY ACTIVITIES– Awareness raising– Increased use of MCHservices– Removal of barriers toservice use– Parental education– Supp. feeding (insec.)SERVICE PROVISION :Sanitation marketing –approach- Formative marketresearch- Behavioral changecommunications menu- Training of sanitationentrepreneurs- Training of villagemasonsCOMMUNITY ACTIVITIES(STBM)- Training of STBMfacilitators- STBM intervention athamlet- Piloting reward andrecognition system- ODF monitoring systemJoining Forces: “Generasi Plus”
  14. 14. Challenges for Merging Interventions• At political level– Multi-sector collaboration: common approach,common language• At strategic level– conditionality or incentives?– centralized and decentralized interventions– targeted grants or whole communities?• At intervention level– Bottlenecks at local level: weak supply side, overloadedfacilitators– Sequencing of interventions

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