Over the past 5 years, we have seen tremendous growth of China. China is now the world’s largest economy and the Chinese government should be proud of implementing such effective and forward-thinking policies. China is now at a crucial turning point, where our policy choices will determine if we will maintain our current economic authority. In order to succeed, China must balance solely economic gains with the international image projected by government actions in order to maintain this growth and current economic standing.
We appreciate that you have identified sanitation as a key pathway to improve china’s economic prosperity and building global partnerships. After all, by improving sanitation, you begin a cascade of effects that improves health, human capital, saving opportunity costs, increasing productivity, bettering labour, education and the environment. These factors all lead to economic prosperity. However, the extent to which this prosperity can be achieve depends on China’s approach and delivery of foreign aid for this project. ==== Sanitation is a catalyst for economic prosperity 1.2 Billion practice open defecation (OD)
As Sanitation is is a We acknowledge that you have a variety of geographic options and technologies to choose to invest in. We as a consortium of experts have analyzed various factors to provide the most optimal solution for china’s prosperity. World map with wihout colour – add a question mark, (find the map with checkmarks removed for places visited)
SE Asia has been identified as the region with the highest potential benefit to china. World map with wihout colour – add a question mark,
There is a myriad of reasons for investment in this region, particularly economic and soft power . Political interest - Historically, there have been contentious relationships between China and SE Asian countries as well as between the countries. Therefore China must refocus and build amicable relationships with these countries to improve regional stability. Regional Stability – Part of building regional stability is to build alliances with neighboring countries and improve relationships and curb American influence International reputation – moving away from the criticism of controversial investments of countries engaged in human rights violations (i.e. countries in Africa) Economic interdependence – for many of these countries, china is not the preferred trade partner Access to natural resources Established infrastructure - selected regions have underlying infrastructure to facilitate success. Geographical proximity– counting reduced travel costs for trade, agricultural tranpsortation, and reducing environmental impact. etc. Economic – there is a 1.8T trade between ASEAN and China. Growing population Increasing purchasing power Need for sanitation improvement Similar rural urban divide to China Relative cultural similarity – compared to the rest of the world
Rural-Urban divide -it is important to address equity in access to improved sanitation -there is huge gap in access to sanitation between rural and urban populations, and it is important that we address this given China’s priority of balancing rural-urban development Within SEA, the countries with the greatest need of improved sanitation are Cambodia, Indonesia and Timor Leste Here the access to improved sanitation is as follows: XXXXXXX Between these 3 countries, there are 93 million people without access to improved sanitation in rural areas – meaning they practice open defecation or use shared or open latrines.
There are huge repercussions due to the lack of sanitation in these countries. As calculated by WSP, Combined, these nationshave an economic loss of $6B per year. This loss is from factors such as the health impacts of diarrheal and other diseases which lead to increased morbidity and mortality, the opportunity costs from lost productivity in both the work force and education, the pollution of water supply and land area, as well as decreased tourism. Taking into consideration this loss, we have calculated the increase in bilateral trade between China and these nations if this economic loss was eliminated – if 100% improved sanitation was achieved. An increase of $240m in bilateral trade. This is a very conservative estimate as it does not account for the exponentially improving prosperity that can be afforded to the people of these countries due to the improved access to education and potential job and financial success of children with improved health.
Lots of choices with pictures, and question mark. Which technology will we choose? Secondly, how will it be implemented.
Diagram instead of words Sanitation intervention + empowerment = adoption A great deal of evidence suggests uptake of sanitation intervention requires not only the provision of technologies, but also empowering communities to take ownership over their own sanitation regimes. Community led total sanitation (CLTS) is a behavioral approach in addressing open defecation in many communities. CLTS is a sustainable approach that focuses on behavioral change through the education of community about the importance of sanitation and handwashing, and shaming of unhygienic practices such as open defacation. CLTS uses shaming as a mechanism to stop unhygenic practices through a 4 step ladder approach. 1) First, there is pre-triggering, which involves the selection of communities, and introduction of a trained experienced facilitator, who is often a member of the community and can even be elected by his or her peers, (similar to the selection of a Community Health Worker). 2) Triggering, is when the community realizes that the unhygienic practices are unacceptable. Participatory sanitation profile analysis: the community maps out where open defecation occurs through a walking tour and analysis. 3) Post-triggering is the phase that involves action planning by the community where they make decisions on how to eliminate open defecation as a group. When these three steps are followed, CLTS can effectively mobilize communities toward healthy behaviour changes.
As noted, we have just described CLTS as generating the demand in communities who have yet to adopt sanitation practices. To maximize potential gains in sanitation, you have to consider both the demand for sanitation and supply of appropriate technologies.
common conventional approaches for waste management are not necessarily environmentally friendly. Looking at the conventional approach illustrated here, waste that is not handled hygienically contaminates surrounding water and land masses. Ecological sanitation on the other hand has been introduced, as a means to harness the nutrients within waste as a natural fertilizer for agriculture, increasing food production, thus improving household food security for various populations. Werner 2009: Moving away from the premise that excreta is waste, and waste is to be disposed of - In nature however, there is no waste. All products of living things are used as raw materials by others as part of a cycle – reframe to waste as a resource that should be made available for reuse Disadvantages of current: Unsatisfactory purification or uncontrolled dis- charge of more than 90% of wastewater worldwide Pollutionofwaterbodiesbynutrients,hazardous sub-stances, pathogens, pharmaceutics, hormones, etc. •Severe environmental damage and eutrophication of the water cycle Consumption of precious water for transport of waste High investment, energy, operating and maintenance costs Frequent subsidisation of prosperous areas, and neglect of poor settlements Loss of valuable nutrients and trace elements con- tained in excrement through their discharge into water bodies Predominance of combined central systems, result- ing in problems with contaminated sewage sludge Advantages of ecosan: • Improvement of health by minimising the introduc- tion of pathogens from human excrement into the water cycle • Promotion of recycling by safe, hygienic recovery and use of nutrients, organics, water and energy • Conservation of resources (lower water consump- tion, chemical fertiliser substitution, minimal water pollution) • Preference for modular, decentralised partial-flow systems for more appropriate cost-efficient solutions • Possibility to integrate on-plot systems into houses, increasing user comfort, and security for women and girls • Contribution to the preservation of soil fertility • Promotion of a holistic, interdisciplinary approach (hygiene, water supply and sanitation, resource con- servation, environmental protection, urban planning, agriculture, irrigation, food security, small-business promotion)
There are many EcoSan technologies that can be implemented depending on the context. Replace with pictures. Description in the appendix. Sophistication from small (left) to large (right) (Werner, 2009) whilst often making treatment easier and less expensive, the separate collection and treatment of the flow stream is not a prerequisite in ecosan systems, and ecological sanitation is also possible in centralised and combined flow systems. Double vault means two side by side that you rotate through on a yearly basis to allow for composting time The urine is collected in a 200 L container and is added, after six months of storage, to compost heaps of biodegradable and organic materials. It adds nitrogen to the garden compost and accelerates the decomposition process. Urine is also used as a side-dress fertilizer after diluting it with water before soil application. Faeces stay in the first chamber for twelve months to kill the pathogens while the other chamber is being used. The treated faeces are used as a soil conditioner. Before this project, the allotment gardeners used to buy expensive animal manure (chicken dung) – now they can use free human manure. yield increases of 13 % for urine-fertilised sweet corn were recorded compared to non-urine fertilised sweet corn. Confirm if the following are in the countries: sweet corn, bougainvillea, euphorbia, santan and coppea, palms and mango seedlings (Rud & Munch) - The recovery of energy through the anaerobic digestion of faeces, organic waste and animal manure can provide biogas for cooking, lighting, heating or electricity generation. - Example in Phillipines – peri-urban setting - Minimum eight families per vegetable garden - UDD toilets - Human excreta collected from toilet can be integrated as raw material for their compost - This project shows how urban agriculture and reuse-oriented sanitation can be combined to improve food security (Miso, 2007).
CLES is the merge of both demand and supply for improved sanitation outcomes. C.L.E.A.N. Communiyt Led Ecosan Approach Network
To implement CLES, CLES Is similar to CLTS in approach, from pre-triggering, and triggering steps. However, instead of the post-triggering step, we introduce EcoSan technology to the community who develops a plan and requests funding for the materials they need to implement CLES technology. The project rollout will involve funding, building, and adoption of EcoSan technology, as well as ongoing progress reports. The provision of materials includes the purchase of materials from China, which enhances China’s export-oriented industry. Continuous Monitoring & Evaluation involves reporting and adaption as necessary, with participation from the community. University evaluators/partnerships Stakeholders meetings – facilitators themselves, UN and university partnerships Evaluation starts at the beginning with a baseline survey.
We have a great deal of evidence for community-led total sanitation, and EcoSan technologies independently, however we will need to invest in building the evidence base for C.L.E.A.N., our proposed combined approach. Therefore, in each target country, it will be important to closely monitor and evaluate progress towards sanitation targets. We have developed an evaluation template to be adopted by each country. Evaluations must follow a longitudinal, prospective design whereby a mix of both qualitative and quantitative methods are used to monitor process and impact of C.L.E.A.N. interventions. -Must collect data for variables in each of 4 categories: - acceptability of the intervention - health impact - cost effectiveness - environmental impact - Changes in stock levels of ORS/other anti-diarrheal meds in local shops (another way to capture changes in diarrheal disease)
Usually, NGOs conduct evaluations internally, often with limited funds and varying degrees of scientific input. We propose to invest in building networks of academic institutions to ensure the highest quality evaluations with as much scientific rigor as possible. Further, evaluations of sanitation interventions have been compromised by methodological challenges, such as: A lack of adequate control groups Difficulty accounting for/measuring confounding factors Failure to tease apart effects of age, income and gender Utilizing a RCT design would address these concerns. By randomly allocating the interventions to villages within each region at the implementation phase, the influence of confounding factors is minimized. By fostering strong partnerships with top universities in each country, the design and implementation of scientifically rigorous evaluations will be more feasible.
It is in China's best interest because it creates cohesion and collaboration within the region leading to increased soft power
“ Yunnan lags in access to improved sanitation and faces significant chal- lenges in catching up with the pace of development in eastern provinces.”
The leverage reputational advantage, with philanthropy, but potential exponential increase with the ripple effect, building massive reputation and finances.
“ Yunnan lags in access to improved sanitation and faces significant chal- lenges in catching up with the pace of development in eastern provinces.”
We have identified three nations that are of particular interest, which have the greatest number of people without access to improved sanitation. They are the Kingdom of Cambodia, 4th most populous country, Indonesia, and newly independent and resource-rich Timor Leste. (proportionately) There are 260 million people in these three countries. In each country, there is a great disparity between rural and urban population, particularly, with respect to access to sanitation. 80% of rural cambodia, 61% of indonesia, and 63% of timor leste practices open defecation or exposed and public latrines, which are less than ideal. We want improve quality of life in rural areas to curb the rate of urbanization which has negative implications for the environment, economy, and for population health. What are they using now: Open defacation 60-80% equals 93 Million people without access to improved sanitation in the rural regions
Using CLES as a framework, stakeholders need to be engaged at multiple levels from micro to macro levels. Bottom two levels – emergence of national leaders -> community consultants Also consider: line ministries, decentralized government, communities, households, commercial operators (Economics-of-Sanitation-Initiative-in-Southeast-Asia) “ Economic growth and welfare depends on productive capital, infrastructure, human capital, knowledge, total factor productivity and the quality of institutions” (Foreign Investment CBA guide2008_en)
While CLTS does a great job of igniting changes in sanitation behaviors, it is not without its pitfalls. For example, this approach does not focus on the supply of sanitation technologies, such as toilets. KRISTY and ANJUM THERE ARE OTHER THINGS TO ADD HERE.
*** implementation stage: randomize the three intervention types to villages (this is facilitated by regional stakeholders)
EcoSan focuses only on the supply side, and does not focus on community engagement, thus it is not a comprehensive approach to community sanitation
University of Toronto: Emory Global Health Case Competition
C.L.E.A.N.The Key to Sustainable Total Sanitation Team 19 Kristy Hackett Samantha Kearney Theresa Lee Nicole Lipana Julia Roy Anjum Sultana S
Can Global Sanitation 2020 Contribute to China’s Prosperity? ?
Catalyst for economic prosperity Improve health Human Environment capital Sanitation Opportunity Education cost Labor Productivity
Why South East Asia?S Economic Gains S Soft Power S Growing population S International reputation S Increasing purchasing power S Political interest S Geographical proximity S Economic interdependence S Regional Stability S Access to natural resources S Need for sanitation S Established infrastructure improvement S Similar rural urban divide to China S Relative cultural similarity
Cambodia, Indonesia, Timor LesteS Rural/Urban Divide S Disproportionate access to improved sanitation S Cambodia – 20% vs. 73% S Indonesia – 39% vs. 73% S Timor Leste – 37% vs. 73%S 93 Million people in rural areas
Economic Cost :: Sanitation Cambodia, Indonesia China Timor Leste S US $6.2 Billion loss due to lack of sanitation  S China’s bilateral trade with these countries will increase by S Health US $240 million per year if universal sanitation coverage is S Productivity (Labor, education) attained S Environment (water, land) S Tourism Water and Sanitation Program (2008)
Step 1: Community Engagement (Create Demand) S Community-Led Total Sanitation (CLTS) S Originated in Rajshahi, Bangladesh by Kamal Karr S Benefits: S Community Ownership S Behavioral Change S Community Empowerment S Evidence-Based S Decrease rates of open defecation: S CLTS: 92% S Non-CLTS: 28%  Rashid et al (2009)
Process of CLTS Pre Triggering Triggering Post Triggering• Selection • Participatory • Action Sanitation Planning• Building Profile Rapport Analysis • Follow Up • Ignition Moment
C.L.E.A.N. Pre-triggering Engage community Building rapport Identify sanitation problems TriggeringParticipatory Sanitation Profile Analysis Ignition Moment Introduction of EcoSan and Solution building Develop plan Funding request Project Rollout Fund Build Adopt Report Evaluation Lessons Learned
C.L.E.A.N. :: Monitoring & Evaluation Template Acceptability Cost • Community-led Effectiveness • Participatory • DALYs avoided/ • Feedback loops 1$ spent • Equity-focused Health Impacts Environmental • Change in % Impacts ODF • Local water • Diarrheal disease quality • <5 mortality
Recommended Evaluation Design Randomized Controlled Trial (Gold Standard) Region Carried out by University partnersCLTS C.L.E.A.N. EcoSan
C.L.E.A.N. :: A Multi-faceted Approach Stakeholder Integration Policy: Governments & Institutions Implementation: Civil Society & NGOs Research: Universities Benefits Knowledge transfer Evidence building in the scientific community Capacity building of community Soft power gains for China
Project Budget US $5 Billion per East Timor; 3% year for 3 years of full-scale Cambodia; 27% implementationIndonesia; 70%
Additional Recommendation :: China in parallel Vast inequities between rural and urban populations within China Curb criticisms of not dealing with sanitation problems at home Lessons learned in neighboring countries are transferrable Strengthen research partnerships Become a world leader in environmentally sustainable sanitation initiatives
Key Messages1. C.L.E.A.N ignites the demand for and provides the supply of improved sanitation2. Benefits of C.L.E.A.N. go beyond sanitation, addressing issues of equity and global responsibility3. Improved sanitation in South East Asia leads to returns on investment and improves international relations and furthers economic gain
References References Avvannavar, S. M., & Mani, M. (2008). A conceptual model of people’s approach to sanitation. Science of the Total Environment, 390, 1-12. Cheng, J. Y. S. (2013). China-ASEAN Economic Co-operation and the Role of Provinces. Journal of Contemporary Asia, 1–24. doi:10.1080/00472336.2012.757430 Ferguson, R. J. (2012). China’s Long-Term Relations With Southeast Asia: Beyond The Pivot. Culture Mandala: The Bulletin of the Centre for East-West Cultural and Economic Studies, 10(1), 3–20. Florini, A., Nachiappan, K., Pang, T., & Pilcavage, C. (2012). Global Health Governance: Analysing China, India and Japan as Global Health Aid Donors. Global Policy, 3(3), 336–347. doi:10.1111/j.1758-5899.2012.00173.x Hubbard, B., Sarisky. J., Gelting, R., Baffigo, V., Seminario, R. & Centurion, C. (2011). A community demand-driven approach toward sustainable water and sanitation infrastructure development. International Journal of Hygience and Environmental Health, 214, 326-334.
References References Langergraber, G., & Muellegger, E. (2005). Ecological sanitation – a way to solve global sanitation problems? Environmental International, 31, 433- 444. Montgomery, M. A. A. (2007). Water and Sanitation in Developing Countries: Including Health in the Equation (pp. 16–24). Mosler, H-J. (2012). A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. International Journal of Environmental Health Research, 22(5), 431-449. Murphy, H.M., McBean, E.A., & Farahbakhsh, K. (2009). Appropriate technology – a comprehensive approach for water and sanitation in the developing world. Technology in Society, 31, 158-167. Nelson, K. L., & Murray, A. (2008). Sanitation for unserved popualtions: Technologies, implementation challenges, and opportunities. Annual review of Environment and Resources, 33 199-151.
References References Rud, S. & Munch, E. V. (2008). Ecological sanitation: Selected example projects from Sub-Saharan Africa, Asia and Europe. International Conference: Pahtways towards Sustainable Sanitation in Africa. Ouagadougou, Burkina Faso. SOIL (February 2011). Introduction to EcoSan toilets. UNICEF, & World Health Organization. (2012). Progress on Drinking Water and Sanitation (pp. 1–66). Water and Sanitation Program. (2007). Economic Impacts of Sanitatn in Southeast Asia Summary (pp. 1–14). Water and Sanitation Program. (2012). Introductory Guide to Sanitation Marketing Implementation (pp. 1–14). Water & Sanitation Rotarian Action Group (2012). Guidelines for planning sustainable sanitation projects and selecting appropriate technologies. Wasrag Technology Series.
References 68). References WaterAid. (2011). Construction Of Ecological Sanitation Latrine (pp. 1– Werner, C., Panesar, A., Rud, S.B. & Olt, C.U. (2009). Ecological sanitation: Principles, technolgoies and project examples for sustainable wastewater and excreta management. Desalination, 248, 392-401. Whittington, D., Jeuland, M., Barker, K., & Yuen, Y. (2012). Setting Priorities , Targeting Subsidies Among Water , Sanitation , and Preventive Health Interventions in Developing Countries. World Development, 40(music), 1546–1568. World Health Organization. (2012). Global Costs And Benefits of Drinking-Water Supply And Sanitation Interventions To Reach The MDG Target And Universal Coverage (pp. 1–67).
Appendix AAdditional Recommendation :: China in parallel Yunnan province Rural population: 31.375 million 46.3% in need of improved sanitation Total cost: US $745 million Including cost of technology, facilitators, evaluation, and overhead cost
Appendix C: Stakeholder Engagement Government – Ministry of Health, Water & Environment, Education (multi- sectional) NGOs Universities and Researchers Leading Sanitation Experts within Ministry Regional District - Health & Environment District Community/Village Level Elders, Leaders, Village Governing Council
Appendix D: Why Not Africa? Maintaining Current Investment Proportion Harder to Achieve Universal Sanitation Risky Investment No Established Infrastructure
Appendix E: SWOT Analysis for Investment in Africa Weakness Strength - Low level of infrastructure- Natural resources - Political uncertainty (Human- Large population (900M, to Rights and conflict)double) - Sanitation infrastructure can’t- Emerging market support population growth- Rising middle class - Low level of ODF in both urbanMany ODF initiatives and rural area - Distance from China is high, meaning increased cost - Most need Total Cost to achieve universal sanitation coverage SSA: US $52 Billion Threat SEA: US $10 Billion - Uncertainty about whether resources exist Opportunity - Urbanization Benefit:Cost Ratio- Generate trade and extraction - Environment SSA: 2.8- Increased purchasing power - Sanitation low in urban areas SEA: 5- Room to improve ODF% - Unfeasible sanitation target due to- Global stability and recognition many confounding issues- High reward - Increased cost due to distance - Soft power decreases - High risk
Appendix L: Philanthropy Lots of money with comparatively little economic ROI Foreign aid can simply be aid and doesn’t have to come with strings attached This further improves international relations, friendliness and soft power
Appendix M: Evaluation Methodology Qualitative: In-depth interviews with key stakeholders at community level (women, children, youth, facilitators, village government members) Focus on equity of uptake/participation/decision making
Appendix N: Evaluation Methodology Quantitative: Household Surveys (pre/post) in each village Measures of water contamination RCT: compare changes in indicators between arms Surveys to capture: Health indicators Cost effectiveness data HH hygiene/sanitation knowledge Attitudes towards C.L.E.A.N. approach