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Supporting water sanitation
and hygiene services for life
22nd October 2019
Sanitation and Hygiene
Sector Trends
Ambrose Kibuuka
In collaboration with:
Eline Bakker
Peter Feldman
Erick Baetings
Index
− SDG status of sanitation and hygiene
− Sector trends focusing on Community Led
Total Sanitation and Sanitation Marketing
− Universal access to sanitation -
How did the (now) rich nations make it?
− Conclusions
SANITATION AND HYGIENE SECTOR TRENDS
2
Proportion of global population with at least basic
sanitation facilities in 2015
SANITATION AND HYGIENE SECTOR TRENDS
Watershed & Simavi, 2018; JMP 20193
Proportion of global population with handwashing
facilities including soap and water at home in 2015
SANITATION AND HYGIENE SECTOR TRENDS
Watershed & Simavi, 2018; JMP 20194
WASH and Climate Change
SANITATION AND HYGIENE SECTOR TRENDS
Photo: Women washing clothes and children playing in a canal in Haiti before Hurricane
Matthew, 2016 (Mosello, B., & Matoso, M., 2017)
WASH and Climate Change
• Climate change induces extreme weather events that lead to
droughts and floods
• These events affect sanitation systems and infrastructure
• Health impacts of poor sanitation expected to increase in future due
to increased risk resulting from increased environmental pollution,
and the limited access to sanitation facilities as systems are
destroyed or damaged
• Adaptation measures will include promoting resilient technologies,
adapting technical norms and regulations and enhancing
management of services
• Potential of waste to energy to mitigate climate change
SANITATION AND HYGIENE SECTOR TRENDS
Mosello, B., & Matoso, M., 2017; Howard et. al,2016, p. 254; Howard et. al, 2010; WHO,
2019a; Hallegatte, Rentschler & Rozenberg, 2019; Verhagen, & Scott, 2019.
Stunting rates and open defecation in Vietnam
SANITATION AND HYGIENE SECTOR TRENDS
Chase, C., & Ngure, F., 20167
WASH and Nutrition
• Child undernutrition and poor conditions of WASH coexist in many low-
and middle-income countries
• Undernutrition is attributed to stunting, wasting and underweight. Long
term consequences include poor cognitive development and limited
human capital attainment
• Effective nutrition oriented programs in high burden countries would
only reduce stunting by 20% globally: WASH as complement
• Environmental enteric dysfunction (EED) explains why truly nutrition
oriented programs have failed to reduce stunting in many contexts over
the long term: Co-location of WASH activities in nutrition vulnerable
areas
• Evidence: Basic WASH has no impact of child
growth and diarrhea: Would safely manages
WASH be the solution
SANITATION AND HYGIENE SECTOR TRENDS
Chase, C., & Ngure, F., 2016; Cumming et.al., 2019; Bery et al., 2019; Pickering et al.
2015
8
WASH, Gender and Social Inclusion
• Evolution of perspectives of women and gender overtime. 1970s,
women in development; the 1980s to 1990s, inequalities; the
2000s, gender mainstreaming in WASH; and since the 2010s,
equity and inclusion
SANITATION AND HYGIENE SECTOR TRENDS
Fischer et. al., 20179
WASH, Gender and Social Inclusion - 1
• Holistic programs that address social norms alongside technical
water and sanitation infrastructure and service provision. WASH in
Schools programs provide avenues to improve menstrual hygiene
management
• WASH in health-care facilities is critical to maternal and neo-natal
health: 10.7% of maternal deaths were related to sepsis (WHO)
• Need to identify the disadvantaged groups, the locations where they
stay, current levels of service and their link to health and nutrition,
and the binding barriers to access of services: Integration of data
into monitoring and planning
• Empowerment in WASH index used to access empowerment
issues so that stakeholders can act
SANITATION AND HYGIENE SECTOR TRENDS
Fischer et. al., 2017; Mosello, B., & Matoso, M., 2017; Sahin, 2015; Rajagopal & Mathur,
2017; Sweetman & Medland, 2017; Watershed & Simavi, 2018; SEI, 2019; Say et al.,
2014
10
Overview of approaches to scale sanitation
SANITATION AND HYGIENE SECTOR TRENDS
USAID, 2018b
11
Community Led Total Sanitation –
Effectiveness (1)
Problem Solving
• Effective at attaining dramatic short-term-midterm open defecation
(OD) reduction
• Common indicator for OD status is latrine coverage, but OD can
persist with full sanitation coverage
• Mixed evidence with regards to sustained cessation of OD
Common slippage rates
• Slippage ranges between 10% and 90%
• Follow-up to ensure sustainability of ODF
• Latrine quality for improvements along sanitation ladder
SANITATION AND HYGIENE SECTOR TRENDS
USAID, 2017a, ix; USAID, 2018a; Tyndale-Biscoe, Bond & Kidd, 2013; UNICEF, 2015,
p.1-8; UNC, 2017
12
Community Led Total Sanitation –
Effectiveness (2)
Effectiveness in driving households up the sanitation ladder
• Almost no evidence of the ability of CLTS to drive households from
basic to improved sanitation facilities
• Moving households up the sanitation ladder requires both
combination of CLTS with sanitation marketing (discussed in next
section) or measures intended to reduce the financial burden on
households e.g. subsidies or credit
• Almost evident that the ‘last mile’/ hard to reach households and
communities will need external support to move up the ladder
SANITATION AND HYGIENE SECTOR TRENDS
USAID, 2018a; Tyndale-Biscoe, Bond, & Kidd, 2013; UNC, 201713
Community Led Total Sanitation –
Effectiveness (3)
Cost effectiveness
• CLTS programs cost US$ 15-30 per household targeted in sub-
Saharan Africa
• Cost increases to as high as US$ 80 per household targeted, with
inclusion of other activities like training natural leaders and hygiene
promotion
• Compared to: well implemented sanitation marketing and output
based subsidy programs from South East Asia (US $20 to $50 per
toilet delivered)
• CLTS implementation costs tremendously financed by external
donors
SANITATION AND HYGIENE SECTOR TRENDS
Myers, 2019, p. 6; USAID, 2018a14
Community Led Total Sanitation – Questions
for further research
• Is it possible to achieve and sustain ODF status without sanctions?
Is there evidence of CLTS achieving total access to improved
sanitation facilities?
• What is the appropriate timing to introduce support mechanisms vs.
the conventional CLTS process? What combination of CLTS and
other programs is most efficient to booster access to improved
sanitation facilities for all? Is there evidence of success of support
mechanisms outside the Asian context, in particular Africa?
• What are the protective effects of improved vs. CLTS related
unimproved latrines?
• What is the impact of slippage on behaviour change and health
indicators?
SANITATION AND HYGIENE SECTOR TRENDS
15
Sanitation Marketing – Effectiveness (1)
Sustainability and scale
• Success in the delivery of on-site sanitation facilities in Southeast Asia
and Bangladesh; difficult to replicate success in other regions,
specifically sub-Saharan Africa
• Few sanitation marketing initiatives have scaled: Fewer that have
scaled have been purely market based. The rest were either heavily
subsidised or relied on short-term hardware supply by the government
or donors which possesses a future sustainability challenge
• Majority of the interventions that scaled, spent roughly US $20 to $50
per toilet delivered; Programmatic costs were variable
• Most successful examples reached scale in 4 to 6 years: need for
continued financing
• But 45 countries have costed sanitation plans, only six of these plans
backed with the required financing mechanisms (WHO-GLAAS, 2019)
SANITATION AND HYGIENE SECTOR TRENDS
USAID, 2018b, p. 14-16; WHO, 2019b; UNC, 201716
Sanitation Marketing – Effectiveness (2)
Sustainability and scale
• Three barriers to scale:
• Context: e.g. social norms, economic environment, and
geographical conditions
• Business environment: shaped by the government policy and
existence of raw materials and financial services
• Core sanitation market: consists of customers, enterprises, and
entrepreneurs
• To scale, well trained professionals in market development, basics
of supply chain networks and some latent demand for sanitation
required
SANITATION AND HYGIENE SECTOR TRENDS
USAID, 2018b, p. 15; USAID, 2018b, ix; UNC, 201717
Sanitation Marketing – Questions to research
• Which market rules can create a positive environment for MBS?
e.g., tax reduction versus a housing policy change with respect to
sanitation
• What is the optimal size and modality of subsidies for unlocking
households’ investment while avoiding market distortion?
• What are the factors that influence entrepreneurs to enter and
remain in the sanitation market?
• What archetypes of entrepreneurs are best suited to different types
of product systems and delivery models?
SANITATION AND HYGIENE SECTOR TRENDS
18
Universal access to sanitation -
How did the (now) rich nations did it?
SANITATION AND HYGIENE SECTOR TRENDS
Bisaga, I. & Norman, G, 2015
South Korea Case
• Total sanitation coverage driven by high-level political leadership, as part of a wider push
towards nation-building, common well-being and modernity
• Initial funding through foreign aid (mostly from the US) in the 1960s for major WASH infrastructure
• Aid was time bound hence alternative sources of funding sought for on-going capital investment
• Tariffs alone were not sufficient and were complemented with proceeds from a national liquor tax
• By 2012, South Korea had achieved 100% access to improved sanitation and 98% access to
improved water.
President Park Chung-hee of South Korea (1917 – 1979)
19
Universal access to sanitation -
How did the (now) rich nations make it?
Lessons learnt from analysis of four East Asian countries – Singapore,
South Korea, Malaysia and Thailand – include, among others:
• high-level political leadership was crucial and did not stem from
community-driven demand;
• some element of subsidy was included, but alongside demand
creation, and was often indirect (such as through the housing subsidy);
• hygiene, cleanliness and public health aims drove sanitation
improvements;
• a well-coordinated multi-sector approach was a necessary condition
for rapid sanitation improvements;
• capacity building happened alongside sanitation improvements;
• and monitoring was continuous and standards raised as goals
were achieved
SANITATION AND HYGIENE SECTOR TRENDS
Northover et al., 2014, p. 220
Conclusions
• Unsafely managed sanitation remains a challenge to developing
world especially the rural sectors
• The impact of poor sanitation expected to increase with population
growth and climate change
• Existing approaches, CLTS and sanitation marketing need to be
adopted to deal with the challenges of slippage and scale
respectively
• Systems strengthening (in particular access to financing) and strong
public commitment is required achieve universal access to
sanitation by 2030
• Much as sanitation tops the SDG development agenda, on-site
sanitation and faecal sludge removal are rarely funded
SANITATION AND HYGIENE SECTOR TRENDS
21
Visiting address
Bezuidenhoutseweg 2
2594 AV The Hague
The Netherlands
Postal address
P.O. BOX 82327
2508 EH The Hague
The Netherlands
T +31 70 3044000
info@ircwash.org
www.ircwash.org
Supporting water sanitation
and hygiene services for life

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Sanitation and hygiene sector trends

  • 1. Supporting water sanitation and hygiene services for life 22nd October 2019 Sanitation and Hygiene Sector Trends Ambrose Kibuuka In collaboration with: Eline Bakker Peter Feldman Erick Baetings
  • 2. Index − SDG status of sanitation and hygiene − Sector trends focusing on Community Led Total Sanitation and Sanitation Marketing − Universal access to sanitation - How did the (now) rich nations make it? − Conclusions SANITATION AND HYGIENE SECTOR TRENDS 2
  • 3. Proportion of global population with at least basic sanitation facilities in 2015 SANITATION AND HYGIENE SECTOR TRENDS Watershed & Simavi, 2018; JMP 20193
  • 4. Proportion of global population with handwashing facilities including soap and water at home in 2015 SANITATION AND HYGIENE SECTOR TRENDS Watershed & Simavi, 2018; JMP 20194
  • 5. WASH and Climate Change SANITATION AND HYGIENE SECTOR TRENDS Photo: Women washing clothes and children playing in a canal in Haiti before Hurricane Matthew, 2016 (Mosello, B., & Matoso, M., 2017)
  • 6. WASH and Climate Change • Climate change induces extreme weather events that lead to droughts and floods • These events affect sanitation systems and infrastructure • Health impacts of poor sanitation expected to increase in future due to increased risk resulting from increased environmental pollution, and the limited access to sanitation facilities as systems are destroyed or damaged • Adaptation measures will include promoting resilient technologies, adapting technical norms and regulations and enhancing management of services • Potential of waste to energy to mitigate climate change SANITATION AND HYGIENE SECTOR TRENDS Mosello, B., & Matoso, M., 2017; Howard et. al,2016, p. 254; Howard et. al, 2010; WHO, 2019a; Hallegatte, Rentschler & Rozenberg, 2019; Verhagen, & Scott, 2019.
  • 7. Stunting rates and open defecation in Vietnam SANITATION AND HYGIENE SECTOR TRENDS Chase, C., & Ngure, F., 20167
  • 8. WASH and Nutrition • Child undernutrition and poor conditions of WASH coexist in many low- and middle-income countries • Undernutrition is attributed to stunting, wasting and underweight. Long term consequences include poor cognitive development and limited human capital attainment • Effective nutrition oriented programs in high burden countries would only reduce stunting by 20% globally: WASH as complement • Environmental enteric dysfunction (EED) explains why truly nutrition oriented programs have failed to reduce stunting in many contexts over the long term: Co-location of WASH activities in nutrition vulnerable areas • Evidence: Basic WASH has no impact of child growth and diarrhea: Would safely manages WASH be the solution SANITATION AND HYGIENE SECTOR TRENDS Chase, C., & Ngure, F., 2016; Cumming et.al., 2019; Bery et al., 2019; Pickering et al. 2015 8
  • 9. WASH, Gender and Social Inclusion • Evolution of perspectives of women and gender overtime. 1970s, women in development; the 1980s to 1990s, inequalities; the 2000s, gender mainstreaming in WASH; and since the 2010s, equity and inclusion SANITATION AND HYGIENE SECTOR TRENDS Fischer et. al., 20179
  • 10. WASH, Gender and Social Inclusion - 1 • Holistic programs that address social norms alongside technical water and sanitation infrastructure and service provision. WASH in Schools programs provide avenues to improve menstrual hygiene management • WASH in health-care facilities is critical to maternal and neo-natal health: 10.7% of maternal deaths were related to sepsis (WHO) • Need to identify the disadvantaged groups, the locations where they stay, current levels of service and their link to health and nutrition, and the binding barriers to access of services: Integration of data into monitoring and planning • Empowerment in WASH index used to access empowerment issues so that stakeholders can act SANITATION AND HYGIENE SECTOR TRENDS Fischer et. al., 2017; Mosello, B., & Matoso, M., 2017; Sahin, 2015; Rajagopal & Mathur, 2017; Sweetman & Medland, 2017; Watershed & Simavi, 2018; SEI, 2019; Say et al., 2014 10
  • 11. Overview of approaches to scale sanitation SANITATION AND HYGIENE SECTOR TRENDS USAID, 2018b 11
  • 12. Community Led Total Sanitation – Effectiveness (1) Problem Solving • Effective at attaining dramatic short-term-midterm open defecation (OD) reduction • Common indicator for OD status is latrine coverage, but OD can persist with full sanitation coverage • Mixed evidence with regards to sustained cessation of OD Common slippage rates • Slippage ranges between 10% and 90% • Follow-up to ensure sustainability of ODF • Latrine quality for improvements along sanitation ladder SANITATION AND HYGIENE SECTOR TRENDS USAID, 2017a, ix; USAID, 2018a; Tyndale-Biscoe, Bond & Kidd, 2013; UNICEF, 2015, p.1-8; UNC, 2017 12
  • 13. Community Led Total Sanitation – Effectiveness (2) Effectiveness in driving households up the sanitation ladder • Almost no evidence of the ability of CLTS to drive households from basic to improved sanitation facilities • Moving households up the sanitation ladder requires both combination of CLTS with sanitation marketing (discussed in next section) or measures intended to reduce the financial burden on households e.g. subsidies or credit • Almost evident that the ‘last mile’/ hard to reach households and communities will need external support to move up the ladder SANITATION AND HYGIENE SECTOR TRENDS USAID, 2018a; Tyndale-Biscoe, Bond, & Kidd, 2013; UNC, 201713
  • 14. Community Led Total Sanitation – Effectiveness (3) Cost effectiveness • CLTS programs cost US$ 15-30 per household targeted in sub- Saharan Africa • Cost increases to as high as US$ 80 per household targeted, with inclusion of other activities like training natural leaders and hygiene promotion • Compared to: well implemented sanitation marketing and output based subsidy programs from South East Asia (US $20 to $50 per toilet delivered) • CLTS implementation costs tremendously financed by external donors SANITATION AND HYGIENE SECTOR TRENDS Myers, 2019, p. 6; USAID, 2018a14
  • 15. Community Led Total Sanitation – Questions for further research • Is it possible to achieve and sustain ODF status without sanctions? Is there evidence of CLTS achieving total access to improved sanitation facilities? • What is the appropriate timing to introduce support mechanisms vs. the conventional CLTS process? What combination of CLTS and other programs is most efficient to booster access to improved sanitation facilities for all? Is there evidence of success of support mechanisms outside the Asian context, in particular Africa? • What are the protective effects of improved vs. CLTS related unimproved latrines? • What is the impact of slippage on behaviour change and health indicators? SANITATION AND HYGIENE SECTOR TRENDS 15
  • 16. Sanitation Marketing – Effectiveness (1) Sustainability and scale • Success in the delivery of on-site sanitation facilities in Southeast Asia and Bangladesh; difficult to replicate success in other regions, specifically sub-Saharan Africa • Few sanitation marketing initiatives have scaled: Fewer that have scaled have been purely market based. The rest were either heavily subsidised or relied on short-term hardware supply by the government or donors which possesses a future sustainability challenge • Majority of the interventions that scaled, spent roughly US $20 to $50 per toilet delivered; Programmatic costs were variable • Most successful examples reached scale in 4 to 6 years: need for continued financing • But 45 countries have costed sanitation plans, only six of these plans backed with the required financing mechanisms (WHO-GLAAS, 2019) SANITATION AND HYGIENE SECTOR TRENDS USAID, 2018b, p. 14-16; WHO, 2019b; UNC, 201716
  • 17. Sanitation Marketing – Effectiveness (2) Sustainability and scale • Three barriers to scale: • Context: e.g. social norms, economic environment, and geographical conditions • Business environment: shaped by the government policy and existence of raw materials and financial services • Core sanitation market: consists of customers, enterprises, and entrepreneurs • To scale, well trained professionals in market development, basics of supply chain networks and some latent demand for sanitation required SANITATION AND HYGIENE SECTOR TRENDS USAID, 2018b, p. 15; USAID, 2018b, ix; UNC, 201717
  • 18. Sanitation Marketing – Questions to research • Which market rules can create a positive environment for MBS? e.g., tax reduction versus a housing policy change with respect to sanitation • What is the optimal size and modality of subsidies for unlocking households’ investment while avoiding market distortion? • What are the factors that influence entrepreneurs to enter and remain in the sanitation market? • What archetypes of entrepreneurs are best suited to different types of product systems and delivery models? SANITATION AND HYGIENE SECTOR TRENDS 18
  • 19. Universal access to sanitation - How did the (now) rich nations did it? SANITATION AND HYGIENE SECTOR TRENDS Bisaga, I. & Norman, G, 2015 South Korea Case • Total sanitation coverage driven by high-level political leadership, as part of a wider push towards nation-building, common well-being and modernity • Initial funding through foreign aid (mostly from the US) in the 1960s for major WASH infrastructure • Aid was time bound hence alternative sources of funding sought for on-going capital investment • Tariffs alone were not sufficient and were complemented with proceeds from a national liquor tax • By 2012, South Korea had achieved 100% access to improved sanitation and 98% access to improved water. President Park Chung-hee of South Korea (1917 – 1979) 19
  • 20. Universal access to sanitation - How did the (now) rich nations make it? Lessons learnt from analysis of four East Asian countries – Singapore, South Korea, Malaysia and Thailand – include, among others: • high-level political leadership was crucial and did not stem from community-driven demand; • some element of subsidy was included, but alongside demand creation, and was often indirect (such as through the housing subsidy); • hygiene, cleanliness and public health aims drove sanitation improvements; • a well-coordinated multi-sector approach was a necessary condition for rapid sanitation improvements; • capacity building happened alongside sanitation improvements; • and monitoring was continuous and standards raised as goals were achieved SANITATION AND HYGIENE SECTOR TRENDS Northover et al., 2014, p. 220
  • 21. Conclusions • Unsafely managed sanitation remains a challenge to developing world especially the rural sectors • The impact of poor sanitation expected to increase with population growth and climate change • Existing approaches, CLTS and sanitation marketing need to be adopted to deal with the challenges of slippage and scale respectively • Systems strengthening (in particular access to financing) and strong public commitment is required achieve universal access to sanitation by 2030 • Much as sanitation tops the SDG development agenda, on-site sanitation and faecal sludge removal are rarely funded SANITATION AND HYGIENE SECTOR TRENDS 21
  • 22. Visiting address Bezuidenhoutseweg 2 2594 AV The Hague The Netherlands Postal address P.O. BOX 82327 2508 EH The Hague The Netherlands T +31 70 3044000 info@ircwash.org www.ircwash.org Supporting water sanitation and hygiene services for life

Editor's Notes

  1. In 2017, around 27% (1/3) of the global population still lacked access to at least basic sanitation facilities. 40% had no basic hygiene facilities in 2017 Greater portion of this unserved population lies in the rural areas Only 12 of 104 countries below the 98% coverage in the rural sector are on track to achieve universal access to basic sanitation services by 2030 Increasing water quality deterioration due to faecal contamination
  2. In 2017, around 27% (1/3) of the global population still lacked access to at least basic sanitation facilities. 40% had no basic hygiene facilities in 2017 Greater portion of this unserved population lies in the rural areas Only 12 of 104 countries below the 98% coverage in the rural sector are on track to achieve universal access to basic sanitation services by 2030 Increasing water quality deterioration due to faecal contamination
  3. The effects of climate change will be felt unequally across society due to the deepening inequalities in sanitation access Nevertheless there remain keen uncertainties surrounding sanitation planning and management regarding how the climate will change in specific locations and when the impacts will be experienced
  4. A study by Wriege-Bechtold et al. (2010) found no sanitation technology with low climate resilience For wetter climate, all on site sanitation systems are susceptible to flooding. Only dry urine-diverting latrines could be considered resilient The effects of climate change will be felt unequally across society due to the deepening inequalities in sanitation access Nevertheless there remain keen uncertainties surrounding sanitation planning and management regarding how the climate will change in specific locations and when the impacts will be experienced.
  5. Herd effects - Household health impacted by the toilet coverage of the neighborhood and not necessarily the household's own toilet ownership Without safely managed sanitation faecal matter remains in the environment
  6. Issues related to girls and children in schools, menstruation and disabled people have also risen since 2000s
  7. In Asia and sub-Saharan Africa, the lack of facilities in schools for menstrual hygiene management contributes to girls’ absence from school, mainly after menarche
  8. Sanitation marketing was first piloted in Benin in 1996 in the PADEAR Program: Applies social and commercial marketing approaches to scale up the supply and demand for improved sanitation facilities CLTS and sanitation marketing not only mutually compatible, but mutually complementary Increasing evidence that both approaches are needed to scale up sustainably and impact poverty and health
  9. CLTS was Developed around 2000 in Bangladesh: CLTS focuses on ending open defecation (OD) through demand creation, behaviour change, community empowerment and collective community action Effective at ending OD, but less effective at driving households up the sanitation ladder CLTS has been more influential in changing behavior towards habits but not towards the intended investment Whereas, habits can be influenced through conservative social influence on behavior, e.g. social norms, the intended investment is influenced by possible positive social influence such as prestige and self-presentation. Hence CLTS messages of shame and disgust need to be supplemented with those about pride and self-respect, and reinforcing sustainability of positive achievement
  10. Additionally, development bank loans in the WASH sector tend to focus on large infrastructure projects such as sewerage networks, wastewater treatment plants, and water supply systems
  11. The history of US, Britain and South Korea indicates that domestic public finance was and is critically important even in strongly market-led economies like the US, and that government leadership and high-level political commitment has been a key driver. In no country up to date has the private sector alone achieved universal access to water and sanitation In 1971, due to poor water services and absence of handwashing practices, more than 84 percent of fecal samples contained helminth contamination, a parasitic worm whose eggs are infective and can cause severe morbidity, malnutrition, anemia and other immunological changes. https://blogs.worldbank.org/water/korea-model-development-water-and-sanitation-sector In 1965, to overcome the water shortage and its intermittent supply, the Government developed a 20-year National Water Resource Plan, which was successfully modified and updated periodically to manage water demand.
  12. While in all cases sanitation progress is punctuated by moments of crisis that triggered action, e.g. slum fires, disease outbreaks and civil unrest, the overall strategy was primarily motivated by the positive goal of nation building
  13. While there may be leadership commitment, like first lady in Burkina, or Ministry of WASH in Ghana, available finance for sanitation is the true measure of commitment....