Frontieri was awarded from United Nations Office for Project Services(UNOPS)/ Water Supply and Sanitation Collaborative Council (WSSCC) to conduct Ethiopia Programme Outcome Survey for Global Sanitation Fund (GSF). The Main objective of this outcome survey was to assess the use, access, reach, program exposure, equity, social norms, and behaviors to make inferences on the level of beneficiaries of the program in Ethiopia. The following brief description provides insight into the key findings from this outcome survey.
Access to safe drinking water, sanitation, and hygiene is essential to human survival. Providing access to these facilities to most poor and vulnerable people in developing countries remains one of the major and persistent challenges to governments. In Ethiopia, given 60 to 80 percent of communicable diseases are attributed to limited access to safe water and inadequate sanitation and hygiene services (UNICEF, 2018), the WaSH sector is recently receiving greater policy attention. The government has set ambitious targets for the sector including “elimination of open defecation by 2024, achieving universal access to safe water services by 2030 and improved sanitation by 82% by 2020”.
The Water Supply and Sanitation Collaborative Council (WSSCC), a United Nations hosted partnership and membership organization through Global Sanitation Fund (GSF), invests in collective behavior change approaches that supports large numbers of people in developing countries, including Ethiopia. The GSF program in Ethiopia is known as the Ethiopia Sanitation and Hygiene Improvement Program-Two (ESHIP-2) and is managed by the Federal Ministry of Health (FMoH). The main objective of the GSF program in Ethiopia is to end open defecation practices through community collective actions and increased access and utilization of improved latrines in equitable and sustainable ways. The program included a wide range of interventions including community level behavioral Change Communication (BCC), support construction of water, hygiene, and sanitation facilities; equity in access and utilization …ect. In November 2019, the UNOPS/WSSCC awarded Frontieri PLC to conduct this study in the four intervention regions (Oromia, Amhara, SNNP and Tigray regions).
THE DATA AND METHODS IN BRIEF
This outcome survey employed a cross sectional study design. The target population of the outcome survey comprises all households and individuals living in communities where the GSF program has been initiated. The study population is all the 40 treatment woredas from which household and community samples were taken. The kebeles/communities were selected only from the treatment woredas. The sample size estimation was developed based on the WSSCC_GSF outcome survey protocol. A minimum of 400 households per region was estimated, giving a total size of approximately 2,016 households. The households were then drawn randomly from the 40 targeted woredas in the four regions (Oromia, Amhara, SNNP, and Tigray), proportional to the total number of interventions woredas. Thus, the study included 12 woredas from Amhara, 14 from Oromia, 10 from SNNPR and 4 from Tigray regions. In addition, 122 schools and 124 health facilities were surveyed. Due to the interruptions and temporary lockdown imposed by COVID-19, data were collected in two time periods: phase I: in March-April 2020, and phase II: October- November 2020.
Participation: It was noted that relatively higher proportion of the respondents from Oromia and Tigray regions (26% and 31.6%, respectively) reported participating in none of the GSF sanitation activities (such as construction of and use of toilets and handwashing). It is noted that more male respondents (70.6%) than female respondents (63.9%) reported involving in decision making about the kind of toilet a household would build.
Access to water: Overall access to safely managed water sources is too low across the four regions. The proportions having access to limited and basic services were less than 50% in almost all regions. The distribution of access by age categories shows slightly higher proportion for safely managed water among older respondents (18 and 19 percent for 65+ age group compared to 13% for the youngest age group/15-19). Likewise, access to safely managed water source was much higher for those with higher education (46.5%). On the other hand, access to water at school is much better where 85% of schools use various sources of water for hand washing. Similarly, access to water at health facilities was generally good as 41% of the facilities had availability throughout the entire year.
Access to toilets: It is noted that Tigray had the highest proportion of households having no access to any type of toilet facilities (i.e. 57% of households practice open defecation). This is followed by Oromia (44%) and Amhara (30%) regions. On the contrary, only 0.4% of households were found to practice Open Defecation (OD) in SNNP region. The prevalence of OD among those with college education was only 1% compared to 38% for respondents with no education. The toilet facilities in schools, on the other hand, was much better in terms of providing access to users. Ninety percent (90%) of schools surveyed had toilets outside buildings, but on premises and 7.4% within school building. It was also noted that none of the households across the four regions had access to safely managed toilet.
Sanitation construction and financing: The finding indicates that 48% of households in Tigray, 28.7% in SNNP, 25.6% in Oromia and 18.7% in Amhara reported they paid some money for constructing toilet facilities at household level. Most households paid from their own family income. About 82% of the respondents indicated that they themselves made the decision in the construction of the toilet. Similarly, nearly all schools and health facilities cover their own cost for constructing sanitation facilities.
About 80% of households in three of the four regions had no lid/cover for pit hole (85% in Amhara, 83% in Oromia, and 85% in SNNP regions). The proportion is somewhat lower in Tigray (63%). This varies across educational categories, ranging from 8% for those with no education to 13.7% for respondents with higher education. About 83% of all households in the four regions had no lid/cover for pit hole. Overall, 60% of households had no slab in the observed sanitation facilities.
Handwashing practices: It is observed that larger proportion of households in Oromia (87.5%) and Amhara (59.7%) regions were reported to have no handwashing services at home. The proportion in Tigray and SNNP regions were significantly lower (28.4% and 12.5%, respectively). In terms of access to handwashing basic services, Tigray had the highest access (54.9%) followed by SNNP (29.6%), whereas in terms of access to limited handwashing facilities, SNNP had much higher access (57.9%) followed by Amhara region (25.5%). Respondents with higher education level had much better access to both basic and limited handwashing services. As corroborated by structured observation, 45.2% of the respondents did not wash their hands when defecate/ use toilet, 34.15 use water only, and about 20% use water and soap/ash. On the contrary, larger proportion of the respondents (>80%) reported handwashing practice either using water only or with soap/ash, during food preparation and feeding of children under five. In health facilities, handwashing is available in 49% of those surveyed; soap is available in 46.4% of the health facilities. Composite indicators for drinking water (reported water source, location and time required to obtain water), handwashing (observed handwashing facility, soap, and location of the facility) and sanitation (reported type of sanitation facility used, safe disposal of feces) have been used to measure the type of facilities (basic versus limited).
Social norms on sanitation: The findings showed that community and neighbors showed interest in proper use of toilets given availability of the services. This was confirmed by the results of the empirical expectation score, which suggests that two thirds of respondents from both sexes would use toilet services, in the event of availability of the facilities. There was also gender difference in handwashing norms and habits where the empirical expectation scores for male was lower than that of female respondents.
Menstrual Hygiene Management (MHM): Overall, 85.5% of female respondents had appropriate MHM facilities as part of the home menstrual hygiene management. While access to menstrual hygiene management services is very high across all regions, significant proportion of women reported that their menstrual experience is accompanied by discomfort with the hygiene materials used, lack of awareness of first menstrual experiences, stigma, and social exclusion.
Equity: It was noted that 34.3% of those with visual/ mobility limitations defecate in bush and 21% use another family’s latrine. While significant proportion of those having toilet facilities do not have any complain of comfort, having a third of them practicing open defecation warrants close attention. More than 80% of them had access to hand washing services and drinking water when they need to. In the schools, most toilet facilities surveyed were disability friendly with clear path from building to toilet and enough space for wheelchair. However, only 11.6% of schools had a toilet modified or designed for students with disabilities.
Sustainability: The results of the study witnessed that some communities and households revert to Open Defecation (OD practices) due to several reasons. The SNNP region has the highest proportion of households with access to basic sanitation facility of all households in previously Open Defecation Free (ODF) declared villages (47.3%), followed by Amhara region (40%). Oromia and Tigray regions had low percentages, 13% and 19%, respectively. The percentage with observed evidence of continued latrine use was relatively higher in Oromia and Amhara regions (30 and 27 percent, respectively).
PROGRAM AND POLICY IMPLICATIONS
The overall findings of the present analysis suggest that despite several achievements in improving the water and sanitation services in the target areas, the sector still needs a big push (or system strengthening) in terms of ensuring adequate capacity, financing, advocacy, and monitoring to achieve transformational change so that the 2030 SDGs’ sanitation, water, and hygiene targets can be achieved.
The findings suggest that managers of community water and sanitation projects together with development partners need to monitor the GSF’s key sanitation pillars (especially access, equity, habit/behavioral change, satisfaction, financing, and construction, etc) to monitor rapid progresses and transition to safely managed toilets, and importantly improving effectiveness/sustainability.
Narrowing down the gender gap in terms of decision making around access to water and sanitation services and reducing the very high level of stigma associated with menstrual management are crucial to improve equity in the sector. Equally important is drawing more attention to those with visual/ mobility limitations, most of whom do not use toilet facilities due to poor access. In this regards, schools and health facilities should allocate resources for educating the communities and institute affirmative actions.
The low level of sustainability in sanitation utilization in some of the regions (such as Tigray and SNNP) warrant more investments in the most left behind communities and closely monitor progresses to add momentum to achievement of national goals on sanitation and hygiene (i.e eradication of open defecation by 2030).
It is needless to mention that the government needs to increase budgeting and incentives to schools and health facilities for construction of improved water points and sanitation facilities. Continuous supervision of these facilities may be necessary to ensure continued access by the public.