Monitoring Sanitation And Hygiene In Rural Ethiopia
Water and Sanitation Program: TECHNICAL PAPERMonitoring sanitation andhygiene in rural Ethiopia:A diagnostic analysis of systems, toolsand capacityOliver JonesJune 2015
Author: Oliver Jones, Senior Water and Sanitation Specialist,The World Bank – Water and Sanitation Program, Africa.The Water and Sanitation Program is a multi-donor partnership, part ofthe World Bank Group’s Water Global Practice, supporting poor peoplein obtaining affordable, safe, and sustainable access to water andAcknowledgementsWith thanks to Dagnew Tadesse, Ministry of Health, andAbiy Girma and Tamene Hailu, Ministry of Water, Irrigationand Energy, for their support during the implementation ofthis project and development of this report; Anne Bakilana,Gulilat Birhane, Glenn Pearce-Oroz, Juliana Victor, TesfayeBekalu and Yolande Coombes for their critical reviewand helpful suggestions; to Rahel Wogayehu and YaredLegesse for their research assistance; and a special thankyou to Kebede Faris who also managed the performancemonitoring project, which led to the development of thisTechnical Paper.sanitation services. WSP’s donors include Australia, Austria, Denmark,This Technical Paper draws from experience of WSP’sScaling Up Rural Sanitation project in Ethiopia. This globalproject focused on learning how to combine the promisingapproaches of Community-Led Total Sanitation andSanitation Marketing to generate sanitation demand andstrengthen the supply of sanitation products and services atscale, leading to improved health for people in rural areas.It is a large-scale effort to meet the basic sanitation needsof the rural poor who do not currently have access to safeand hygienic sanitation. The project is being implementedby local and national governments with technical supportfrom WSP. For more information, please visit www.wsp.org/scalingupsanitation.Copyright StatementThis Technical Paper is one in a series of knowledgeproducts designed to showcase project findings,assessments, and lessons learned in the Global ScalingUp Rural Sanitation Project. This paper is conceived asa work in progress to encourage the exchange of ideasabout development issues.Photo Credits: Meseret Tsegaw and Andreas Knapp.Finland, France, the Bill & Melinda Gates Foundation, Luxembourg,Netherlands, Norway, Sweden, Switzerland, United Kingdom, UnitedStates, and the World Bank.DisclaimerThe findings, interpretations, and conclusions expressed hereinare entirely those of the author and should not be attributed to theWorld Bank or its affiliated organizations, or to members of the Boardof Executive Directors of the World Bank or the governments theyrepresent. The World Bank does not guarantee the accuracy of thedata included in this work.The material in this work is subject to copyright. Because The WorldBank encourages dissemination of its knowledge, this work may bereproduced, in whole or in part, for noncommercial purposes as longas full attribution to the work is given. 2015 International Bank for Reconstruction and Development/TheWorld Bank.
Monitoring sanitation andhygiene in rural Ethiopia:A diagnostic analysis of systems, toolsand capacityOliver JonesJune 2015www.wsp.org
Table of Contentsiv
Monitoring sanitation and hygiene in rural Ethiopia: A diagnostic analysis of systems, tools and capacity Table of Contentswww.wsp.orgv
uired Immunodeficiency Syndrome(Regional) Bureau of Education(Regional) Bureau of Finance & EconomicDevelopment(Regional) Bureau of Health(Regional) Bureau of Water ResourcesCentral Statistics AuthorityCommunity Led Total Sanitation & HealthDevelopment Assistance GroupDemographic and Health SurveyGross Domestic ProductGrowth and Transformation PlanHealth CentreHealth Extension WorkerHealth Extension programHuman Immunodeficiency VirusHouseholdHealth Sector Development PlanImproved Hygiene and SanitationJoint Monitoring ProgrammeJoint Technical ReviewMonitoring and EvaluationMillennium Development GoalMinistry of EducationMinistry of Finance and EconomicDevelopmentMinistry of andum of UnderstandingMinistry of Water, Irrigation and EnergyMinistry of Water Resource – now theMinistry of Water, Irrigation and EnergyMulti-Stakeholder ForumNational WASH Technical TeamNon-governmental organizationNational Hygiene and Sanitation Task ForceOne WASH National ProgramOpen Defecation FreePrimary Health Care UnitsRegional Health Bureau(Hygiene and Sanitation) Strategic ActionPlanSustainable Development GoalsSouthern Nations and Nationality RegionSector Wide ApproachUniversal Access ProgrammeUnited Nations Children’s FundWater, sanitation and hygieneWoreda Education DepartmentWoreda Health DepartmentWorld Health OrganizationWelfare Monitoring SurveyWoreda Finance &Economic DevelopmentBureauWoreda Water Department
Executive SummaryMonitoring changes in the coverage of sanitation1 andhygiene facilities continues to be a challenge faced bymany governments in the developing world. Effectivemonitoring is further complicated by the need not justto count related infrastructure but to also track changesin individual, household and community behaviors, aswell as the economic and health impact of these changes.The 2014 GLAAS report highlights, for example, that“most sector decisions are not evidence-based due to thewidespread lack of capacity for monitoring, inconsistent orfragmented gathering of data and limited use of informationmanagement systems and analysis”2.The responsibility for monitoring sanitation and hygieneinterventions in Ethiopia rests with the Ministry of Health,however the prevailing trend in recent years has been toalign the planning, monitoring and reporting of thedrinking water, sanitation and hygiene (WASH) sector.To achieve this there has been increased dialogue andcoordination between the Ministry of Health, Ministry ofWater, Irrigation and Energy, Ministry of Education, andMinistry of Finance and Economic Development. This hasresulted in some progress in the establishment of systemsto effectively monitor the status of water and sanitationservices in Ethiopia against sector targets.This report is based on a four year initiative by WSPundertaken at the request of the Ministry Health toimprove the monitoring protocols of sanitation in aneffort to provide clear evidence for decision-makers. Forthe first time, this report brings together an analysis of themultiple monitoring systems that have been developedby the WASH sector Ministries. The report aims tosystematically analyze the evolution of the systems, toolsand capacity in place to capture and analyze sanitation andhygiene related monitoring data. The recommendationsin this report aim to inform the Ministry of Health, andwider One WASH National Program (OWNP), to furtherstrengthen the monitoring of sanitation and hygieneinterventions going forward.1For the purposes of this document any reference to sanitation is deemed to refer to ‘onsite sanitation’ and primarily the containment of human excreta.2UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS),“Investing in Water and Sanitation: Increasing Access, Reducing Inequalities, 2014.www.wsp.orgWhile the WASH sector in Ethiopia has improvedmechanisms to align planning and programming, in aneffort to move towards a Sector Wide Approach (SWAp),the systems to enable the relevant Ministries to collate andanalyze monitoring data are still weak. This gap is hamperingefforts to achieve the goals of having one coordinated plan,budget and report for the WASH sector.Despite the improvement of Health MonitoringInformation System’s indicators, there is still misalignmentbetween the indicators, and their definitions, used bydifferent institutions and systems. This issue results incontinued confusion over the “correct” coverage figuresand hampers the effectiveness of strategic decision-making.However the progress made in aligning indicators hasincreased the sector’s ability to accurately report progressagainst targets.The analysis in this report provides evidence that there isstill a lack adequate resources to establish and effectively runthe WASH monitoring system at the Federal, Regional andWoreda levels. The inability to identify and retain personnelwith the right mix of skills, continues to be a bottleneckto the implementation of a fully functioning monitoringsystem within the sector. This is further compoundedby lack of financial resources available, specifically at theWoredas level, to undertake data collection and supportivesupervision activities.A well-functioning monitoring system in the sanitationand hygiene sector is essential to effectively target resources,identify emerging lessons and make modification to programapproaches, as well as report progress against targets.Underpinning this is the availability of good quality dataand the ability to analyze and share the findings. Due to theunreliability of data gathered and poor capacity to manageit, currently data is not effectively analyzed and used formanagement decisions or learning.While some progress has been made in monitoring theavailability of services, the more nuanced monitoring ofaccess to and use of services is still not being systematicallycaptured. In relation to sanitation and hygiene,methodologies and systems to monitor behavior changein relation to toilet use and hand washing practices arevii
Monitoring sanitation and hygiene in rural Ethiopia: A diagnostic analysis of systems, tools and capacity Executive summarystill not in place. Without monitoring the sustainabilityof services and behaviors the reliability of access and usefigures continues to be questionable.To improve the monitoring of sanitation and hygieneinterventions this report concludes that four main areasshould be addressed. The first of these is the harmonizingof indicators and their definitions across different sectorsurveys and monitoring systems. This process should alsoinclude the further alignment of indicators with sanitationand hygiene targets.The second area related to the strengthening of the Hygieneand Environmental Health program monitoring systems. Inaddition to the establishment of a stronger and more relevantset of standard indicators, those implementing the programmonitoring system require clearer guidance and tools tosupport data collection and analysis. It is also proposedthat the monitoring system should be shifted from being asystem focused on upward reporting, to a system of two wayinformation flows, which promotes feedback and supportsthe dissemination of analyzed data and emerging knowledge.Technology, specifically mobile phone technology, could bemore effectively harnessed to ensure information is morereadily available to decision makers.viiiThe third area relates to the resources available to supportthe monitoring systems and their implementation. Anadequate number of trained personnel, with knowledgeof both monitoring system and sanitation programs, aswell as a clear mandate, need to be deployed at all levels toundertake monitoring and program analysis activities. Inaddition, financial resources need to be available to supportthem undertake their roles effectively, and enable ongoingsupportive supervision and ensure quality control protocolsare fully implemented.Finally increased focus should be placed on enabling theOWNP monitoring system, to facilitate the development ofone plan, one budget and one report for the wider WASHsector. With an MOU in place between the key sectorMinistries, commitment to improve the monitoring ofsanitation and hygiene needs to be made at the very highestlevel. Critical to this is the strengthening of coordinationstructures and mechanisms to improve dialogue betweenthe relevant Government agencies and developmentpartners. This would improve common understanding andfacilitate the flow of information and knowledge to realizethe OWNP.
I.Introduction1.1. Sanitation and Hygiene in EthiopiaAccording to the latest Joint Monitoring Program (JMP)of United Nations Children’s Fund (UNICEF) and WorldHealth Organization (WHO) basic and improved householdsanitation coverage in Ethiopia is estimated to be at 63%.As a result it is estimated that around 37% of the population(over 35 million people) still don’t have access to any formof toilet and therefore defecate in the open. Within thisthere are disparities between the rural and urban context,with 43% of people living in rural area defecating in theopen compared to 8% in urban areas. Consistent withglobal trends, in Ethiopia those lacking access to improvedsanitation are those in the bottom poverty quintiles, withmore than three quarters of the poorest quintile practicingopen defecation compared to just 12% of the richest.3The lack of access to improved sanitation and the practiceof open defecation have significant socio-economic impacton the households without access and those living incommunities where access to sanitation is low. While it isclear that access to latrines in Ethiopia is still low, trendsshow a slow increase in those people adopting fixed placedefecation. Latrine coverage in Ethiopia has increased to63% in recent years, however high levels of unhygieniclatrines (62% of all latrines) and the practice of opendefecation (37%) result in a continuing disease burden.The lack of robust monitoring processes and accuratedata is hampering the ability to track progress, analyze theeffective of interventions and ultimately inform decisionson targeting those without access.1.2. Rationale and Objectives of the ReportThe International Development Association (IDA) and UKGovernment’s Department for International Development(DFID) supported the Water Supply and Sanitation Projectconcluded in 2014 and invested US 166 million over aperiod of 9 years. During this period over 5 million peoplegained access to improved water services as a result of theUNICEF-WHO, Joint Monitoring Report, “Progress on Drinking Water andSanitation, 2014 Update”, 20143www.wsp.orgproject. In line with Government of Ethiopia policy theproject also supported the promotion of sanitation servicesin rural and urban areas. However despite the resourceallocated to sanitation activities and some evidence ofprogress on the ground, it was very difficult for the programto report accurately the achievements and contribution inrelation to improvements in sanitation coverage.The World Bank’s Implementation Completion Report(ICR) for Water Supply and Sanitation Project (P076735)noted that while the project made a “significantcontribution to hygiene promotion, sanitationmarketing,and the integration of hygiene, sanitation and water; thissub-sector was notadequately monitored and data onsanitation aspects is poor.”4 DFID’s Project CompletionReport (PCR) of its parallel intervention points to thelack of community based monitoring systems, inadequatereporting by the health sector and inadequate followup by the WSSP Program Management Unit. Both theWorld Bank and DFID’s completion reports identify thatweakcoordination between the three sector ministries(Water, Health and Education) at all levels made it difficultto report sanitation and hygiene progress.This report aims to systematically analyze the currentsystems, tools and capacity in place to capture andanalyze monitoring data on sanitation and hygiene relatedinterventions. It will make recommendations to informthe Ministry of Health, and wider OWNP, to strengthenthe monitoring and reporting of sanitation and hygieneinterventions and impacts. This will included informingthe new Hygiene and Environment Health Strategy, andguide the indicators and systems put in place to monitortheagreed objectives.This report also aimsto contribute to the Ministry of Health’scommitment to strengthen the monitoring system forenvironmental health activities made through the SanitationWorld Bank the Implementation Completion and Results Report for Ethiopia WaterSupply and Sanitation Project (P076735) Pg. 1641
Monitoring sanitation and hygiene in rural Ethiopia: A diagnostic analysis of systems, tools and capacity IntroductionipsrshneartEp3.dan.10 ion ingstirv dipe auSu atadM&6co . M&mm E aun dvoicccu ation acy,lture s and7. Routineprogramonit mmeoring11an . Evd alre uase tioar nchfor212. Datadisseminationand use4. M&E planDialogue was facilitated with and between the followingGovernment of Ethiopia entities; Ministry of Health(MoH), Ministry of Water, Irrigation and Energy(MOWIE), Ministry of Education (MoE), Central StatisticsAgency (CSA), Regional Health Bureaus (RHB), RegionalWater Bureaus, Woreda Health Bureaus and WoredasAdministrations. In addition consultations were held withmany development partners, including UNICEF, WHOand DFID.National LevelMeetingsSanitation and Water for All is a global partnership of over 90 developing countrygovernments, donors, civil society organizations and other development partnersworking together to catalyze political leadership and action, improve accountabilityand use scarce resources more effectively5ityDesk Reviewacapnc Em a M&HuConceptDevelopment8. Surveys andsurveillance&E9. M asebdataThe methodology adopted to undertake this diagnosticanalysis included a mix of analysis of existing systems, aliterature review, stakeholder consultations (see Annex 2for semi-structure questionnaire used) and workshops. Thisanalytical work formed part of a broader effort of WSPtechnical assistance, requested by the Ministry of Health,focused on shifting the enabling environment in order toaccelerate the access to rural sanitation.1. Organisationalstructures with M&E&EdMste planCo5. work1.3. MethodologyThe analysis undertaken in this report has been guided bya framework developedby Water and Sanitation Program(WSP) of the World Bank’s Water Global Practice to reviewEthiopia’s sanitation and hygiene monitoring system. Theframework was adapted from a tool developed by USAIDto support the review of national HIV/AIDS monitoringsystems. The USAID tool was chosen as it is consideredto be one of the most robust frameworks for analyzingmonitoring systems in the health sector. It consists oftwelve components, set out in the diagram below (the fullframework is included in Annex 1).Figure 1: Components Monitoring & EvaluationSystem Assessment Tool2.and Water for All5 (SWA) process. While the report willfocus on sanitation and hygiene monitoring the report willplace sanitation and hygiene monitoring in the context ofwider WASH sector monitoring. As a result it is expectedthat this report will provide significant inputs to guidingthe technical assistanceto strengthen the monitoring of theOWNP, to be provided by DFID and the World Bank.Sub-NationalLevel MeetingsWorkshop
II.WASH Sector Monitoring2.1. National Statistics and SurveysThe CSA implements a wide range of nationallyrepresentative household surveys. In the 2008 review ofthe Health Monitoring Information System (HMIS),the Ministry of Health acknowledged the importanceof the Demographic and Health Survey (DHS) andWelfare Monitoring Survey (WMS) in providing healthinformation, including access to drinking water and toiletfacilities, as well as waste disposal.The DHS provides baseline data to support the M&Esystem of the Growth and Transformation Plan (GTP), aswell as various sector development policies and programs.The WASH indicators used by the DHS align with thoseprovided by the Joint Monitoring Program for Waterand Sanitation (JMP) of the World Health Organization(WHO) and UNICEF, which is mandated by the UNto track global progress towards the water and sanitationMDG targets.6The Ministry of Health recognizes that in order to improveconsistency between national surveys and other datasources, including the HMIS, the establishment of commondefinitions and understanding on how to interpret theresults are essen
3 UNICEF-WHO, Joint Monitoring Report, “Progress on Drinking Water and Sanitation, 2014 Update”, 2014 4 World Bank the Implementation Completion and Results Report for Ethiopia Water Supply and Sanitation Project (P076735) Pg. 16 1.1. Sanitation and Hygiene in Ethiopia
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tle introduction into state-of-the-art description logics. Before going into technicalities the remainder of this section will brie y discuss how DLs are positioned in the landscape of knowledge representation formalisms, provide some examples for modeling features of DLs, and sketch the most prominent application context: the Semantic Web. Section 2 starts the formal treatment by introducing .
