09 March 2012

Cross-sectoral collaboration is needed to make sanitation projects work

A teacher in northern Vietnam shows the children how to wash their hands with soap. The school - and health sectors must work together to make hygiene and sanitation projects a success, recommends the research project SANIVAT.

Access to water and sanitation has high political priority in Vietnam, but the efforts seldom reach the ethnic minorities in the Northern part of the country. There is too little focus on collaboration across sectors and the health promotion which comes along with the projects is often outdated, emphasizes the research project SANIVAT which is funded by DANIDA

Text: Kathrine Storm

The World Health Organisation, WHO, estimates poor sanitary conditions to be the fourth leading cause of death globally and the second leading cause of death in low- and middle income countries. According to UNICEF (2009) hygiene efforts should therefore be a top priority to strengthen children’s health in the low and middle income societies.

During 2011, the research project SANIVAT has explored the water and sanitation conditions and behavior among the local communities in two rural communes in the Northern Vietnam. These communes were chosen because they are home to several groups of ethnic minorities who live in the low- and highland. Compared to the rest of the population the ethnic minorities have a far higher disease occurrence and it is often related to poor sanitation and hygiene behavior. The project SANIVAT therefore puts spotlight on the health and diseases of the ethnic groups in Vietnam.

“It is very positive that access to good sanitary conditions receives high political attention in Vietnam, but if the projects which the authorities are starting up also are to include the ethnic minorities the projects must be implemented differently. Today there is a lot focus on the hardware, especially the construction of latrines but too little focus on the software – efficient training and communication about sanitation and hygiene. And what is it worth to build new toilets if they are never used or disliked?” says Thilde Rheinländer who is postdoctoral researcher at the University of Copenhagen.

Thilde Rheinländer has completed her PhD in connection to SANIVAT and points out that the current health promotion in the communes needs to be updated and become far more participatory. Today the sanitation and hygiene promotion is mainly based on one-way communication with posters, brochures and speaks from locally appointed health promoters to the women of the villages and this has several implications:

“The information does not create lasting behavioral changes and it does not reach the target groups in several aspects.  Firstly, the information is only in Vietnamese but several of the women have not attended school and only speak the local ethnic minority languages. Secondly, there is a great focus on the women but grandparents, children, husbands and key institutions such as schools and health clinics should also be included. Thirdly, the current health promotion is very standardized and following national guidelines. But in order to successfully make people build and use the latrines the promoters must know and understand the local context and the sanitary facilities that match the families’ needs. Therefore it would be a really good idea to include the heads of the communities,” suggests Thilde Rheinländer.

Health promotion should be a cross-sectoral act

Thilde Rheinländer bases her recommendations on a thorough fieldwork including interviews with 56 stakeholders from three different sectors (including health, education, and agriculture) and grass root organizations at three administrative levels – from province, districts, and communes to the locally appointed village health workers. The purpose of the study was to analyze the roles of all stakeholders involved with water and sanitation promotion. The analysis showed that there is a great need for the sectors to coordinate and integrate their efforts in sanitation promotion especially at the local level in communes and villages.

The link between the health sector and the school sector is one of the key areas that needs attention says Le Thi Thanh Xuan from Vietnam, who is a medical doctor also participating in the SANIVAT project. As a PhD student at the University of Copenhagen she has explored how hygiene and sanitation is prioritized in the school teaching. She has also interviewed a broad range of people from political decision makers, to school children, parents and teachers. This gave her a clear picture of where the effort could be concentrated.

“Vietnam has a very strong educational system partly because it is based on national guidelines. However, in connection to education of sanitation and hygiene these guidelines are less appropriate.  They are too standardized and only give general rules e.g. where to place the latrines and the number of latrines,"says Le Thi Thanh Xuan. 

But theses standardized guidelines do not capture the reality in the communities where there are too few latrines compare to the number of school children resulting in over-usage, and poor accessibility of latrines for children.

School children are important agents in community health promotion because they bring their skills home, but posters alone are not sufficient.

 But beside a need for adapting the physical facilities to the children, they also lack training of how to practice good hygiene behavior including how to use a toilet.

 “The national guidelines only provide information, but schools lack a practical guide adjusted to the children’s everyday life. It could for example be training the kids how to wash their hands. The schools are a really important place to focus on; there is a great potential in strengthening the school-home link, because the children learn fast and they can bring their knowledge and skills home to the families”, emphasizes Le Thi Thanh Xuan.

Usage instead of coverage

Collaboration between sectors; greater focus on creating sustainable good hygiene behaviour; efficient training, and adaption of the national guidelines to the ethnic minorities. In headlines, these are the recommendations from the researchers, and it demands a complete change of the way the authorities measure the projects’ success, recommends Professor Anders Dalsgaard, from the University of Copenhagen, who is the Danish leader of SANIVAT:

“Today the improvement of sanitation is evaluated in relation to coverage, e.g. if the number of latrines or sources to clean drinking water has increased. Instead the authorities should look at how many people actually use the facilities and if they are happy using them. We need to giver higher priority to collaboration, education, behavior and efficiently adapted communication to ensure the success of the sanitation projects. Otherwise you risk the efforts and the money is wasted”, stresses Anders Dalsgaard.