A sanitation success story - the effects ofdemand creation in Bangladeshby Derrick O. Ikin

The rural health horror - a thing of the past?

Despite Bangladesh's great achievements inincreasing drinking-water coverage, there wereno parallel improvements in the health of itspeople - until a radical rethink of the country'ssanitation focus. Derrick Ikin describes somedramatic developments.

programmes.Through its 494 partner

In partnership withUnicef, the Governmentof Bang]adesh has carriedout a number of socialmobilization programmesfor sanitation; andbetween 1993 and 1995,SOC and DAN IDA pro-vided funding of US$3.7million. In effect, this is amassive demand-creationprogramme, based on peo-ple's needs and linked totheir cu]tural understand-ing, incorporating contri-butions from prominentfigures, ranging from thePrime Minister, to villageleaders. Even moreimportantly, it promoteda range of availab]e,affordable alternatives. ~The results of these social ~mobilization/social mar- ~keting efforts are being ~continually analysed, and ~

<.>fed back into the .~

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needs of Bangladesh's 120 millionpeople. This led to a re-thinking of theprogramme and, after considerableinternal and external efforts, (market-ing-oriented input and pressure toimprove the health impact), the countryprogramme was reoriented to promot-ing affordable solutions and hygienicbehaviour. This pioneering effort beganin 1990 with a DPHEfUnicef imple-mentation of a social mobilizationprogramme that encouraged betterhygiene practices as well as the buyingor building of basic latrines.This sanitation promotion consisted

of a mix of interpersonal and appropri-ate mass-media techniques, andresulted in tens of thousands of latrinesbeing built or bought. Many latrinesthat had been built over water sourceswere destroyed, and open defecationdecreased. The real breakthrough wasthe development, and innovative masspromotion of, an affordable, sanitary,home-made latrine which had a slaband one ring. This socia] marketingbuilt on previous efforts to improvesanitation; but although the basicknowledge was there, before seriouspromotion began, no action had beentaken.

usually subsidizing their own produc-tion costs and selling at market, or nearmarket, prices.

Demand creationIn 1989, Strauss and Chadha's ideas onthe promotion of rural sanitation inBang]adesh contributed greatly to theprocess of treating beneficiaries as cus-tomers with needs and an ability topay. I Despite subsidies, over 80 percent of the population could not affordthe product promoted by DPHE,Unicef, and the various NGOs. It wasalso estimated that, by 1989, about 700commercial latrine producers wereoperating, despite the subsidies.It also became increasingly apparent

that neither the government nor donorscould afford to meet the vast sanitation

THE DEATHS, SUFFERING, andfinancial losses caused by sanitation-related diseases cry out for the urgentpromotion of sanitation at all levels.There are about two billion incidents ofdiarrhoea per year; the real costs of nosanitation are astronomical.A rough cost estimate for basic oral

rehydration for only 20 per cent ofdiarrhoeal incidents worldwide is U$5million per day. These estimatesexclude hospital and burial costs, andworking days lost.In Bangladesh, there are 61 million

cases of diarrhoea, and approximately260 000 children die, every year. Theoverall problem is directly related tothe 28 000 metric tonnes of faecal mat-ter deposited openly into the environ-ment every day. Unsanitary hygienepractices and the lack of facilities aremajor problems. Drinking-water cover-age in Bang]adesh is estimated to beover 90 per cent, reaching about 85million people. Yet, because of the san-itation situation, no beneficial healthimpact seems to have occurred.With this in mind, we will examine

in this article the 'sanitation success'which is taking place in Bangladesh.Sanitation success can be defined ascoverage, users paying, commercialproducers supplying hardware, and thesafe removal of faeces from people'simmediate environment. Longer-termsuccesses are a sustained, positivehealth impact, and regular, safe, pit-emptying and latrine maintenance.Since ] 965, the Government of

Bang]adesh's Department of PublicHealth and Engineering (DPHE) haspromoted a simple water-seal slab andring-lined pit.Coverage never rose beyond between

2 and 3 per cent in the late ]960s. In1975, DPHE and Unicef began toexpand the sale of this subsidized prod-uct and, by 1993, over 1000 village-sanitation production centres had beenestablished. In addition, numerousNGOs focused on similar products,

WATERLINES VOL. 14 NO.3 JANUARY 1996 9

Although expensive, the government model helped populanze the Idea oJpaymg Jor samtatlOn.

Future challengesFor the Bangladesh programme, theultimate goal is to attain a positivehealth impact. The immediate chal-lenge is how to reach the remaining2650 - out of over 4450 - unionsthat are still without commercialproducers. The large number ofcommercial producers makes the gov-ernment village production sanitationcentres redundant, and a decision toclose or move superfluous centres iscritical to the continued spreading ofthe sanitation success. DPHE is experi-menting with mobile latrine produc-tion, and with this selling units inunions without production centres.A WHO study confirmed that nearly

half the water-seals had been broken byusers, and it has often been observedthat water-seal latrines are only flushedoccasionally, leaving accumulated fae-ces exposed to animals and flies. Newproducts such as the Sanplat (without awater-seal)2 are being introduced veryslowly; further options are required.Then there is the question of subsi-

dies: both the government and Unicefare resisting calls to remove or reducelatrine subsidies - although, togetherwith other NGOs, they are looking

o For the averageBangladeshi, owning abasic latrine was not,ten years ago, a priority.Following product pro-motion, however, it isseen as integral to tak-ing care of one's familyand being a responsiblecitizen. Demand hadbeen created.

o Users as customers,commercial producers,and an affordableproduct all formedcentral aspects of theprogramme strategy.

o Core promotional mate-rial was professionallydeveloped and used.Latrines were promotedon the basis of privacy,prestige, and conve-nience for women.

o Some larger NGOsbought directly fromcommercial producersinstead of establishingtheir own centres.

o Religious leaders actively supportedthe campaign for sanitation, andthousands of schoolchildren andteachers played a leading role.

o Research before, during, and after thecampaigns allowed the programme tobe modified.

learning experiences are disseminatedto NGOs, and are fed into theongoing social mobilization forsanitation programme.

Secrets of successSeveral factors have contributed tothis success:

The producersIn 1991, interviews were carried outwith 50 latrine producers. Theiranswers were revealing; they demon-strated remarkable production flexibil-ity, an ability to adapt the product tocustomers' requirements, a willingnessto deliver to people's homes, and tosurvive on small profit margins. To alarge extent, commercial producers hadmanaged their own credit needs and, ingeneral, preferred non-interferencefrom the authorities.Many producers set up their busi-

nesses near the government latrine-pro-duction centres. The government cen-tres introduced an 'expensive' statusproduct that, over the years, played aseeding role in popularizing the idea ofpaying for sanitation.A recent countrywide survey showed

that the number of commercial produc-ers in Bangladesh had increased fromapproximately 700 in 1989, to 2542 in1994. Sanitary latrine coverage is nowabove 25 per cent; in five 'model' dis-tricts, coverage ranges from 60 to 80per cent, and health conditions arethought to be improving. In addition,latrine-pit cleaners reported anincreased demand for their services.

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NGOs, the NGO Forum for Drinking-water Supply and Sanitation has beensupporting Bangladesh's sanitationprogramme, with success. The Forumis implementing social mobilizationprogrammes in close co-operation withDPHE and Unicef and its partnerorganizations in 20 thallas. Positive

10 WATERLINES VOL. 14 NO.3 JANUARY 1996

Slab ahoy! Commercial latrine producers know it makes business sense to deliver to their customers' homes.

promotion of latrine production by privateproducers in rural/semi-rural areas ofBangladesh', SKAT, St. Gallen, ]992.5. Minnatullah, K.M. et al., 'Communitymanagement of rural water supply and sanitationservices - a Bang]adesh case study', UNDp·World Bank Regional Water and SanitationGroup South Asia, Dhaka. 1991.6. Wijk. C. van, Gender aspects of sanitation:The missinR slipper of Cinderella? IRC, TheHague. 1993.

Derrick O. Ikin of SKAT has been backstopping(providinR occasional inputs to) the BClIIgllldeshproRralllme on behalf of SDC and DANIDA. Heis currell/ly workinR with SDC in Mozambique- Caixe Posta Ie /35. Maputo. Mozambique.

ReferencesI. Chadha, S., and Strauss, M., 'Promotion ofrural sanitation in Bangladesh with private sectorparticipation', Swiss Development Co-operation,1991.2. Brandberg, 8., 'Improved sanitation using theSanplat System', Waterlines, Vol. 12, No.4;Brandberg, B., Latrine Bui/ding: A handbook forimplementing the Sanplat system, ITPublications, London, 1996.3. Hoque, B.A., and Briend, A., 'A comparisonof local handwashing agents in Bangladesh',Journal of Tropical Medicine and Hygiene, 94,1991.4. Ikin. D.O., and Rahman, M., 'Report of theconcept mission to develop a proposal for the

closely at different options - becauseof the current political climate.Another challenge is to establish how

much of this type of mass promotionand social mobilization is needed toensure sustainable changes from gener-ation to generation. A demand was cre-ated for products that are available,affordable (with or without subsidies),and meet the needs of the users.People's needs and perceptions werestudied, and appropriate promotionstrategies were developed. The usersand sanitation promotionhad now become a centralfocus. This marketingapproach moves away fromthe false assumption com-monly held that, because Xis good for the beneficia-ries, they will buy it orchange elements of theirbehaviour. Demand cre-ation increases families'willingness to pay, and totake action.Commercial producers

are recognized as anessential element in solvingthe problem of sustainablesanitation. The success inBangladesh is even moreremarkable in view of thelarge number of poorBangladeshis. People the world over know what they want, and will work together to bring about change.

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