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Health, Water Supply,
Sanitation and the Poor
Hanoi, 2008
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Copyright 2008 o Vietnam Ministry o Natural Resources and Environment (MONRE)and United Nations Development Programme (UNDP)
Published in Vietnamese and English with the approval o MONRE and UNDP.Publishing contract Number .. date
Responsible or publishing:
Asso. Pro.Dr. Truong Manh Tien
Edition:Dr. Nguyen Trung Thang
Dr. Michael ParsonsMSc. Kim Thi Thuy Ngoc
MA. Nguyen Thi Phuong NganMs. Phan Th H
Ms. Nguyn Th Ngc nhMs. Hong Hng Hnh
Mr. Nguyn Hong Minh
Printed in Hanoi, Vietnam
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Preace
Strengthening capacity or sustainable natural resource use and environmental protection to reduce povertypresents a major challenge to Viet Nam and its development partners. Environmental conditions have asignifcant impact on the livelihoods, health and security o poor and vulnerable groups in particular womenand children and better environmental management is vital to poverty reduction, sustainable growth andattainment o Viet Nams Development Goals.
The Harmonizing Poverty Reduction and Environmental Goals in Policy and Planning or Sustainable Development(2005-2009) project, better known as the Poverty and Environment Projector PEP, seeks to strengthen Governmentcapacity to integrate environment and poverty reduction goals into national and provincial policy and planningrameworks or sustainable development. The project has our ocal areas; orestry, fsheries, renewable energyand natural resources and environment. It is unded by UNDP and DID, and implemented by MONRE withthe participation o the MPI, MARD, MOIT, and DONREs in our provinces. Ha Tay and Ha Tinh are the two pilotprovinces and Ha Nam and Ninh Thuan are the two replication provinces where pilot activities will be extended.
The goals o PEP are to achieve:
Improved knowledge and awareness within government and civil society o barriers, capacities andopportunities or natural resource use and environmental protection to contribute to national goals,targets and strategies or poverty reduction and sustainable development;
Strengthened institutional capacity to monitor and report on poverty-environment indicators andoutcomes, and to use those data eectively;
Strengthened institutional mechanisms and capacity to integrate poverty reduction and environmentalconcerns into development policy and planning rameworks;
Strengthened capacity in MONRE to set strategic priorities and develop policy and legal instrumentsthat encourage environmental protection and natural resource use and support poverty reductionand improved equality;
Strengthened institutional capacity o MONRE to coordinate donor support within a programmatic
ramework, regarding natural resource use and environmental protection, and links to povertyreduction.
To ulfll these objectives PEP put out to Public Tender three separate sets o activities, as Tender Packages. Thefrst set aims to identiy and raise awareness on poverty-environment linkages and promote best practicesin poverty reduction and environmental protection. It is being conducted by a consortium led by ICRAF. Thesecond set, being carried out by IMHEN, aims to strengthen poverty-environment monitoring capacity andprocedures. The fnal package, being undertaken by SDIN joint venture, seeks to mainstream environmentaland poverty concerns into policy and planning at national and provincial level, to enhance MONREs capacity todevelop policy and legal instruments and to build stronger partnerships to secure poverty reduction throughenvironmental protection.
The frst Tender Package, named Support expansion o the knowledge base on poverty-environment linkagesthrough conducting 10 case studies, reviews o national programmes and ocussed projects and the developmento policy and investment models, includes the ollowing ten case studies:
Understanding the voice o the poori.
Impact o the environment on healthii.
Water supply and sanitation or poor communitiesiii.
Poverty in environmental policies and legislationiv.
EIAs and the poor / coping strategiesv.
Income sources or poor people rom the environmentvi.
Improvement o environmental conditions or the poorvii.
Renewable energy or poor communitiesviii.
Gender dimension o povertyenvironment issuesix.
Impact o migration on environx. ment
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Health, Water Supply, Sanitationandthe Poor
and two policy-investment models, which are to be piloted in Ha Tay and Ha Tinh. These models will suggestthe policy support required to ensure the long-term success and replication elsewhere in Viet Nam o practicalpoverty reduction measures or environmental protection.
The research outputs o these ten case studies are presented in a series o six thematic study reports namely:
Understanding the Voice o the Poor1.
Environmental Polices, Legislation and the Poor,2.
Health, Water Supply, Sanitation and the Poor,3.
The Environment, Income Generation and the Poor4.
The Environment, Renewable Energy and the Poor5.
The Environment, Gender, Migration and the Poor6.
All edited reports will be available or download rom the Poverty Environment Network (PEN) website www.povertyandenvironment.vn managed by PEP on behal o the ISGE. PEN members are regularly invited tomeetings and seminars held by PEP, and are able to participate in other events organized by the Network onpoverty and environment issues. This research output would be interesting or all development stakeholders
and useul or policy makers. The PEP also strongly encourage the readers to become members o the PovertyEnvironment Network, to participate in PEN activities and to provide eedback on issues raised by postingcomments and contributing to discussions on the website orum
It is our honour to present this report to readers
NATIONAL PROJECT DIRECTOR
ASSOC. PROF. DR. TRUONG MANH TIEN
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Acknowledgements
We would like to express our gratitude to the kindly support and participation in feld work, report writingactivities as well as valuable comments rom Mr. Nguyen Doan Sang, Mr. Pham Van Binh, Ms. Nguyen Thi ThanhThuy (PEP Ha Tinh), Ms. Nguyen Thi Ha Tan (Chairwoman o Women Uniton, Loc Ha District, Ha Tinh Province,Mr. Nguyen Vinh Luyen (PMU or Da Lat sanitation project), Dr. Vo Thi Khuong (Deputy Director o Da Lat HealthCare center), Mr. Dagoud Tri (Deputy Director o Lac Duong PC), Mr. Doan Van Ti (Director o Xa Lat communePC, Head o Health Core Group), Mr. Le Huu Tuc (Deputy Director o Don Duong PC), Mr. Tran Tan Xi (Directoro Da Ron commune PC), Mr. Tran Manh Thang (Vice Director, Phu Tho Cerwass), Ms. Nguyen Thi Lan (MedicalDoctor, Phu Tho HIV/AIDS preventive and control cente), Ms. Tu Thi Thanh Giang (Vice Chairwoman o Viet TriWomen Union), Ms. Luu Thi Ban (Chairwoman o Tien Cat Ward, Viet Tri Women Union), Mr. Le Van Ton (Head oHealth Care Station, Thach Son commune, Lam Thao, Phu Tho), Mr. Vu Xuan Sinh ( Head o Unit 5, Trung Vuongcommune, Viet Tri, Phu Tho) and Ms. Bui Quynh Nga (Carl Bro Vietnam sta)
Last but no least, we desperately appreciate the great supports o local sta and people in studied sites: HaTinh, Lam Dong and Phu Tho or ulflling our feld trips.
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Abbreviations and Acronyms
ADB Asian Development Bank
AusAID Australian Agency or International Development
CBO Community Based Organisation
CPC City Peoples Committee
DANIDA Danish International Development Assistance
DFID Department or International Development (UK)
DONRE Provincial-level Department o Natural Resources and Environment
DOSTE Department o Science, Technology and Environment
DPI Provincial- level Department o Planning and Investment
DVC Latrine Double Vault Composting Latrine
GTZ German Technical Cooperation
HIA Health Impact AssessmentICRAF World Agroorestry Centre (International Centre or Research in Agroorestry)
IEC Inormation, Education and Communication
IMHEN Institute o Meteorology, Hydrology and the Environment
ISGE International Support Group on Natural Resources and Environment
KW Kreditanstalt ur Wiederaubau (German Development Fund)
MARD Ministry o Agriculture and Rural Development
MOIT Ministry o Industry and Trade
MOH Ministry o Health
MOLISA Ministry o Labour, War Invalids and Social Aairs
MONRE Ministry o Natural Resources and EnvironmentMPI Ministry o Planning and Investment
MRDP Rural Development Programme
ODA O cial Development Assistance
PAPOLD Participatory Analysis o Poverty and Livelihood Dynamics
PCERWASS Provincial Centre o Rural Water Supply and Sanitation
PEP Poverty and Environment Project
PHAST Participatory Hygiene and Sanitation Transormation
PPA Participatory Poverty Assessment
PPC Provincial Peoples Committee
PRA Participatory Rural Appraisal
PTWSC Phu Tho Water Supply Company
RWSS Rural Water Supply and Sanitation
SCUK Save the Children UK
SDIN Sustainable Development Institute o the North
SEDS The National Strategy or Socio Economic Development or 2001- 2010
SIDA Swedish International Development Agency
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URENCO Urban Environmental Company
UNDP United Nations Development Programme
UNESCAP United Nations Economic and Social Commission or Asia and the Pacifc
WB World Bank
WPC Ward Peoples Committee
WSC Water Supply Company
WSS Water Supply and Sanitation
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Table o Contents
Preace ...........................................................................................................................................................................................................i
Acknowledgements .............................................................................................................................................................................. iii
Abbreviations and Acronyms.............................................................................................................................................................. v
Table o Contents ..................................................................................................................................................................................vii
CHAPTER 1. Introduction ......................................................................................................................................................................1
1.1. Introduction ............................................................................................................................................................................... 3
CHAPTER 2. Methodology and Site Selection ............................................................................................................................... 5
2.1. Methodology ............................................................................................................................................................................. 7
2.2. Sites and Programmes or Reviews, PRAs and Case Studies ..................................................................................... 8
2.3. Principles, techniques and materials .................................................................................................................................9
CHAPTER 3. Summary o Findings ..................................................................................................................................................113.1. Summary o Findings
CHAPTER 4. Analysis o Findings......................................................................................................................................................29
4.1. Links between Health and Environment .......................................................................................................................31
4.2. Links between Health, Environment and Poverty ......................................................................................................32
4.3. WSS Technologies Directly Assisting the Poor .............................................................................................................33
4.4. Gender Issues ...........................................................................................................................................................................34
CHAPTER 5. Conclusions and Recommendation .......................................................................................................................37
5.1. Links between Health and Environment .......................................................................................................................39
5.2. Links between Health, Environment and Poverty ......................................................................................................39
5.3. WSS Technologies Directly Assisting the Poor .............................................................................................................40
5.4. The Importance o IEC Activities and Participation o both Women and Men.................................................40
5.5. The Importance o Strengthened Co-ordination ........................................................................................................41
APPENDIX 1. CASE STUDY 1: Impacts o Environment on Health. Community Awareness Campaign, Phu Tho
Water Supply Company, Viet Tri City, Phu Tho Province ..........................................................................................................43
APPENDIX 2. CASE STUDY 2: Water Supply and Sanitation or Poor Communities. The Rural Water Supply and
Sanitation Project, Ha Tinh Province, Viet Nam (incorporating the Project/Programme Review) ...........................51
BIBLIOGRAPHY .......................................................................................................................................................................................61
LIST OF RESEACHERS/EXPERTS INVOLVED IN THIS STUDY .....................................................................................................63
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Chapter 1
Introduction
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Chapter 1: Introduction
1.1. Introduction
The Poverty and Environment Project o MONRE unded by UNDP and DFID began its work in October 2005.One o its earliest activities was to initiate research into poverty-environment linkages; the frst output othis research was an initial review o existing inormation on such linkages in Viet Nam; the report rom thatStudy, hereater called the Inception Report, was presented at a national workshop held in Hanoi on the 5th
o February 20071. The Inception Report was to be ollowed by six thematic study reports, covering ten casestudies.
This Report is the second o the 06 thematic study reports, the thematic study dealing with health, watersupply and sanitation and the poor. It is perhaps in this area, the area o water supply and sanitation, thatthe lessons in development practice, the concerns or sustainability and the need to address both povertyand gender have been around the longest. Early ailures in development projects, and the lessons learnedabout citizen participation in particular, came rom attempts to provide clean water in communities withoutproper consultation about location, technology and operation and management issues2 . Many o the toolkitscurrently in use have been developed out o the lessons learned rom water, and more recently rom waterand sanitation programmes. In many locations, and especially so in Viet Nam, sanitation has been intended bydonors to ocus on latrines, but has developed a wider meaning in terms o environmental cleanliness which
can include waste management and avoidance o pollutants.
The link between water and sanitation and health has been very early documented, and orms the primarybasis or water and sanitation projects. The link between health and poverty is also well established withthe cycle o poor health, low productivity, low income, poor acilities and poor health care aordability beingwell accepted. The gender dimensions o the health/poverty/water and sanitation matrix have also been welldocumented, with women having most household responsibility or household sanitation and water supplies345, and suering most o the consequences o the lack o these including care o household members whoare ill, long working hours etching adequate supplies and in more remote areas chronic back pain related tocarrying water or long distances. This thematic study seeks to elaborate the linkages described above.
The Inception Report on Poverty-Environment Linkages pointed out that our main gaps in knowledge can beound in current policies, programmes and projects.
Firstly, there is a signifcant level o inequity in access to sae water and sanitation throughout VietNam because o (i) low investment in sae water and sanitation, and; (ii) poor management. Signifcantnumbers o lowland poor using dug wells or surace water are aected by lack o access to, or pollutiono drinking water. However, the question oHow much o this is due to (i) poor rural inrastructure? (ii)high price? (iii) low income? has not been answered or addressed in current studies.
Secondly, the ethnic minorities are in higher incidence o diseases related to water and sanitationis visible but not ully explained. There is no inormation on diseases and sanitation measures, noknowledge about diseases and their causes and no eort to treat diseases and take sanitation measures.These are gaps that have not been well-addressed in published documentation and papers.
Thirdly, sae water and sanitation programmes ace a challenging issue o targeting. Competitionor access to improved services arises between poor and non-poor households or communities in a
context o limited budgets. Government Programme 135 allows targeting at the commune level. Howcan poorer villages within these communes be most eectively targeted?
Finally, pro-poor solutions to the dug-well pollution issue will require aordable technicalinnovations. Pollution rom local domestic and human sources can be addressed through improvedwaste management. It is not so, however, or diuse pollution o agricultural and, increasingly,industrial origin. How can we ensure that the poor have access to aordable alternative solutions todug wells?
1 Poverty and Environment Linkages in Viet Nam, Report 1, Hanoi, April 2007, p. 6.2 Kumar, S 2002, Methods or Community Participation: A complete guide or practitioners, Vistaar Publications, New Delhi.3 Bergho, C & Dinh, T 2002, Men and women in rural water supply and sanitation in Viet Nam, Ministry o Agriculture and Rural
Development Centre o Rural Water Supply and Sanitation, Hanoi4 Viet Nam Womens Union, 10 July 2005 accessed at http://hoilhpn.org.vn5 Danida, 2006 Management Lessons Learned during the Implementation o the WaterSPS and NTP 1 and Recommendations or
Next Phase Drat Document, Hanoi August, 2006
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Among the lessons most recently learned in Viet Nam through the implementation o the National Rural Waterand Sanitation Strategy, as well as through programmes o urban and peri-urban health promotion and waterand sanitation provision, are the ollowing:
Health promotion needs to incorporate both traditional and modern approaches in order to beeective and to promote changes in health behaviour. The PHAST6 method (Participatory Hygieneand Sanitation Transormation) provides or participatory approaches to increasing awareness in
communities, as well as or community approaches to planning health goals and activities. Addedto this has been the experience o social marketing, mainly until now used in the fght againstHIV/AIDS, which looks or both barriers and incentives or behaviour change and places emphasison fnding the cues to prompt more rapid behaviour change in the individuals, households andcommunities7 . Change happens slowly step-by-step is a common theme in planning meetingsin Viet Nam, and this is true in terms o maintaining valued traditions and customs. However,environmental protection and poverty reduction are both issues which cannot wait a generationor change.
Communities must have access to afordable and appropriate technologies or the provision o watersupply and sanitation.
Households even poor households - must also have access to afordable credit in order to makeinvestments in household and community inrastructure. Micro credit programmes operated
through the Viet Nam Womens Union and other sources, together with inormal community creditmechanisms, have been shown to have had considerable success in making improvements towater supply and sanitation acilities.
Participation must be ocused to planning and implementation, including the participation owomen. In Viet Nam we know that the participation o the Mass Organizations is one way toachieve this.
Health, water and sanitation issues , along with environmental concerns do not exist in a vacuumand must be integrated into the broader aspects o development, including the promotion ointer-agency co-operation and collaboration and provision o local planning and consultationmechanisms.
The objectives o this study are:
To elaborate linkages between health, the environment and poverty among the rural and urban poor.
To examine, in particular, issues surrounding the development o environmentally sound, clean and e cient
water supply and sanitation technologies that directly assist the poor in urban and rural areas (including
means o disseminating and replicating environmentally appropriate technologies).
The outputs o this study are:
Adapted PRA methodology1.
Summarised results o PRAs in target districts (Fact Sheets)2.
Six separate Fact Sheets have been prepared, one or each o the PRA sites
Project programme reviews, highlighting lessons learned (Fact Sheets)3.
Three separate project review documents have been prepared
Detailed PRA analysis4.
One PRA analysis document has been prepared, based on the six PRA studies and the act sheetsproduced or each PRA
Case study reports5.
Two case studies have been prepared. Each case study is based on one o the project reviews (output3) and two PRAs, all rom the same province.
Minutes o the national workshop held on 29 August 20076.
An Analytical Paper summarising all the above outputs7.
Comments received rom during the national workshop held on 29 August 2007 and subsequent comments
received rom the Poverty and Environment Project (PEP) have been incorporated into the above-mentionedoutputs.
6 WHO, 1998 PHAST step-by-step guide: A participatory approach or the control o diarrhoeal diseases7 McKenzie-Mohr, D. and Smith, W, 1999 Fostering Sustainable Behaviour: An Introduction to Community Based Social Marketing.
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Chapter 2
Methodology and Site Selection
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Chapter 2: Methodology and Site Selection
2.1. Methodology
The methodology or the Health, Water Supply and Sanitation Studies included a combination o qualitativeand participatory tools used or the PRAs in selected districts and communes, together with Project Reviewsincorporating document reviews and in some cases key inormant interviews with project sta, communityleaders and health authorities.
The combination o methods enabled the triangulation o qualitative and some quantitative data collected,which is a means o validation, particularly or qualitative studies.
Adapting the PRA Methodology
The methodology or the PRAs included a combination o qualitative and participatory tools representing bothwell established PRA methods and introducing an adaptation o the PAPOLD (Participatory Analysis o Povertyand Livelihood Dynamics) methodology, mainly involving the collection o some Stages o Progress8 data andensuring that both poor and non-poor participants were selected.
The PRA approach included our data collection methods;
Secondary data review: books, fles, reports etc.; this mainly took place at Project/ City/ Province levelin connection with the three project reviews and at national level in relation to national policies,strategies, reviews and evaluations. In addition, water supply and sanitation data as well as healthdata were collected rom relevant local authorities in connection with the six community-level PRAs.
Observation: direct observation and wandering were done in connection with the six commune-levelPRAs.
Semi-structured interviews were carried out in connection with the six commune-level PRAs: AnInterview Guide was prepared in which only some o the questions were pre-determined, allowingnew questions to arise during the interview in response to the interviewees answers and romobservations. The guide was pre-tested, discussed among the research team and revised beorethe data collection began. The interviews consisted o: (1) key inormant interviews, (2) ocus groupdiscussion, and (3) individual in-depth interviews.
Workshops: Mini workshops were conducted in each province and were attended by representatives
rom related organisations, local authorities and local people.
Formal permission rom local authorities was sought prior to the feld study. Consent o the participants wasobtained beore conducting interviews and ocus group discussions. Confdentiality and anonymity o theinormants was maintained at all times.
Local languages were used in the interviews and discussions, where necessary. The Interview Guide is includedbelow. The ocus group discussions were held with groups o 10-15 community members chosen rom ourgroups o households (male-headed and emale-headed, poor and non-poor) as well as choosing both olderand younger participants.
Field notes rom the interviews and ocus groups at community level were taken by hand and quotationsand personal stories were recorded. The recorded inormation included the observation o the surroundings,inormants attitudes and photographs.
Data collected during the interviews and ocus group discussions at community level was sorted and checkedor completeness and internal consistency. This process started during the data collection period in order to
achieve timely detection and supplement missing data, to re-check ambiguous inormation and addressnew questions that arose. The inormation was cross-checked against observation and independent sources.Manual compilation was used due to the limited number o the inormants, as well as the qualitative nature othe inormation collected.
8 The Stages o Progress method, when implemented ully, involves choosing participants or the PRA who are older and areable to provide an historical perspective on changes in the community oten up to 25 years o change. Whilst the team elt itimportant to get the views o older people about the changes, it was also considered important to have the views o youngerpeople, and to look at the impact o more recent change. Hence in the sample selection both older and younger people wereselected, and additional questions about change were asked o the older people.
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2.2. Sites and Programmes or Reviews, PRAs and Case Studies
The team chose to conduct the studies in Lam Dong, Ha Tinh and Phu Tho Provinces, in order to achieve a mixo coastal and northern locations, highland, rural and peri-urban environments and to incorporate the views oethnic minority as well as Kinh majority populations.
We included Ha Tinh Province as representative o the coastal areas, and because we identifed relevant projectsin environmental management and rural water supply and sanitation in that province. Ha Tinh is one o the frstpilot provinces or the implementation o the participatory and demand-responsive National RWSS Strategy.The Ha Tinh RWSS project has been included to explore the lessons learned rom the pilot implementation othe Strategy. Ha Tinh Province was also chosen because there was a synergy in relation to the cross-cuttingthematic studies and the fnal target pilot plans.
Lam Dong Province was selected as representative o the highland areas, and because o the high degreeo poverty experienced there, much o which has been linked to environmental conditions and to trans-migration. Furthermore, Lam Dong Province is home to a large population o ethnic minority groups. Therehave been our major Danida-supported projects in Lam Dong province around urban and peri-urban watersupply, urban and peri-urban sanitation, water resources management and rural water supply and sanitation.Within all o these, Danida has had a strong ocus on poverty alleviation and reduction. We have included theDalat Sanitation Project as an example o an urban environmental sanitation project.
We selected Phu Tho Province, and in particular Viet Tri City, as representative o northern areas. The completedKW Water Supply project incorporated a water treatment plant and construction o a new piped water system,as well as promoting alternate clean water and sanitation acilities or those in the poorer, peri-urban areas notcovered by the grid. There was signifcant participation o the Viet Nam Womens Union and the PreventiveHealth Centre in the awareness campaign, which incorporated both Participatory Hygiene and SanitationTransormation (PHAST) and social marketing approaches. The lessons learned rom this project have beenincorporated into international presentations as well as into urther PHAST and social marketing training inViet Nam. Looking at this project again provided an opportunity to look not only at the lessons learned, but ataspects o sustainability which can only be observed ater completion o the intervention.
In each province two districts/sites were selected. One o the PRA districts was part o an ODA-supportedproject with an innovative implementation approach, while the other PRA district had had support eitherthrough a National Government programme or rom local authorities. One peri-urban and one rural district/site were chosen in each province.
All o the selected areas and their related projects were chosen because they could shed light on the mainobjectives o the study, both to elaborate the linkages between health, environment and poverty among bothrural and urban poor and to look at issues related to water supply and sanitation technologies that assist thepoor in improving their WSS situation, including the means o dissemination and replication.
The table below gives an overview o the water and sanitation projects reviewed as well as the districts andsites selected or the community-level PRA studies.
Table 1: Overview o Provinces, Projects Reviewed and PRA Districts and Site
Region Province Project Review
(urban/rural)
PRA district/ward 1:
ODA-supported
PRA district 2:
Gov./local auth. sup-
ported
Highlands Lam Dong Dalat Sanitation Proj-ect (urban)
Lac Duong District, LacDuong Town (peri-urban)
Don Duong District, DaRon Commune (rural)
Coastal Ha Tinh Rural WSS Project(rural)
Cam Xuyen District, CamQuan Commune (rural)
Loc Ha District, Ho DoCommune (peri-urban)
Northern Phu Tho Phu Tho WSC: Commu-nity Awareness Project,
Viet Tri (urban)
Viet Tri City, Tien Cat Ward(peri-urban)
Lam Thao District, ThachSon Commune (rural)
Note 1: All the PRA districts and sites selected had a high level o poverty, except or one o the sites, Tien Cat Ward, Viet Tri, Phu ThoProvince
Note 2: The ODA-supported PRA districts received support under the projects reviewed, e.g. Lac Duong district received support underthe Dalat Sanitation Project
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Chapter 2: Methodology and Site Selection
2.3. Principles, techniques and materials
The ollowing key PRA principles were taken into account when the study team designed and conducted thecommunity-level PRAs:
Participation o the local people who served as partners in data collection and analyses.
Flexibility: Semi-structured questionnaires were developed but room was let or acilitators to expand
depending on the concrete situation.
Team work: Both outsiders and insiders, men and women, mix o disciplines: public health, NGO socialworker, teacher, women union, IEC sta were chosen to ormulate the team.
Optimal environment: Facilitators in cooperation with local community representatives chose themost appropriate times or group discussion ensuring that when participants participated in thegroup discussions they were concentrated on sharing opinions and not worried about their domesticwork or feld work.
Systematic principle: For validity and reliability, partly stratifed sampling and cross checking wereapplied
Concrete techniques and materials used or conducting PRAs in each site:
Focus group discussions and in-depth household interviews: In each commune our groups ohouseholds were chosen: male-headed and emale-headed, poor and non-poor, and including someolder household members.
Key inormant interviews: In addition to group discussions, in connection with community-levelPRAs the ollowing key inormant interviews were carried out: Leader o Provincial Centre o RuralWater supply and Sanitation (PCERWASS); Leader o Phu Tho Provincial Urban Water supply company;representative o Commune health station, Commune Peoples Committee, two Project cooperators(one in commune and one in ward/district)
Observation: direct observation at household and community levels to veriy and get urtherinormation related to water supply and sanitation acilities and the environmental and hygienesituations
Secondary inormation collection: Secondary inormation regarding social economic status, % o poorhouseholds, % o access o dierent socio-economic groups to water supply and sanitation, incidenceor prevalence o water sanitation related diseases have been collected rom health stations, romvillage and district data and rom data collected in some cases by the Projects.
To assist in the conduct o PRAs a semi-structured questionnaire was developed, based on material in severalmain documents and reports:
Report 1 Analytical Paper o PART 1 with conclusions and guidance or urther detailed studyemphasizing three main areas that need attention in the Health, Water Supply and Sanitation study
Final report o project Viet Tri Community Awareness Campaign on Water Supply and Sanitation or Public
Health
National Rural Water Supply and Sanitation Strategy up to year 2020
Joint Government Donor Review o the Rural Water Supply, Sanitation and Health in Viet Nam - Summary
Sector Status Report Nov.2004 with conclusions and lessons drawn rom reviewing dierent rural watersupply and sanitation projects throughout Viet Nam
Evaluation o water supply and sanitation projects in urban areas with community participation , andemphasis on the question Can poor households get better water supply and sanitation service?supported by World Bank -2003
In accordance with the Terms o Reerence or the Study, two case studies were prepared. One case study wasor Ha Tinh Province, while the second was or Phu Tho Province. Each case study was based on the projectreview and the two PRA studies in the respective province.
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Chapter 3
Summary o Findings
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Chapter 3: Summary of Findings
3.1. Summary o Frindings
The fndings outlined below are drawn rom the six community-level PRAs and the three project reviews in thethree Provinces o Lam Dong, Ha Tinh and Phu Tho, and are also presented separately in the case o Ha Tinhand Phu Tho in the two case studies.
Some fndings rom the six PRA sites are summarized in Table 2 below. It includes inormation on the generalsocio-economic and health situation, the water supply and sanitation inrastructure used, WSS project supportprovided to the sites and some issues identifed. Additional fndings rom the six PRA sites are included in thedocument Detailed PRA Analysis (output 4 o the Study).
Table 3 includes an overview o the three water and sanitation projects reviewed, including objectives, povertytargeting, key elements and approach, and achievements and issues. Additional fndings rom the projectreviews are included in the three project review documents (output 3 to this Study) and the two case studies(output 5 to this Study).
The tables are intended to serve as background or the subsequent more overall analysis o fndings rom theStudy.
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Health,WaterSupply
,Sanitationand
thePoor
Table2:CharacteristicsandFindingsfromSixPRASites
Province/District/Site
Socio-economicandHealthSituation
ofTown/Commune/Ward
TypeofWSSInfrastructure
ProjectSupport
andIssues
LamDongProvince
Distric
t:LacDuong
Site:LacDuongtown
Socio-economicsituation:
Peri-urban,closetoDalatCity
Populationintown:4,828
CilandLachethnicminoritygro
ups:
45%
Poverty15%;othese75%et
hnic
minoritygroups
Healthsituation:
No
epidemicsrelated
towater-
bornediseasesinlast5years
Malarialcasesinsignifcant
In2006,57casesoacutediarrh
oea,
butnoatalities
Health
station
sta
considered
improved
health
situationto
be
duetomostpeopleusingc
lean
water
and
improved
latrines;
improvedhygieneawareness;
and
adiarrhoeacontrolprogramme
Watersupplyintown:
90%householdshavep
ipedwater
supplyromDalatCity.
Traditionalwatersourc
es:springs
anddugwells.
Sanitationintown:
70%
ohouseholdsh
ave
septic
tanks.
30%
ohouseholdshavesimple
duglatrines.
In1999,theDalatWate
rSupply
RehabilitationProjects
upportedthe
connectiono500poo
rhouseholds;
duringthetimeothePRA(2007),
therewere60poorhouseholdsnot
connectedtothepipedwatersystem.
In2005,nearly600sep
tictanklatrines
wereconstructedwith
supportrom
theDalatSanitationProject;80%o
thesewereusedatthe
timeothe
PRA.Thehouseholdco
ntribution
consistedintheconstructiono
thesuperstructure,butsomepoor
householdssaidtheyc
ouldnotaord
this.
Healthandhygieneeducationwasa
veryimportantcomponentoboththe
WaterSupplyRehabilit
ationProject
andtheSanitationProject.
Thereisstillaseriousis
sueo
inadequatewastewate
rdisposaland
solidwastecollectioninthetown.
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15
Chapter
3:SummaryofFindings
Province/District/Site
S
ocio-economicandHealthSituation
ofTown/Commune/Ward
TypeofWSSInfrastructure
ProjectSupportandIssues
District:
DonDuong
Site:Da
RonCommune
Socio-economicsituation:
Rural,mountainous
Population:7,482
Ethnicminority:45%
Poverty:29%,othese71%
eth
nic
minority
DaRonrecognizedasveryp
oor
communesince2001
H
ealthstationinormation:
It
wasnotpossibletocollectanyhealth
d
ata
WatersupplyinDaRonComm
une:
70
households
connec
ted
to
3
bore-wellsthrough
Government.
Programme134;poorhouseholds
supplementwithrainw
aterand
waterromdugwells.
Remaining
households
use
dug
wellsandrainwateronly;dugwells
havetobeverydeep.
SanitationinDaRoncommune:
55%
Kinhhouseholdsuseseptic
tanklatrines.
Greatmajorityoethnicminority
householdsuse
simple
dug
pit
latrines.
TheGovernmentProgra
mme134
hassupportedtheconstructiono3
bore-wellsandtheestablishmento
apipedsystemwithcon
nectiono70
households.Thereseem
ednottohave
beensucientundsto
connectmore
households,butpeople
wereunsureo
thereasons.
TheNationalRWSSTarg
etProgramme
supportedtheconstruc
tiono100
septictanksorethnicm
inority
households.Atthetime
othestudy,
halotheacilitieswerenotusedas
theprogrammedidnot
completethe
construction.
Manyintervieweescom
plainedthat
theyhadnotbeenprovidedwith
sucientinormationbeoreand
duringtheimplementationothetwo
programmesandtheyd
idnotknow
thereasonswhythecon
structionshad
stopped.
Healthandhygieneedu
cationhad
notbeenpartothesup
portromthe
twoprogrammes,butresidentshad
receivedsomeinormat
iononhealth
andhygienethroughvillagemeetings
andthechurch.
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17
Chapter
3:SummaryofFindings
Province/District/Site
S
ocio-economicandHealthSituation
ofTown/Commune/Ward
TypeofWSSInfrastructure
ProjectSupportandIssues
H
ealthsituation:
Thenumberodiarrhoeacasesis
signifcantlyhigherthaninothe
r
areas
Noseriousepidemicshavebeen
recordedrecently
Sanitation:
Noinormationwascollectedonthe
sanitationsituation,asthePRA
ocused
onthepoorwatersupplysitua
tion.
However,neithertheco
mmune
authoritiesnorlocalpeoplewere
consultedonhowtousethemoney
allocatedbyHaTinhPPCinanecient
way.Peoplehadthushadtoqueueor
alongtimetogetasmallamounto
waterandtherewasins
ucientmoney
oroperationandmaintenanceothe
reservoirs.Ateroneyea
rthereservoirs
hadbrokendownandt
heoperation
stopped.
PhuThoProvince
City:VietTri
Site:TienCatWard
S
ocio-economicsituation:
Peri-urban
Population:14,856
100%Kinhpopulation
Poverty:3%ohouseholds
H
ealthsituation:
Beoreproject,diarrhoea306
cases/100,000population;worm
inestationnearly100%
Watersupply:
95%householdsconnectedto
theVietTripipedwatersupply;
theremaining5%haven
otbeen
connectedmainlybecauseo
topographicalproblems;8%o
thepoorhouseholds(10/125poor
households)arenotconnected.
Theremaininghouseholdsmainly
usedugwells.
In2001-2002,theComm
unity
AwarenessProjectlinke
dtotheViet
TriWaterSupplyProjectassistedin
promotingexistingand
newcustomers
toconnecttoanewpip
edwatersystem.
TheVietTriWaterSupplyProjectdidnot
specifcallytargetthepoorhouseholds
inacttheoriginaltargetgroupwas
peoplewhocouldaordtoconnectto
thepipedwatersystem
.
InTienCatwardthepro
portiono
peopleconnectedtoth
epipedwater
systemincreasedromapprox.50%to
95%.Bothexistingandnewcustomers
hadtopayaconnection
ee.
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18
Health,WaterSupply
,Sanitationand
thePoor
Province/District/Site
So
cio-economicandHealthSituatio
n
ofTown/Commune/Ward
TypeofWSSInfrastructu
re
ProjectSupportandIssues
Atertheproject,theregistered
casesodiarrhoeaandworm
inestationdecreasedandalso
malnutritioninchildrenell
Noepidemicscausedbywateran
d
sanitationrelateddiseaseshave
beenreportedsincetheproject
Sanitation:
Thenumberohygieniclatrines
and
bathroomshasincreasedsignif
cantly
asaresultotheCommunityAw
areness
Project.
Nospecialfnancemechanismwas
establishedorpoorhouseholdsto
connecttothepipedsystem.Forvery
poorhouseholdswhoco
uldnotaord
theconnectionevenwithareducedee
(becauseomanyhouseholdsconnecting
tothesamepipe),thewh
olegroupo
householdsotenpaido
rthemand
poorhouseholdswouldrepaythegroup
monthlywithoutanyinte
rest.
TheCommunityAwarenessProjectalso
assistedwithlocalcomm
unityinitiatives
toconstructlatrinesand
bathrooms.
Inaperi-urbancommuneoTienCat
ward73newbathrooms
and310new
latrineswereconstructed
andrepairsand
maintenancewasdoneto63%othedug
wells.
Inormation,educationand
communication(IEC)activitieswasvery
importantinconnection
withthelocal
communityinitiatives,wherenofnancial
supportwasprovidedorconstruction
andimprovementsoWS
Sacilities.
Distric
t:LamThao
Comm
une:ThachSon
So
cio-EconomicSituation:Peri-urban
Rural,thoughclosetoVietTriCity
Population:7,346
100%Kinhpopulation
Watersupply:
Mosthouseholdsusewa
terrom
shallowdugwells.
50%ohouseholdsareabletogeta
verysmallquantityowaterroma
pipedwatersystem
estab
lishedin
2001;accordingtoprovincialtests,
thequalityothepipedwa
terisnot
good.
Thenumberocasesorespiratory
diseasesandcancerarev
eryhighinthe
commune,withincreasingincidenceso
cancersince2005.TheCo
mmuneHealth
Stationdoesnotknowth
ereasonsorall
theincidencesocancer,
butconsidersit
verylikelythatpollutionromtheertilizer
actorythroughbothairandwastewater
disposalisthereason.
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19
Chapter
3:SummaryofFindings
Province/District/Site
S
ocio-economicandHealthSituation
ofTown/Commune/Ward
TypeofWSSInfrastructure
ProjectSupportandIssues
Poverty:13%ohouseholds
Asuperphosphateertilizeractory
islocatednearthecommunean
d
causesmuchpollutionotheair
andwatercanals
H
ealthSituation:
Inrecentyearsnoserious
outbreaksointestinaldiseases;
120cases/10,000populationo
diarrhoea(onlyslightlyhigher
thannationalaverage)
Numberocasesorespiratory
diseasesveryhigh
Casesocancerveryhigh(seealso
lastcolumnotable)
Sanitation:
Noinormationwascollectedabout
latrinesasthePRAocusedon
the
environmentalpollutioncause
dbythe
ertilizeractory.
NoThesediseasesorce
peopletospend
alotomoneyortreatm
ent,whichhas
resultedinsomeamilie
sbecoming
poor.
Recently,inordertosup
portthese
people,theCancerHospitalinHanoi
agreedtoprovidereetreatment
orpeoplecomingrom
ThachSon
Commune.
Alsorecently,thedistric
tPeoples
Committeehasprovidedundssothe
communecanbeconne
ctedtothe
VietTripipedwatersyst
em.Atthe
timeothePRA,thebid
dingorthe
constructionworkhadbeencompleted.
Note:Thep
overtyfguresmentionedaboveareaccordin
gtothecriteriaromtheMinistryoLabour,InvalidsandSocialAairs(MOLISA)
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21
Chapter
3:SummaryofFindings
Provi
nce/NameofProject/Period
ObjectivesandTargetGroups
KeyElementsandAppro
ach
AchievementsandIssues
Resettlemento358house
holds
aectedbythelandacquis
itionre-
quiredortheprojectcomponents.
Alsorelocationoanabattoirsitu-
atedinthecentralpartotheCityto
asparselypopulatedareat
oallow
ortheconstructionoapu
mping
station.
Implementationoacomp
rehen-
siveEnvironmentalManagement
Plantopreserveandimpro
vethe
Cityenvironment.
Healthandhygienepromo
tion
activitiesatcommunitylev
el,with
usetheParticipatoryHygie
neand
SanitationTransormation(PHAST)
method,competitionsinschools
andotherplaces,TVandra
diopro-
grammesandothercommunication
channels.Face-to-acecom
munica-
tionthroughvolunteermo
tivators
wasanessentialpartothe
health
andhygienepromotionactivities.
itwasagainsttheirt
raditionand
culturetore-usethe
composted
sludgeasertilizer.F
ollowing
communityconsultations,agreat
numberoDVClatrineswere
changedintoseptic
tanksor
modifedtosuitthe
inhabitants
needs.
Generally,householdsoundseptic
tanktoiletsverycon
venientand
appropriate.However,somepoor
householdsaceddicultiesin
fnancingconstructionolatrine
superstructures;manyneededtime
orthis,sothenumb
erolatrinesin
useonlyincreasedg
radually.
TheproblemswithD
VClatrines
andconstructiono
superstructures
ortheseptictanksmaynothave
occurreditherehadbeenproper
consultationromth
estart.
Poorhouseholdslivingcloseto
thestreamarenowrelocatedtoa
betterenvironment,i.e.inproperly
establishedresettlementareas,ater
properconsultation.
Therelocationotheabattoirhas
considerablyimprov
edtheenviron-
ment,asitisnolong
erpolluting
thestreamwithitsw
astewaterand
otherpollutantmatters.Thisisto
thebeneftopoora
ndnon-poor
householdsalike.
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22
Health,WaterSupply
,Sanitationand
thePoor
Prov
ince/NameofProject/Period
ObjectivesandTargetGroups
KeyElementsandApp
roach
Achievements
andIssues
Thehealthandhygien
eeducation
activitiesotheDalatS
anitationProject
wereacontinuationotheactivities
startedundertheDala
tWaterSupply
Projectin1999.
Thehealthandhygien
eeducation
activitiesstartedintwopilotwards
withduplicationtoall
16wardsand
communeswithinthe
projectarea.
Steeringcommitteesc
onsisting
orepresentativesrom
relevant
institutions,especially
theHealth
ServiceandtheWome
nsUnion,were
establishedbothatcityandward/
communelevels.Thesecommittees
wereessentialortheecient
andcoordinatedplann
ingand
implementationoact
ivities.Inthe
fnalstagesotheproject,thesteering
committeesweregrad
uallyableto
operateontheirownw
ithoutproject
support.
Nohealthimpactassessmentassuch
wascarriedoutorthe
DalatSanitation
Project,butHealthSer
vicedatashowed
adecreaseindiarrhoea,dysenteryand
typhoidrom4-5%in1
999to1.7%in
2006.Thisisassumedtobepartlydueto
projectactivities.
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24
Health,WaterSupply
,Sanitationand
thePoor
Province/NameofProject/Period
ObjectivesandTargetGroup
s
KeyElementsandApp
roach
Achievements
andIssues
3.Toincreaseawarenessothelinkage
betweenimprovedhygieneand
sanitationandhealthandimproved
hygienepractices
HaTinhwasoneothefrstpilot
provincesorimplementationo
theNationalRuralWaterSupplyand
SanitationStrategy
Thepoorwasaspecifctargetgroup,see
alsoimmediateobjective2
Improvedhealthandhygien
e
awarenessandpracticeswereother
importanttopicsotheIECa
ctivities.
Avarietyocommunication
methods
wereused,includingace-to
-ace
communicationthroughlocalRWSS
motivatorsandcommunest
a,
distributionomaterials,spe
cialevents
anduseothemassmedia.I
ECgroups
wereestablishedatprovincialand
districtlevelsconsistingorelevant
departmentsandmassorganisations
HaTinhIECstaplayedakeyrole
indevelopingIECmaterialsor
implementationotheNatio
nalRWSS
Strategy,includingdevelopm
ento
picturesetsandamotivatorsmanual
orthePHASTmethod.
Agenderocalpointperson
was
appointedatprovincialleveltoprovide
supportorthemainstreamingo
genderissues.Keyactivities
inannual
genderactionplanswerege
nder
trainingatvariouslevelsand
promotion
oarelativegenderbalance
invarious
groups/unitsandamongvillage
motivators.
andbecausetheWSS
acilities
constructedbypoorh
ouseholdsacted
asdemonstrationmodelsorother
households.
Throughouttheproje
cttherewasa
degreeotensionbetweentheneed
toraiseawarenessandbringthe
communitieson-boar
dandtheneed
tocompleteconstructionaccordingto
projecttimelinesand
targets.Insome
cases,constructionha
dtowaitwhile
communitiesdiscusse
dandselected
amongdierentWSSoptionsand
raisedtheirfnancialc
ontributions,
butthiswasconsideredimportantto
ownershipandsustainability.
Ahealthimpactassessment(HIA)was
carriedoutin2006in
thefrsttwopilot
districtsbasedonavailablehealth
servicedataonWSSrelateddiseases,
cleanwatersupplyan
dhygienic
sanitationcoverage,a
ndinterviewsand
observationsin8villagesand7schools.
DataondiseasesandWSScoverageare
notdisaggregatedaccordingtopoor/
non-poorpeople.Itw
asthereorenot
possibleintheHIAto
includespecifc
dataontheprojectsh
ealthimpacton
thepoor.
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25
Chapter
3:SummaryofFindings
Province/NameofProject/Period
ObjectivesandTargetGroups
KeyElementsandAppro
ach
Achievementsa
ndIssues
TheHIAconcludedthat
theprevalence
oWSSrelateddiseaseshadgenerally
decreasedovertheprojectperiod.Inone
districtdiarrhoeaandm
alariahadbeen
nearlyhalved,whereast
rachomahad
beenstable.Intheotherdistrict,thelow
prevalenceodiarrhoea
hadbeenstable,
whereastrachomawasv
eryhighbuthad
decreasedconsiderably
tonearly1/3.
Malariaprevalencehadbeenlow,but
increasedslightly(repor
tedlyimported
romoutside).
TheHIAalsooundthatcoveragewith
hygienicbathroomswas
74%,whichis
high,aswasthepercent
ageopeople
notedoralwayswashin
ghandswith
waterandsoap.Ahighp
ercentage
thoughneverwashedhandswithsoap
andwateraterhelpingchildrenwith
deecation.
Theuseohumanandlivestockexcreta
orertilizerwasverycommoninnearly
allthesurveyedvillages
andreported
tobeusedsaelybynearlyallthe
households.
Saedisposalosolidwa
stewas
practicedinthemajority
(83%)othe
households.
AccordingtotheHIA,thementioned
improvementswerelike
ly,toalarge
extent,tobetheimpact
othehigh
WSScoverageandhealt
h&hygiene
educationactivities.
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27
Chapter
3:SummaryofFindings
Province/NameofProject/Period
ObjectivesandTargetGroups
KeyElementsandAppro
ach
AchievementsandIssues
Asaresultothehealthandhygiene
promotionactivities,the
rewas
constructionoapprox.2000latrines,
repairoanother1300-1
400latrines,
construction/improvem
entoapprox.
2000bathroomsandimprovementsto
morethan2000dugwellsinareasnot
coveredbypipedwater.
Therewerealso
localinitiativesanddiscu
ssionswiththe
UrbanWasteManageme
ntCompany
regardingimprovedsolidwaste
collectionandmanagem
ent.
Thehealthandhygienepromotion
activitiesotheprojectw
assosuccessul
thatanumberocommu
nesnotinitially
involvedintheprojectaskedithey
couldbeincludedinthis
partothe
project.
InterviewswithHealthC
entresta
indicatedareductioninWSSrelated
diseasessincetheimplementation
otheproject.However,
becausethe
projectdidnotsetoutto
measurehealth
improvements,nobaselinewastaken.
Furthermore,theprojectwastooshort
oranyhealthimpactto
bemeasuredat
theendoit.
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Chapter 4
Analysis o Findings
Photo: Chu Duc Hoa
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31
Chapter 4: Analysis of Findings
The frst part o this section ocuses on the links between health and environment seen in relation to both poorand non-poor households, while the second part looks specifcally at the situation o the poor and how theirpoverty is linked to their environmental and health situations. The third part ocuses on WSS technologiesassisting the poor, while the last part looks at gender issues.
4.1. Links between Health and Environment
Out o the three WSS projects reviewed only the Ha Tinh RWSS project had conducted a health impactassessment (HIA) at the end o the project. This was carried out in the frst two pilot districts, where activitieshad started 4-5 years beore the assessment. The HIA ound that the prevalence o WSS-related diseases hadgenerally decreased over the project period. In one district diarrhoea and malaria had been nearly halved,whereas trachoma had been stable. In the other district, the low prevalence o diarrhoea had been stable,whereas trachoma was very high but had decreased considerably to nearly 1/3. Malaria prevalence had beenlow but increased slightly (reportedly imported rom outside).
The availability o hygienic bathrooms is considered an important indicator o good hygiene practices, whichare known to inuence health. The HIA ound that the coverage with hygienic bathrooms was 74%, which ishigh, as was the percentage o people noted or always washing hands with water and soap (ater deecation,
beore eating, beore preparing ood, and ater helping children with deecation.), a high percentage thoughnever washed hands with soap and water ater helping children. As to the impact on environmental pollution, itwas ound that the use o human and livestock excreta or ertilizer was very common in nearly all the surveyedvillages and reported to be used saely by nearly all the households. Sae disposal o solid waste was practicedin the majority (83%) o the households.
The HIA concluded that the above improvements in health, personal hygiene and reduced environmentalpollution were probably attributable to the impact o the increased coverage with clean water and hygienicsanitation (rom 30% in 2002 to 63% in 2006) and to health and hygiene education activities.
No health impact assessments had been carried out in the areas that had benefted rom the WSS projects inViet Tri and Dalat. However, data rom the Health Service in Dalat showed a decrease in diarrhoea, dysenteryand typhoid rom 4-5% in 1999 to 1.7% in 2006 in Dalat City, although fgures were not readily available or the
poorer ethnic minority area o Xa Lat/Lac Duong. The decrease in the prevalence o the mentioned diseasesis assumed to be at least partly due to activities under the Dalat Sanitation Project and the previous DalatWater Supply Project. In connection with the latter, a number o additional poor and non-poor householdshad been connected to the rehabilitated water supply network, while many poor and non-poor householdshad experienced improvements in their living conditions as a result o the sewer network and the constructiono on-site sanitation acilities. Improved hygiene practices had also been an important ocus o both projects.Furthermore, the reduced ooding and improved garbage disposal/collection around the two major streamsin Dalat City had resulted in improved living conditions and reduced environmental pollution. The relocationo an abattoir rom the central area o the City had a similar eect.
In Viet Tri, interviews with Health Centre sta indicated a reduction in WSS-related diseases since theimplementation o the Viet Tri Water Supply Project and the attached Community Awareness CampaignProject. Furthermore, no epidemics caused by water and sanitation related diseases have been reportedsince the project. In Viet Tri many households experienced improvements in their living conditions ater theirtranser/ new connection to the new water supply network. The number o customers connected had thusincreased rom approximately 7,500 in 2001 to nearly 35,000 in 2007. Furthermore, as a result o the health andhygiene education activities many households had improved existing latrines and bathrooms or constructednew ones. Also solid waste disposal/ collection had improved through local initiatives. Both poor and non-poorhouseholds thus had their living conditions improved as a result o the project and many people consideredthese improvements as important or improving their own health situation, as or example illustrated in thePRA rom Tien Cat Ward.
One o the PRAs in Phu Tho (in Thach Son commune) noted that local community members and health stalinked the increasing number o cases o respiratory diseases and cancer with the air and waste water pollutionrom a nearby ertilizer actory.
Both the PRAs and the project reviews thus indicate that the commonly accepted link between improvedwater supply, latrines, waste disposal and improved hygiene practices on one side and improved health on theother side can also be made or the locations included in this Study.
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32
Health, Water Supply, Sanitationandthe Poor
4.2. Links between Health, Environment and Poverty
The links between health, environment and poverty were more di cult to establish through this Study, as theHealth Services data on water- and sanitation-related diseases are not disaggregated according to poor/non-poor people and neither are the WSS coverage data available at dierent administrative levels. However, theperceptions o participants in the PRA studies suggest that the links are strong. One example is that people in
Thach Son commune in Phu Tho province, who were exposed to air and waste water pollution rom a ertilizeractory, mentioned that the many cases o respiratory disease and cancer had orced people to spend muchmoney on treatment, which had resulted in some amilies becoming poorer.
The point was made in all three Provinces that poor households and communities suer more greatly romgeographical isolation than other households. This isolation makes it more di cult to provide poor householdswith sustainable and aordable water, sanitation and solid waste management options. The urther away romthe main road a community is, the greater the cost o, or example, connecting to a piped water supply orsewerage system, or o aordable household-level water supply and latrine acilities (the construction costsare oten higher in more remote areas because some materials have to be transported over longer distances).In mountainous areas, this oten becomes an even greater problem because o lack o water and/or dug wellshaving to be very deep. For many, this issue o accessibility was seen as a greater problem or poor communities
than was aordability.
It is, however, still important that the ability o the poor, including the poorest o the poor, to pay or theconstruction and operation and maintenance costs o improved water supply and sanitation acilities isconsidered. The situation in Da Ron commune in Lam Dong province gave one example o this. Here three bore-wells and a small piped water system had been constructed with support rom the Government Programme134. Interviewees considered the piped water sae and convenient, but many poor ound the water tari highand thereore reduced their consumption by supplementing with water rom dug wells or rainwater. This againaected the fnancial sustainability o the piped system, so that the supply had to be restricted. Furthermore,during dry seasons water in dug wells was scarce, while in rainy seasons it turned very turbid. The lack osu cient quantities o water during the dry season and use o potentially low-quality water during the rainyseason may have resulted in a worse health situation or the poor than or other households.
Another example was the situation in Ho Do commune in Ha Tinh where the only water sources were rainwater and water purchased in 20-litre cans at around 20 times the price o piped water in other areas. Themany poor households in the commune (30% o the population) were not able to aord construction o bigrain water tanks as were the wealthier households. The poor households thus had purchase water at a highprice and were, as mentioned by many interviewees, orced to severely restrict their use o resh water and tore-use it wherever possible. The prevalence o diarrhoea was signifcantly higher in Ho Do commune than inother areas with more clean water was available at a more aordable price. The poor in Ho Do commune arelikely to experience more and more severe - episodes o diarrhoea than other households because o theirmore limited access to resh water.
It was ound that generally the poor attach higher importance to access to clean water than to hygienic latrines,proper disposal o garbage and other improved hygiene practices (as or example hygienic bathrooms). In
many cases, clean water was one o frst household spending priorities, whereas improved latrines, bathroomsand appropriate garbage disposal had a lower priority. It is thus the experience o IEC sta and grass-rootWSS motivators that commitment to sanitation improvements is typically more di cult to achieve thancommitments to improved water supply. However, the project reviews and PRAs o this Study suggest thatsimple PHAST, social marketing and other IEC methodologies targeting community members and householdsdirectly can be very eective in achieving sanitary improvements and improved hygiene practices amongboth poor and non-poor women and men. The Lessons Learned case study rom the Danida-supported RWSSprogramme in Viet Nam, which was recently published on Danidas web-site, also demonstrates this9.
The PRAs and project reviews clearly show the importance o using a demand-responsive approach in relationto both poor and non-poor households, enabling poor households to choose among several environmentallyappropriate WSS options and to be properly consulted beore construction starts. The problems experienced
in connection with the construction o on-site sanitation acilities by the Dalat Sanitation Project could withoutdoubt have been avoided, or minimised, i the poor ethnic minority households had been properly consulted
9 Nguyen, TA and Stoltz, HT, Good Practice Case story, Rural Water Supply and Sanitation Programme, Viet Nam Danida, 2007 located at http://www.danidadevorum.um.dk/NR/rdonlyres/255CE9CB-6C46-424B-8963-38B060E38EA2/0/Viet NamR-WSS2007.pd
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about dierent latrine options beore the start o construction and had had su cient inormation abouttheir own contribution. As a consequence o inadequate initial consultations, a great number o double vaultcomposting latrines had to be changed into septic tanks or modifed to suit the inhabitants needs, while poorhouseholds needed time to invest in the construction o the superstructures or the septic tanks provided bythe project. A survey in the last quarter o 2007 showed that 80% o the new septic tank latrines were in use.
The Viet Tri Community Awareness Project is an example o a project where the demand-responsive approachresulted in considerable, low-cost sanitary and environmental improvements. Participation in the programmeo environmental clean-up became so popular that even the more remote and poorer peri-urban communitieso Viet Tri City asked i they could participate, even where there was no intention to extend the water networkto those communities.
The Study also showed that some communities have been willing to support the poor to invest in improvedwater supply and sanitation. The best example o this is the Viet Tri Community Awareness Project, whereneighbours and communities helped their poorer members with loans or gits, in the knowledge that the morecustomers that connected to the piped water system, the lower the cost would be or everyone.
However, the availability o appropriate fnance mechanisms or the poor, in the orm o subsidies and/or loansor improvements to existing or construction o new water supply and sanitation acilities, are also importantas illustrated by the Ha Tinh RWSS Project. Here grants were provided to households that were registeredas poor according to the poverty criteria o the Ministry o Labour, Invalids and Social Aairs. A demand-responsive approach was used, allowing poor households to choose among a number o locally appropriateWSS technologies. Grants covered 80% o the construction costs, within an upper limit or each type otechnology. Furthermore, low-interest loans were provided through the Womens Union to women rom allsocio-economic groups. Those that were o cially poor, but not able to beneft rom a grant, could apply orloans and a signifcant number o poor households did so. The loans also benefted many households whowere just above the o cial poverty line.
4.3. WSS Technologies Directly Assisting the Poor
4.3.1. Inormed Choice between WSS OptionsAs mentioned above, the availability o - and dissemination o inormation on - low-cost WSS technologies areimportant or the poor to be able to improve their own water and sanitation situation. This was done in theHa Tinh RWSS Project by developing IEC materials on a range o locally appropriate water supply and latrineoptions, including several low-cost options. Both poor and non-poor households were then able to chooseamong these options ater having obtained inormation on technical aspects, construction costs as well asoperation and maintenance requirements and costs.
The same approach was used by the Viet Tri Community Awareness Project as ar as sanitation was concerned.The project developed, or example, a sanitation ladder, showing how improvements can be made gradually.
Low-cost improvements to existing acilities were also promoted by the two projects, e.g. putting a cover on
the dug well and improving the oor surace o an existing latrine so it was easier to keep clean and hygienic.
4.3.2. Low-Cost Water Supply Options
In many rural areas, people are able to improve their water supply situation by using airly low-cost technologieslike dug wells or through rainwater collection. In some areas, the use o low-cost water supply technologiesis, however, restricted because o the water resource situation. An example is that in many coastal areas inHa Tinh, and also in other provinces o Viet Nam, much o the groundwater especially in the upper aquiers issalty which means that dug wells and boreholes are oten not appropriate options. Rainwater collection maystill be an appropriate and low-cost option in many o these areas, but is dependent on people having a roothat is suitable or collection o rainwater. Furthermore, poor households are very unlikely to be able to storesu cient rainwater to last throughout the dry season (this is also a problem or many non-poor households).
In airly densely populated urban and peri-urban areas, like Viet Tri City, piped water supply is oten theonly appropriate water supply option, as water rom lower-cost water supply options like dug wells havea considerable risk o being polluted by nearby latrines, waste water disposal rom small- and larger-scale
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industrial production, households etc. In Viet Tri a substantial number o poor households were able to geta house connection to the new piped water system because o the assistance, in the orm o loans and gits,provided by other households in their local areas. The establishment o communal water taps or kiosksconnected to a piped water system is another lower-cost option that can be considered by poor communitiesoten ound in peri-urban areas. Experience in Viet Nam and elsewhere, however, shows the importance osetting aside su cient time or community consultations and discussions beore such a communal option is
selected and implemented.
4.3.3. Low-Cost Latrine Options
In many rural areas, people are able to improve their sanitation situation by constructing low-cost pit latrines,using local materials.
The lowest-cost latrine option which the Ministry o Health (MOH) considers appropriate in rural areas is theventilated improved pit (VIP) latrine, one o the requirements being that it has to be constructed at least 10meters rom any drinking water source (MOH Decision rom March 2005). This type o latrine can be constructedquite cheaply in most areas, as materials are available locally, perhaps with exception o the vent pipe and insome cases concrete or the slab. However, the VIP latrine is not appropriate in all areas, e.g. not in areas proneto ooding or in densely populated areas.
Furthermore, in many areas, particularly in the central part o Viet Nam, as or example Ha Tinh, people wouldlike to use composted human excreta as ertilizer on their felds and thereore preer to construct double vaultcomposting (DVC) latrines although the cost is higher than that o the VIP latrine. I poor rural householdscannot aord to construct a DVC latrine, they are likely to fnd a cheaper, less hygienic way o storing thehuman excreta until it is time to use it on their felds (without frst composting it properly).
In the case o urban areas, like Dalat, connection to a sewer system in areas where this exists is oten compulsoryas this is the most technically and environmentally appropriate technology. This would not be an aordabletechnology or poor households i they were to pay their ull share o the construction costs, either through ahigh connection ee or a tari that had built in the construction costs. In Dalat, all households were connected tothe sewer system ree o charge, so connection was not a problem or poor and other low-income households.Furthermore, cross-subsidization rom better-o to poor households has been built into the wastewater tari.
4.3.4. Afordability through Finance Mechanisms
Both the Dalat and Ha Tinh projects provided subsidies to poor households so they were able to improve theirwater supply and sanitation situation using technically and environmentally appropriate technologies. In HaTinh, low-interest loans were also provided to both poor and non-poor households, with a number o o ciallypoor and households just above the o cial poverty line benefting.
Provision o subsidies to the construction o on-site latrines in Dalat gave rise to some problems because o thelack o proper consultation beore the start o construction. However, in Ha Tinh there were generally positiveresults with the subsidies as they enabled many poor households to improve their own water supply andsanitation situation and surveys showed that the ar majority o poor households used their subsidies or theagreed WSS improvements.
In Viet Tri, some poor households got loans rom their neighbours and community members which enabledthem to connect to the new piped water system. Another way that connections to a piped water system or asewer network could be made more aordable or poor households is to allow them to pay the connectionee in instalments.
4.4. Gender Issues
Interviewees during the six PRA studies and the three project reviews all agreed that women bear the brunt oinadequate water and sanitation acilities. They are responsible or the management o water in the home andmost o its use washing, cooking, cleaning, bathing children, as well as, in rural settings, being at least hal othe armers. Carrying water is time consuming and causes chronic back-ache, as well as, in many cases keeping
young girls away rom school. Girls school attendance has thereore oten improved because o improvedwater and sanitation acilities and because o their improved health. In Lam Dong, one participant commentedthat many women have seen the arrival o piped water as emancipation rom hard labour.
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Chapter 4: Analysis of Findings
Improvements in household health have also reduced the burden or women, both in labour and cost ormedicines. Participation in awareness campaigns and community consultations has increased some womensdecision-making position within the household and/or their standing in their communities, thereby providingthem with new leadership opportunities. This was ound to especially be the case or women who have beenactively involved with the Womens Union.
Generally, the water and sanitation situation o poor women is worse than the situation o women rom othersocio-economic groups. Consequently, their health is also oten more adversely aected than is the health oother women.
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Chapter 5
Conclusions and Recommendations
Photo: Do Thuy Mai
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Chapter 5: Conclusions and Recommendations
5.1. Links between Health and Environment
The health impact assessment carried out at the end o the Ha Tinh RWSS project concluded that theimprovements in health, in the orm o a reduced prevalence o water and sanitation related diseases, personalhygiene and reduced environmental pollution were likely to the impact o the increased coverage with cleanwater and hygienic sanitation (rom 30% in 2002 to 63% in 2006) and the health & hygiene education activities
support by the project. No health impact assessments have been carried out in areas included in the DalatSanitation Project and the Community Awareness Project in Viet Tri, but there are similar indications that theimproved water supply and sanitation combined with health and hygiene education also in these locationshave lead to improved health and reduced environmental pollution.
This Thematic Study is not an epidemiological study, so it has had to rely on available studies and data. Thesedo, however, indicate that the commonly accepted link between improved water supply, latrines, wastedisposal and improved hygiene practices on one side and improved health on the other can also be made orthe locations included in this Study.
5.2. Links between Health, Environment and Poverty
It is more di cult to reach a relatively frm conclusion concerning the links between health, environment andpoverty, as the Health Services data on water and sanitation related diseases are not disaggregated accordingto poor/non-poor people and neither are the WSS coverage data available at dierent administrative levels.However, the perceptions o participants in the PRA studies suggest that the links are strong.
The evidence rom the Study suggests that remoteness (or geographical inaccessibility) has more to do with thedecisions about allocation o water supply systems than has poverty, although o course these are oten linked.Ethnic minority communities, or example, are oten the most remote, and are also among the poorest peoplein Viet Nam. Peri-urban areas, such as some areas around Viet Tri city and Dalat city, can also be consideredto be geographically remote or the purposes o inrastructure development where the terrain has made itdi cult or communes to be linked to the piped systems being developed close by. It is oten the poorerhouseholds that live in these locations, and hence the poor suer urther rom lesser access to environmental
and health acilities.
By speaking directly with poor and non-poor households in the communes aected by the projects which werestudied, we were able to gain a sense o the overall value and commitment that communities and householdsplace on water and sanitation as a path to improved health, and thereore also to improved productivity andeconomic development. While perhaps not being able to aord some technical options, poor and non-pooralike placed a high value on clean water, in some cases coming frst in household spending priorities, or secondater the education o children. Improved sanitation was also oten considered to be important, but still had alower priority than access to clean water.
The PRAs and project reviews clearly show the importance o using a demand-responsive approach in relationto both poor and non-poor households, enabling poor households to choose among several environmentally
appropriate WSS options and to be properly consulted beore construction starts. More generally, it can beconcluded that while most water and sanitation projects have stated objectives to target health and poverty,and many do provide measures to assist the poor to participate, in many cases projects are still construction-and investment-ocused; where this is the case, the demand-responsive approach adopted is really aboutcreating demand or technical options rather than responding to need. Hence, many poor people in di cultgeographical areas are still struggling to have clean water supplies and appropriate sanitation solutions.
The Study showed that some communities have been willing to support the poor with no- or low-interestloans and gits to improve their water supply and sanitation situation. This may o course not apply in the sameway in every community, but does highlight the need to consult community members and to point out thebenefts or every one o community participation and co-operation.
It is, however, still critical to consider appropriate fnance mechanisms or the poor and also or those just
above the o cial poverty line. The Study indicated that both subsidies and loans can be appropriate, as long asa demand-responsive approach is used. Direct loans, as well as group-based micro-fnance projects have been
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successul, particularly when targeted at women. The Viet Nam Womens Union has thus managed such loanschemes in connection with, among other programmes, the Ha Tinh RWSS Project and a number o other WSSprojects and has developed considerable experience in loan management something which should not belost but which should be harnessed or use in other development activities. In addition, Government supportor appropriate fnancial mechanisms, particularly through the Viet Nam Bank or Social Policy, is playing apositive role in progressing clean water supply and sanitation in rural areas in Viet Nam.
It should though be emphasized that clean water and hygienic sanitation is still not available in many ruralcommunities in Viet Nam, and particularly not to the poor, and thereore needs urther attention romGovernment agencies and donors.
Finally, it should be mentioned that while the three projects reviewed demonstrated participation o the poor,and in some cases specifc measures to ensure subsidies or low cost loans are in place, there has been littlemeasurement o the impact on poor people, and o the level o their participation in the programmes designedto beneft them. We are still struggling with the questions o the impact o environment on poverty and viceversa, with suggestions rom the project reviews and PRA studies that the impacts work both ways.
It may be more di cult to measure the impact on poverty in the short term ollowing a WSS project, but itmight be possible now that there are a number o WSS projects have been completed over a decade or more.Further, it is also recommended that projects include specifc poverty impact evaluation measures.
5.3. WSS Technologies Directly Assisting the Poor
Technical WSS options need to be locally appropriate, aordable and acceptable, and should not be morecomplex than is necessary. Keeping it simple is the key to community perceptions o appropriateness andthereore community engagement.
The Study showed that the availability o and dissemination o inormation on low-cost WSS technologies isimportant or the poor to be able to improve their own water and sanitation situation. Low-cost improvementsto existing acilities can oten be the frst step in this connection.
In many rural areas, people are able to improve their water supply situation by using airly low-cost technologieslike dug wells or through rainwater collection. However, in some rural areas the use o low-cost water supplytechnologies is not possible because o the water resource situation. Likewise in densely populated urbanand peri-urban areas, there may only be one appropriate water supply option, namely piped water, which isnormally not a low-cost option. However, also lower-cost options can be presented to and discussed with poorcommunities in connection with piped water systems, namely in the orm o communal water taps or kiosks.
In many rural areas, people are able to improve their sanitation situation by constructing low-cost pit latrines.Local materials can oten be used or the construction o a hygienic pit latrine and is thereore oten relativelyaordable, even to poor households, but perhaps not to the poorest o the poor. Pit latrines are, however, notappropriate in all areas, e.g. not in areas prone to ooding or in densely populated areas.
It can thereore be concluded that although priority should always be given to presenting poor householdswith low-cost water and sanitation options, such options are not technically and environmentally suitable inall areas. This points to the importance o making appropriate fnance mechanisms available to the poor orthem to fnance the initial investment costs. Cross-subsidization in piped water and wastewater taris will alsomake the consumption o adequate amounts o water and disposal o the same water - more aordable topoo