health, wss& the poor

8/3/2019 Health, WSS& the Poor

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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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i

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

Photo: Pham Thi Thu


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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

Photo: Bui Hoa Tien


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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

Photo: Le Huu An


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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


S

ocio-economicandHealthSituation

ofTown/Commune/Ward


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


S


ofTown/Commune/Ward



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


So

cio-economicandHealthSituatio

n

ofTown/Commune/Ward

TypeofWSSInfrastructu

re


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


S


ofTown/Commune/Ward



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


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



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



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


40/73


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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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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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33


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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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

health, wss& the poor

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