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TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

  • Roslyn
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TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

As we enter into the last week of the thematic discussion on The Sanitation Ladder: Next Steps, the theme for week 3 will approach the practical side and operationalisation of the sanitation ladder with the theme: The way forward…adaptation of the sanitation ladder to the post-2015 period.

In weeks one and two topics were discussed such as:

TDS: Week 1 Theme - Evolution and Further Development of the Sanitation Ladder
- Advantages and criticisms of the functional sanitation ladder and ladder concept
- Alternative and complementary ideas to the sanitation ladder
o Ex. an index scoring system, service levels, sanitation ladder adaptations, shaping design according to service levels, good practice databases/ case studies

TDS: Week 2 Theme - The post-2015 agenda and emerging monitoring challenges in the sanitation sector
- Roles of the Open Working Group and JMP in post-2015 development goal process
- Considerations for formulating targets for the SDGs
- What is considered as safe and “adequate” sanitation

To build on the discussions from week 1 and 2, now in week 3, the discussion will focus on questions of implementation and adaptation of the sanitation ladder, such as:
  • How can the functional sanitation ladder be used at a local level by implementers, to guide their sanitation and hygiene interventions within the SDG framework?
  • How can the functional framework be adapted for practical use at a local level?
  • What are some examples of implementation of a functional framework in sanitation planning and monitoring?
  • In general, what are limitations in implementation that you would like to see addressed in functional ladder?

Roslyn Graham
MSc Global Health
Member of SuSanA www.susana.org
Newfoundland, Canada
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  • JKMakowka
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

Well it seems like one of the take over messages of the 2nd week was the JMP's handling of "basic sanitation" and on to of that the concept of "safely managed sanitation". Maybe the function based ladder could be used as a tool to facilitate the process from one to the other?

Microbiologist & emergency WASH specialist
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

What this post is about: Some questions regarding the definition of target elements.

Looking at the continuum as "target language - definition of target elements - JMP core and supporting monitoring indicators - data collection through surveys/administrative data & implementation", please find below some questions regarding how the definition of target elements would apply:

For quick reference:

Target 6.2: By 2030, achieve access to adequate and equitable sanitation and hygiene for all, and end open defecation, paying special attention to the needs of women and girls and those living in vulnerable situations.

Normative definition of target elements:

Target 6.2 - By 2030, achieve
  • Access (for all): Implies facilities close to home that can be easily reached and used when needed
  • To adequate: Implies a system which hygienically separates excreta from human contact as well as safe disposal of excreta in situ, or transport to a treatment plant
  • And equitable: Implies progressive reduction and elimination of inequalities between population sub-groups
  • sanitation: Sanitation is the provision of facilities and services for safe management and disposal of human urine and feces
  • And hygiene: Hygiene is the conditions and practices that help maintain health and prevent spread of disease, including, hand washing, menstrual hygiene management and food hygiene
  • For all: Suitable for use by men, women, girls and boys of all ages including people living with disabilities
  • End open defecation: Excreta of adults or children are: deposited (directly or after being covered by a layer of earth) in the bush, a field, a beach, or other open area; discharged directly into a drainage channel, river, sea, or other water body; or wrapped in temporary material and discarded
  • Paying special attention to the needs of women and girls: Implies reducing the burden of water collection and enabling women and girls to manage sanitation and hygiene needs with dignity. Special attention should be given to the needs of women and girls in 'high use' settings such as schools and workplaces, and 'high risk' settings such as health care facilities and detention centers.
  • And those in vulnerable situations: Implies attention to specific WASH needs found in 'special cases' including refugee camps, detention centres, mass gatherings and pilgrimages

Questions:

1. Features of toilet facility:

1.1. Does "suitable for use" mean the entire facility (viz., user interface + superstructure) or only the user interface? For instance, disabled friendly access for a toilet facility will include additional features, such as, ramps for wheelchair access, adequate space inside the toilet for rotating the wheelchair, height of the door latch and light switch, etc.

1.2. Disabled-friendly access: While guidelines exist for disabled friendly access, "disabilities" cover a wide range of physical and mental disabilities and all of these may not be covered in the guidelines. In this regard, (a) which guideline should be used in case of differences between guidelines, (b) which disabilities should certainly be covered (minimum list), (c) should disability-friendly access cover households as well as other specified outside-household facilities? and (d) should "households" for this purpose mean those with at least one member having a disability?

1.3. Suitable for all age groups: Definition of target element "for all" includes "of all ages". Further, the Equality and Non-Discrimination Working Group, WHO/UNICEF JMP, has recommended monitoring of sanitation access based on age also. In this regard, (a) should all outside-household toilet facilities specified for monitoring have provision for all age groups? (b) with respect to household toilet facilities, there might be different periods during which the household might have individuals in age groups with special needs (babies, children and very old persons) and so, would monitoring be based on whether during the particular annual survey, did the household have facility suitable for all the individuals in the household based on age?

2. Specific situations of toilet facility: Definition of target elements specifies three categories viz., (a) high use, (b) high risk and (c) special cases viz., WASH needs in schools, workplaces, healthcare facilities, detention centers, refugee camps, mass gatherings and pilgrimages.

2.1. The definition of target element "paying special attention to the needs of women and girls" states "high use settings such as schools and workplaces" [underline emphasis added, not in original definition] which means that "high use settings" is an inclusive (and not exhaustive) definition --> therefore, apart from schools and workplaces, will "high use settings" include the following and are these covered under the definition of the target element?: tourist places, restaurants, highway toilets, commercial establishments for public (such as, shopping malls, movie theatres, halls), entertainment theme parks, parks and public facilities (such as, libraries, museums), bus stations, train stations, trains, airports and public toilets in cities?

2.2. Should "schools" mean "educational institutions"? This has two implications: (a) "educational institutions" would then include colleges and universities, (b) the definition of "school" can vary between different geographies. For instance, a "school" in Tamil Nadu State in India means 10+2 years of education (apart from kindergarten) while the "+2" years is considered as pre-university in Karnataka State in India (not sure about current status but this used to be the case, but this could be the case elsewhere and therefore, there could be a difference of 2 or more years of education when children would be assured of JMP sanitation monitoring) --> Are there definitions for "school" in terms of number of years of education (with and without kindergarten), and (c) will the definition of "school" include kindergarten and creche / day care centers?

2.3. The target element "access" has been defined to mean "facilities close to home that can be easily reached and used when needed". Is "home" meant in the sense of "residential facility"? How are the target elements interpreted for persons in special situations? "Home" generally refers to "household" or normal home settings. Therefore, it may not include special situations, such as, detention centers, refugee camps, residential facilities in educational institutions (important when considering there are hostels attached to schools for children from disadvantaged groups), working women hostels.

2.4. Are all types of residential facilities included under high use/ high risk/ vulnerable situations? For instance, orphanages, senior citizen homes, homes for the terminally ill (not sure if such facilities exist),

2.5. What is the definition of "health centers"? Do they include ambulatory surgical care centers, nursing homes, diagnostic laboratories, home clinics run by medical practitioners, dental clinics, primary health centers, primary health sub-centers, etc. Would the requirement of "suitable for use" differ according to the type of health center? For instance, those in hospitals, psychiatric care centers, dental clinics and diagnostic labs can have very different requirements to meet "suitable for use" criteria of the SDG target.

2.6. The term "basic sanitation" has been defined to specifically exclude shared toilet facilities. However, hostels, refugee camps, mass gatherings, etc., (essentially, all situations of other-than-household toilets) are necessarily shared facilities. What are the criteria for defining "shared toilet facilities" in each of these cases? How are each of the target elements applied to each of these facilities?

2.7. While "workplaces" have been mentioned in the normative definition of target language, it has not been included in the list of supporting indicators when schools and health centers have been included?

3. Handwashing facility and menstrual hygiene needs: This might require a checklist of features to be included in what constitutes such a facility with respect to the toilet.

4. Food hygiene: Food hygiene, while include in the target elements, are not included in any of the current indicators and it would also be hard to measure. [WSSCC Webinar on 17 Feb 2015 and summary posted on SuSanA #12141 dated 18 Feb 2015 by Elisabeth Kvanström]. Just for my knowledge, are there guidelines regarding food hygiene in various settings or a checklist regarding food hygiene as part of WASH?

Warm regards,

Sowmya

Sowmya Rajasekaran
Director
Verity SmartLife Solutions
www.veritysmartlife.com
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  • bracken
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

As Krischan noted, from the JMP's perspective there has been a significant shift from their MDG indicator considering access to improved sanitation as the top rung of a monitoring ladder, (i.e. flush toilets, connection to a piped sewer system, connection to a septic system, flush / pour-flush toilets to a pit latrine, VIP latrines, or composting toilets) to what is their current proposed top rung "of safely managed sanitation" (defined as the population using an improved sanitation facility which is not shared with other households and where excreta is safely disposed in situ or transported to a designated place for safe disposal or treatment).
There is here a definite and clear movement towards looking at the entire sanitation system, with the system boundaries possibly being set at city / town / settlement level (if the JMP choose to use SFDs as one tool to assist monitoring).
For me already this means that in the coming years monitoring MUST be based on functionality - "safely managed" cannot be assessed in any other way.

Irrespective of the final indicators decided upon by the JMP or the OWG for the SDGs, this move towards functionality will require tools to agree upon, conceive, design, and implement sanitation systems. I think here the ladder can and will be very useful. Already, as mentioned in the very first post of this discussion, some organisations use a slightly modified version of the functional ladder as the basis for their sanitation and hygiene interventions (Note chapter 6 in this publication from WeltHungerHilfe / German Agro Action here: www.welthungerhilfe.de/fileadmin/user_up...ungerhilfe_02_13.pdf ).

The challenge I now see is how to adapt the existing functional ladder to the needs of implementing organisations (e.g. local authorities, water and sanitation utilities, NGOs, international development partners etc.) working at the cutting edge of hygiene and sanitation, to ensure that they have a tool that facilitates the evaluation of the functionality of the system and includes mechanisms to assess the equity of this implementation, addressing the concerns of the HRWS.

At the start of this discussion I was unsure if this would be a way forward, but I am now quite sure that adapting the ladder and orienting it towards practitioners would be a vey constructive way to support implementers in the post-2015 framework.

Water and Sanitation Specialist
AHT GROUP AG
Management & Engineering
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  • dorothee.spuhler
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

Dear all

From the outcomes of week 1 and 2 and the webinar of last week, it seems to me that the best entry point would be to built on existing suggestions and to try to best integrate the "functionality" into proposed targets and indicators. From the version sent around prior to the meeting last week (attached by Elisabeth here ) it is not clear to me how monitoring should be done. Elisabeth, can you clarify a little bit on the idea of using these "core indicators" and "supporting indicators"? -> I added the two relevant tables from the document again to this post so as it becomes easier to follow the discussion (see below).

If I do understand this correctly, all levels (except greywater, but there may be an option in other targets such as 6.3, I also reattach the current suggested SDG goals for people joining our discussion here) of a functional ladder could potentially be integrated:

1. Excreta containment
-> proposed indicators "Safely managed sanitation (...) where excreta is safely disposed in situ or transported to a designated place for safe disposal or treatment."

2. Safe access and availability
-> target 6.2 "access (for all)
to adequate and equitable"

(3 - Greywater management -> target 6.3)

4 - Pathogen reduction in treatment -> proposed indicators "Safely managed sanitation"

Based on this interpretation, we then could propose definitions for the different indicators (e.g. what is a "safely disposed in situ" and which places merit to be designated for "safe disposal or treatment"). At this level, a technology based definition would maybe, facilitate data collection for monitoring. But I also have somehow the feeling that a scorecard helping for identifying if something is "safe disposal" or "safe treatment" would be even more practical in the field.

However, from a less pragmatic point of view, we may also question the whole , but as Elisabeth highlighted it at the end of last week: we need to enter in dialogue with the SDG open working group...




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  • joeturner
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

It seems to me that the critical question for SuSanA members is how exactly this will affect the delivery of sanitation systems.

Presumably funding bodies and governments will be keen to work within the agreed SDG framework, so it seems to me that SuSanA members need to know whether their interventions would meet the standards of safety (and other issues highlighted by Sowmya above).

A composting toilet (as we've discussed recently with reference to the World Bank report) might have score highly on access, but low on pathogen destruction. Does that mean that this is a safe intervention?

And I can't really see how Patrick's idea of wider boundaries would work in a situation where people live with varying sanitation provision. Isn't it true that a small % of people practicing open defecation in a village which is considered "open defecation free" would (potentially or actually) affect the health of everyone else?

Surely then we are back to the consideration of the poorest form of sanitation in a community to determine safety.
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  • elkv
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

Hi Dorothee,
thank you for your post. Yes, my understanding too is that the functional ladder's first four steps are relevant to safely managed, although greywater does fit better under target 6.3 as you pointed out. I can, unfortunately, not highlight you on the core and supporting indicators very much more beyond my own interpretation. As I understood the Tuesday meeting notes from the WSSCC-hosted webinar, it seems like the core indicator will be broad, and that it will be supported by the supporting indicators which can be more specific and target different issues more specifically. It also seemed like, in the meeting, that JMP will continue to monitor on a more detailed level on their core interests.

Personally I cannot envision how one indicator will look like to encompass "safely managed sanitation". I do, however, agree with Patrick that this web discussion has also made it clear to me that the thinking of the functional ladder clearly can be one tool to use to monitor success in "safely managed sanitation", and I am happy to see that the German Agro Action has actually started using its own version! :).

I would like to underline Patrick's and Dorothee's call for web discussion inputs on adaptations of the functional ladder to be able to use it towards target 6.2 and 6.3. A functional ladder, with indicators that measure towards "safely managed sanitation" that organizations can use locally in their sanitation work would be great.

Just to start, personally I think the suggested indicators for the first step are quite straightforward, but I may be wrong of course.:).

For the second step, and given the formulation of the target formulation with "for all" and "equitable" and "special needs for women and girls" (see Dorothee's post) and Sowmya's post earlier, what indicators could be used here to ensure measurement of "for all" and "equitable" and "special needs for women and girls"?

If we leave greywater for the moment, and then look at the pathogen reduction step. What indicators could be used here? Should we be going with WHO guidelines for reuse and its use of treatment proxys (time, temperature etc) to avoid too complicated indicators? And propose some such for different flowstreams? What do you think?

Kind regards

Elisabeth

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  • joeturner
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

Here is a radical thought: maybe measuring pathogens directly is a nearly impossible task in many situations. Maybe instead we need to be measuring some health-related target, such as (say) the incidence of watery diahrrea per thousand people.

We may not be able to identify exactly what is causing the high/low levels of illness, but presumably we can be pretty sure it is a combination of safe/unsafe water, sanitation or hygiene practices.

If the number of infections was set at a sensible level, this is almost inevitably going to show that good and safe provision of water, sanitation and hygiene practices are in place.
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  • JKMakowka
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

Diahrrea and the way it is recorded (or not) makes for a bad indicator in my opinion.
Maybe one could do representative spot checks via stool samples of some common pathogens (and symptoms of environmental enteropathy?) to determine the percentage of occurance in a population? A relative decrease (taken during the same time of the year to reduce climate related distortions) could then be counted as a proof that the intervention worked?
Of course these campaigns and the testing would cost quite a bit, but since it only needs to be done now and then, a mobile laboratory that "tours" the country could be used.

Difficult to get a representive population sample of the stool samples though...

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  • Sowmya
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

Regarding Testing for Pathogen Reduction:

Stool testing from representative population: I agree with Krischan Makowka. Lab testing facilities requires skills and equipment that situations most in need of them do not have at present and so, either the sanitation SDG has to bear the cost and the logistics of training & running a lab facility (mobile or otherwise) or measurement of the sanitation target becomes dependent on achievement of some other SDG (for instance, we could have increase in lab infrastructure at the primary health center / sub-center level with samples being collected from each community around same time every year, as Krischan suggested, but this requires additional healthcare infrastructure and, diarrhea incidence being more common during the monsoons, healthcare staff would be hard-pressed to work on 'other domain' work when they have to deal with diseases that have high incidence during monsoons, such as, malaria and fever).

SDG monitoring indicator measures output while testing stool samples would be measuring outcome: Outputs are the actual, tangible results that are a consequence of the project's activities. The outputs/results are a description of the value of the products/services produced by the project within the framework of what the project stakeholders can guarantee. Outcomes are the difference made by the outputs. [Definitions used in Logical Framework Analysis (LFA) viz., the framework for project planning]

In case of interventions for pathogen reduction, measurement of output should be at the point of discharge into the environment (be it agricultural fields or open ground). Pathogen reduction in stools is an outcome. Using diarrheal incidence as a measure is also subject to other difficulties: (a) if a diarrhea vaccine were to be introduced, the vaccine would become a confounding factor ie., sanitation efficacy will seem high according to stools testing but it would be due to the vaccine and not sanitation, (b) if a diarrhea vaccine were introduced, another common disease that is both water- and soil-borne has to be found (because diarrhea is only one of the diseases caused by inadequate sanitation) which creates issues in comparability of sanitation results between countries and between different time periods (spatially and temporally), (c) it would not measure the risk of virulent diseases that have only periodic outbreaks and are region-specific (eg., Ebola) and (d) we cannot anticipate the impact of a newly emerging disease on the immune systems of population which may impact diarrheal incidence.

What do we want to measure? Do we want to measure the efficacy of the technology (can a VIP pit latrine reduce pathogens and, if yes, to what extent) or pathogen reduction in actual practice (quantum of pathogens reduced in each household with a VIP pit latrine)?

Further points for consideration:

(1) Pathogen reduction in actual practice is also a function of level of O&M as well as hydro-geological factors and symptoms may surface only during monsoons (flooding of the pits / sewer overflow during monsoons). Are the results of O&M included in measurement of the SDG target? If yes, what are the implications for technology assessment and technology selection?

Further, it has been found that households do not always wait until complete pathogen destruction period before using the excreta as soil amendments in the fields. This is an issue relating to improper use and not a direct result of sanitation provision. Therefore, while disease incidence may continue to be high, it is not low project output but a risk associated with the sanitation intervention.

(2) Data collection method: Data for all the SDG targets will be collected through census or annual surveys that are population-based (DHS, LSMS, MICS, CWIQ, etc) or sector-based (agricultural census, economic survey, etc). It is generally best if the data for measuring sanitation target does not require separate efforts.

(3) Agricultural reuse and food safety: The main reason why use of human excreta has been prohibited (except sewage biosolids) in several countries is the public health risk aspect. It is necessary that the method used in the sanitation SDG indicator to declare effluent discharge as pathogen free should also be a method that may come to be accepted by food safety regulators as a measure to decide on permitting agricultural reuse.

My apologies, I do not have a suggestion yet but the above are some points I wanted to mention.

Warm regards,

Sowmya

Sowmya Rajasekaran
Director
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  • joeturner
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

I think these are two different things: (1) an assessment of the efficacy of an individual sanitation project (which I believe is best measured by batch testing of the pathogens in faeces) and (2) the kind of community-wide assessments of performance against an SDG described by Patrick above.

With regard to the issues you highlight, Sowmya, I do not think that any indicator microbe is ever likely to totally overcome them: I am not even clear that ascaris is a good proxy measure of ebola destruction (and from what I've read, I don't think anyone knows). How it relates to other virilent diseases is also unknown.

I do not see it as a problem if disease burden is reduced other ways, for example by vaccination. If a community has been able to get the incidence down by a combination of vaccination, sanitation, water and hygiene interventions to below a threshold value of diahrreal incidence, I cannot see why that is a bad thing.

Again, to measure the actual effectiveness of individual programmes, other measures (preferably accurate pathogen analysis) would be better, but in terms of the SDGs we need something which can be rapidly measured and collected everywhere to give an overall picture. I cannot see that laboratory technology is likely to increase capacity by 2030 to an extent whereby every project can be routinely measured all the time to give community-scale pathogen indicators.
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  • John Brogan
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Re: TDS: Week 3 Theme - The way forward…adaptation of the sanitation ladder to the post-2015 period

Very much a fan of these three weeks of discussions and all the interventions!
To respond to Joe's point
"Isn't it true that a small % of people practicing open defecation in a village which is considered "open defecation free" would (potentially or actually) affect the health of everyone else?"

I was wondering about the relevance here of a community mechanism for self-monitoring as an indicator for (post) ODF?
Considering the graph from the 2014 UNICEF/ECOPSIS evaluation of the WASH Sector strategy: Community Approaches to Total Sanitation (CATS):




Would adding a "community monitoring mechanism" within the ladder enhance the SDG monitoring?

Best,
John

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