Dear Sowmya and colleagues.

We have been studying the paper Sowmya posted in the forum, that includes the Sanitation Ladder Framework adapted from SEI, and have gone ahead and translated a graphic into Spanish, which we have been using as a reference for years. Sarar team members are close colleagues with Elisabeth K., and other SEI members. For us it is very interesting as it adds other steps at the beginning of the ladder. See attatchement to clarify what we would like to use for a project we are working on in Mexico- a revised version of the one we shared in Spanish recently.

We have a question regarding the indicator on step 7- why wasn´t K removal considered as it also produces eutrophization in acquatic environments?

Kind regards, Fabiola and Magdalena

Note from Moderator: This post is the cut-off point of what will be included in the Thematic Discussion summaries and synthesis. New posts will not be included in the summaries or synthesis, but we welcome new contributions and further discussion in these threads!

Dear All,

I was wondering if we could work on a Recommendations Report that can be sent to, perhaps, the OWG. Would it be possible to contact the OWG regarding the SuSanA discussion during the TDS and see how we can send our inputs to the OWG? Please find attached a draft Recommendations Report that SuSanA members could use. It is very much a work-in-progress document and also contains some notes which I have not yet posted as text content in the TDS thread.

Warm regards,

Sowmya

Just to share, a first draft of a Spanish translation of the Sanitation Ladder!

Hi all,

I agree with Patrick that the key issue of the debate is how to adapt the existing ladder to the needs of implementing organisations. In my opinion, being the ladder a monitoring tool, the ultimate aim should be to provide clear information about who is served and who is not served, and which is the level of service delivered (including not only the conditions of the facility but also the management of excreta).

Two comments in this regard:

A) As has been said repeatedly, the focus should be on first four steps of the functional ladder, as they include the issues of basic infrastructure and excreta disposal / management. In terms of monitoring, I am not sure if an eight-rung ladder is adequate if four rungs are rarely achieved. Therefore, one recommendation could be to focus on a ladder of 4 to 5 rungs.

To me, the current functions of the ladder (Excreta containment; Access; Greywater management and Pathogen) may lead to an incomplete picture from a monitoring viewpoint. Having in the same rung different indicators related to hygienic conditions of the facility (rung 1: excreta containment) or to access (rung 2: access) does not allow at all the differentiation between different service levels accessed by different households. Not sure if a focus on the level of service delivered would help. This would entail identify the different categories of the service, and then describe various levels of service for each category. For instance, we could take into consideration the five HHRR criteria to categorize the service (availability, physical accessibility, safety, acceptability, affordability). Then, identify four different levels of service per each category (no service, basic service, intermediate service and adequate service). We could then apply the rule that moving up the ladder means that the level of service has been fulfilled for all 5 categories … At this stage, one could then relate the levels of service with a function-based approach …

All the best,

Dear all,
Today is officially the last day of this 3 week Thematic Discussion on the Functional Sanitation Ladder. Many thanks to all for the contributions!!!

Whilst I don't think that this is the end of the discussion by any means, I do think that these 3 weeks have been very useful and informative.
Starting into the three weeks, I think none of us three Thematic Lead (Elisabeth Kvarnstrom, Ricard Gine, or myself) had a definite goal in mind, and simply had a rough structure for each week. In retrospect I think this has helped us a great deal. The idea of the functional ladder has been around for a few years, but whilst meeting with broad agreement, it hasn't been broadly used in implementation or monitoring. These discussions have provided an impetus towards making the originally proposed functional ladder more practice-oriented and more relevant in the post-2015 context.

Originally it was planned to organize a webinar within the three week discussion period. However, no clear themes or topics seemed to come from the discussion which we, the thematic leads, felt would lend themselves to a more detailed consideration in a focused webinar. During the last few days though, it has become clear that the significance of the discussion needed to first sink in before we could see in what direction it could be best supported. We now feel that an appropriate next step would be if we, the three thematic leads, return to the original functional ladder and review it, bringing it up to date in light of all the constructive expert contributions made here since the 09.02 and to better address the post-MDG landscape.

Our aim is to produce a new version of the functional ladder that may be of use to implementers, providing them with a clear reference framework for their interventions and for monitoring, which conforms to the demands of the SDGs. We hope to have this review completed by mid-March and to return to the SuSanA group for further discussions, particularly within the framework of a webinar on the updated functional around the end of March.

I'd like to thank everyone who has contributed to this discussion so far with their experience, ideas, comments and analysis, they have all been a great help. I' also like to thank my co-thematic leads for the brainpower they have put in behind the scenes and their insightful contributions and engagement here, in parallel to their busy day jobs, and last but not least, the people at SuSanA, for providing this opportunity and the framework for the discussion, as well as timely summaries of what is going on - particularly Roslyn who has been a great driving force.

Suggestion for reporting multiple dimensions (sanitation coverage, equity, costs and health+environment protection) in one core monitoring indicator.

Abstract: The mandate to JMP from member states is to develop one measurable, robust indicator for monitoring & reporting on each SDG target. However, sanitation has several key dimensions all of which are important (sanitation coverage, equity, costs, health+environment protection). The core monitoring indicator proposed at present covers only sanitation coverage (with "safely managed sanitation" defined as the goal). Therefore, the outcomes in terms of equity, health+environment protection actually achieved and at what costs would not get reported.

This post has the following sections: (a) a suggestion to resolve the above problem by using a multi-part indicator format, (b) a suggestion for the core monitoring indicator, (c) explanation of how the tech-focused and functional sanitation ladder can be applied in the suggested core monitoring indicator and (d) notes giving examples of alphanumeric and multi-part codes used in other domains (to demonstrate acceptability of such codes by the public as well as experts).

Background: The JMP objective is to develop a set of core and supporting monitoring indicators that reflect all the target elements adequately without the performance on any important element getting blurred or masked in the indicator. For instance, while equity, progressive elimination of inequalities, environment-friendliness and affordability of the sanitation technologies being deployed are important dimensions that need to be monitored, performance on these dimensions should not mask the performance on the total sanitation coverage being reported (the present WASH proposal of "percentage of population using safely managed sanitation services" clearly reports performance on sanitation coverage).

Part 1: A suggestion to use a multi-part format for the monitoring indicators.

What a multi-part format means: Let us say we need to report performance on three dimensions. Then a multi-part indicator could take the form of ‘XYZ’ or “X-Y-Z” where X, Y and Z are values for three dimensions. For instance, “1A3” or “1-A-3” or “1.A.3” could be values for a 3-part code where “1”, “A” and “3” are each values for three different dimensions (or measures). The indicator could have only numerals with a separator symbol (such as, hyphen or period) or alphanumeric code with/without separator symbols.

Advantages of using multi-part indicators:
(1) Several measurements and several dimensions can be reported in a compact form;
(2) Multiple levels of reporting can be done in a very compact manner - for instance, Level 1 reporting on 3-4 key dimensions can be done for use by all stakeholders while Level 2 reporting can have more dimensions or different aspects of one dimension (eg., affordability, accessibility, availability and acceptability are different aspects of one dimension viz., equity & human right to sanitation) - even 10 dimensions would have a short length of only "ABCDE12345" while "ABCDE12345-XYZ" reports performance on 10 different dimensions and the final score (core indicator value) as "XYZ";
(3) The multi-part format is very simple for everyone to understand - a small explanation as a footnote is adequate for those completely new to sanitation sector to understand and so, no prior knowledge is necessary for clear understanding and discussions.

Part 2: A suggestion for a multi-part core monitoring indicator:

The core indicator has to report the most important dimensions of sanitation viz., (a) sanitation coverage (ie., %age of population with sanitation access), (b) equitable access for all and in high risk/high use contexts, (c) environment friendliness (safely managed + agricultural reuse) and (d) costs of implementation. Dimensions (a) and (b) are key elements of target 6.2 while (c) is important given the impact that sanitation can have on the environment and (d) costs determine the economic optimality of achieving sanitation-related SDGs.

The above 4 dimensions (sanitation coverage, equity, costs and health+environment benefits) could be condensed into a 3-part code viz., "coverage - equity - cost effectiveness ratio".

This monitoring indicator in the format of "X-Y-Z" would read as: “x% of sanitation coverage with y equity in access achieved at z cost-effectiveness ratio”. Thus, at one glance, it is possible to know performance on four key dimensions of sanitation provision.

The “x% of sanitation coverage” is the same as the currently proposed core monitoring indicator (viz., percentage of population with access to safely managed sanitation). The equity measure could be any index or score (such as the one cited by Ricardgine or the Gini Co-efficient). The cost-effectiveness ratio is a standard measure used in healthcare and several other domains for priority-setting and decision-making.

Why have cost-effectiveness ratio (CER) in the core monitoring indicator: An important function of a performance indicator is that it should be actionable, capable of being used in advocacy & communication and guide decision-making.

Health and environment protection are critical functions of sanitation. However, while health protection is an universal and important priority for the public and policy makers, environment-friendliness are largely considered a “luxury” and not a “necessity”. Indeed, environment concerns are often subjugated to the economics of decision options. Consequently, a value indicating some score on the environment is unlikely to have significant impact and, therefore, probably not actionable.

Further, sanitation interventions vary widely in terms of costs, lifespan and effectiveness (in public health and environment protection). Therefore, the monitoring indicator has to be actionable in terms of reflecting an optimal choice between costs, lifespan and effectiveness of sanitation interventions.

A solution to both issues highlighted above could be to express the total impact and associated costs in the form of cost-effectiveness ratio. The CER has the advantage of being universally understood and is actionable – it can be used for decision-making and performance reporting as well as in advocacy and communication. In case of sanitation, the CER can be improved only by necessarily optimizing on costs, lifespan and effectiveness. And, it would be necessary to improve on both health and environment protection to improve CER. Therefore, CER could be included in the core monitoring indicator.

Advantages of the suggested core monitoring indicator:
(1) Can report on four key dimensions of sanitation provision without performance on any dimension getting blurred in the score;
(2) Indicator is very compact and so presentation of results is very easy;
(3) When sanitation coverage is reported / presented for discussion, it will necessarily include performance on equity and environment aspects;
(4) Actionable and capable of being used in advocacy and communications;
(5) There is no interaction between sanitation coverage and the other dimensions in the final indicator value and, therefore, it does not require extensive consideration of indicator's robustness across different contexts;
(6) There has been considerable resistance (as read in reports) to including human rights aspects in the core monitoring indicator and, therefore, a separate track will give it adequate focus while avoiding the resistance;
(7) Comparison over time on each dimension is easier - can be done using published data instead of having to access special databases.

Part 3: How the tech-focused and functional sanitation ladder can be applied in the suggested core monitoring indicator:

The technology-focused sanitation ladder has basic sanitation access at its top-most rung and, therefore, covers only health protection function of sanitation. This is covered in the first part of the suggested core monitoring indicator viz., sanitation coverage.

The functional sanitation ladder covers both health and environment functions of sanitation. While the health function can be covered in the first part of the suggested core monitoring indicator viz., sanitation coverage, the environment function can be covered in the third part viz., cost-effectiveness ratio.

*

Part 4: Notes - Examples of alphanumeric and multipart codes used in other domains:

Important Note: Multi-part and alphanumeric codes have been used in other domains and some examples are given below to demonstrate the acceptability of multi-part and alphanumeric codes by the public as well as by experts (for use in their everyday work).

However, the code suggested here for the core monitoring indicator is different from the examples in the following ways:
(a) the multi-part format as well as the core monitoring indicator represent values on 2 or more different dimensions / measurements. For instance, the core monitoring indicator has a 3-part format expressed as “X-Y-Z” where X, Y and Z represent values for 3 different measurements (sanitation coverage, equity and CER). In contrast, a credit rating might state "AAA" but it represents a rank/score and not three dimensions; and,
(b) the suggested multi-part code is not hierarchical like a book classification code - it has different components each of which are independent measurements.

The examples given below are (a) book classification using a hierarchial code to locate books in a library’s bookshelves, (b) vehicle registration plates that use an alphanumeric format and (c) credit risk rating that uses an alphanumeric code for performance indicator.

(a) Book classification code – hierarchical format: Libraries use a multi-part code for book classification. Examples of book classification systems are the Dewey Decimal Classification (DDC) , Universal Decimal Classification (UDC) and Library of Congress Classification . However, book classification codes follow a hierarchical structure. For instance, 516.375 represents Finsler Geometry which is a result of:
500 – Natural sciences and mathematics
510 – Mathematics
516 – Geometry
516.3 – Analytic geometries
516.37 – Metric differential geometries
516.375 – Finsler Geometry

(b) Vehicle registration plates – alphanumeric format: A vehicle registration number could read as “EST 622 MHT” where EST stands of “Estonia” ( please see URL ).

(c) Credit risk rating in alphanumeric format: Credit risk rating uses alphanumeric format for performance indicator. For instance, in Fitch ratings , ratings from excellent to poor, range from AAA to AA- for prime/high grade, A+ to BBB- for upper to lower medium grade, BB+ to B- for non-investment grade speculative to highly speculative, CCC+ to C for substantial risks to default imminent and DDD to D for in default.

Warm regards,

Sowmya

I'd just like to return to a point Joe made, regarding boundary conditions in an area with varying levels of sanitation service.

I think this is most definitely a point and will blur the edges of what the JMP might consider "safely managed sanitation". In my understanding, they have moved towards looking at the system, which for me then includes the users of the system, the collection, transport, treatment, and management of end products of human excreta (as well as greywater, solid waste, industrial wastewater, and storm water - but the SDGs aren't going that far, at least not within Goal 6.2).

But what happens when different systems overlap, which is the norm particularly in urban areas? For example, what is the situation when fecal sludge from pit latrines is disposed of untreated, or co-composted or otherwise treated decentrally, whilst some homes are attached to a functioning sewer systems (taking wastewater away) taking wastewater away from their homes to a functioning treatment plant, and some individuals continue to practice open defecation? The overall management of excreta cannot be considered safe, but certain elements of it are.
I suppose one approach, and probably the most pragmatic, would be to disentangle the different practices and service levels and prioritise which ones pose the greatest danger and should be addressed first in the context, using the system boundaries as set by the chain from user to end management as the analytical space.

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

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.

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

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...

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.