Improving Sanitation to Secure Communities and Their Human Capital

In May of 2018, Dr. Ndavukai Larinyoni arrived at Itepula village in the southwestern region of Songwe. This was to be her new workstation as the doctor in charge of the village dispensary. She was transferring from St. Mary’s Dispensary, almost 700km away in the northern region of Manyara. Though both are remote locations, the most significant difference between the two was the fact that in Manyara, her dispensary had access to safe water supply and sanitation; Itepula did not.

“We had to queue for water along with the rest of the residents at the sole borehole, and if you were lucky to find the water flowing, the queue was always something to contend with. When the pump broke down, which was frequently, we had to go find water further out at unsafe shallow wells,” said Dr. Ndavukai. “We also had no toilets on site, so we would go to the village office to use their pit latrine.”

Dr. Ndavukai soon established a routine: She would wake up at 5:00 a.m. to collect water—about a kilometer from her house—and prepare for the needs of her two children at the time (she has three now, aged nine, five and one). Her target was to get to the dispensary by 6:00 a.m. every other day, when it was her turn to collect the four buckets of water that she and her nurse needed each workday; she would clean up the premises and open to start receiving her patients by 9.00 a.m. 

“This was not something I had ever expected to experience in my life as a doctor,” said Dr Ndavukai. “It got harder during the early days of the COVID-19 pandemic when we required all our patients to wash hands before coming in. This increased our water usage so I would use my own money to hire help to fetch the water we needed. That is when I began despairing and considered requesting a relocation.”

She recalled the anticipation around the village when staff of the Rural Water Supply and Sanitation Agency (RUWASA) arrived in mid-2020 to survey the village and hold meetings with the residents. In October 2020, construction of the Itepula Village Water Scheme began and was completed and handed over to the village in December of that year. As priority institutions, the dispensary and the two schools in the village were connected immediately to the water supply scheme. 

An Orphaned Sector

Following various sector analyses that brought to fore numerous factors that contributed to the continued lagging of the rural water supply and sanitation sector, the Government of Tanzania in 2019 moved to establish RUWASA, as the anchor of a new service delivery model focused on providing sustainable water in rural areas through resource mobilization, project implementation, capacity building, and operation and maintenance of projects with the active participation of major stakeholders. 

RUWASA is providing new water supply services to villages like Itepula through the implementation of the $350 million Tanzania Sustainable Rural Water Supply and Sanitation Program (SRWSSP), which is financed by the International Development Association (IDA)*. Implemented since 2019, the SRWSSP’s development objective is to increase access to rural water supply and sanitation services in 86 participating districts in 17 administrative regions of the country and strengthen the capacity of sector institutions to sustain service delivery. 

The SRWSSP is a Program for Results (PforR, or “results-based financing”) which is an effective instrument that creates new incentive frameworks for local institutions to deliver better quality and lasting services and institutionalizes good practices. Under this model, financing is disbursed according to results achieved and verified through the disbursement-linked indicators (DLIs) and independent verification mechanisms. 

As a comprehensive sector-wide program, the SRWSSP has three result areas: sustainable access to improved water services in rural areas (‘Result Area 1’); increased access to improved sanitation services in rural areas (‘Result Area 2’) and strengthened capacity of sector institutions to sustain service delivery in rural areas (‘Result Area 3’). Result Area 1 is implemented by RUWASA, while Result Area 2 by the Ministry of Water (MOW), the Ministry of Health (MOH), and the Ministry of Education, Science and Technology (MOEST). Result Area 3 is implemented by the President’s Office-Regional Administration and Local Government (PO-RALG); as well as MOW, MOH, MOEST and RUWASA.

As part of the analyses done during program design, it was found that WASH promotion in schools and healthcare facilities has received limited attention, and 75 percent of schools lack a functional handwashing facility with available soap and water. Over half of health facilities report routine water shortages, which interferes with hygienic care.

Established in 2015, Itepula dispensary serves 4,500 residents, offering out-patient services (OPD), as well as delivery and reproductive and child health services. In a month, the OPD receives up to 200 patients and handles a maximum of 15 deliveries. Under the SRWSSP, in addition to attaining connection to the new village safe water scheme, the dispensary has also benefited from financing which supported the construction of six flush toilets with self-contained handwashing facilities, one bathroom and toilet for the delivery unit, and a handwashing station, together with a 5,000-liter storage tank. Per program requirements, all the new facilities must include a toilet for persons with disability, along with an accessibility ramp. 

“It makes me happy to just be able to turn around in my chair and wash my hands at the tap here in my office after seeing a patient, as this is how it should be because we come into contact with our patients’ conditions,” said Dr Ndavukai. “But also, when we once had a particularly difficult case of postpartum hemorrhage, we were lucky to have had the few buckets of water that saved the day. Access to water is critical for delivering our services.”

Change by Example

Since the SRWSSP implementation started in 2019, 4.67 million people have gained access to improved sanitation, exceeding the program target of four million by July 2024. To date, the Program has also improved access to safe sanitation and hygiene facilities in 637 public primary schools and 873 health facilities and dispensaries. The SRWSSP targets providing sanitation facilities to 1,500 health facilities and dispensaries by the end of implementation in 2024. Program-supported sanitation facilities (for schools as well) consist of structures such as flush or pour-flush toilets – as a requirement where water is available – or ventilated improved pit latrines, or pit latrines with intact slabs or composting toilets, without leaks or overflow of the superstructure or containment structure. Structures are protected with walls and a door shutter to provide privacy and security for the user. 

Mlowo dispensary is located 20km from Vuawa, the administrative capital of Songwe region where the regional referral hospital is also located. Built in 2001, the dispensary, with a staff of 18, serves a population of 43,252. About 700 patients go through its OPD each month, and up to 40 deliveries are handled by its RCH unit. Open Defecation Free Villages

Iringa, in the agriculturally rich southern highlands, is one of the 17 administrative regions that are implementing the SRWSSP. In addition to the other components of the program, the SRWSSP has supported the region’s implementation of various aspects of the NSC in the three districts of Kilolo, Mufindi and Iringa. The impressive results so far show an overall increase in access to improved latrines from 78 percent in 2020 to 88 percent in 2021. In addition, the number of ODF-certified villages increased from 31 in 2020 to 189 villages in 2021.

One of those villages is Ipalamwa, nestled in the wooded, rolling hills of Kilolo district. When the campaign kicked off there in 2018, only one household out of 274 had an improved toilet. Given the abundant supply of wood in this hillside village, the quintessential toilet structure was a hut walled with leftover bark (“mabanzi”)—or with old banana trees roped together—sitting atop a drop-hole in the middle of the earthen floor. Sometimes the roof was thatched; oftentimes it was bare.  

“If yours wasn’t thatched, you would not go during the rain,” said Valentina Magulilo, the Village Executive. “But these structures were also seasonal as they weakened quite fast with the rains, and when an owner felt it had become a safety hazard, they would break it down and construct another one.” 

By late 2017 when Dr. Zawadi Njinile arrived as the resident doctor, a Good Samaritan had recently donated a water supply system for the dispensary, which had relieved the staff from making the daily trips to distant shallow wells on which they depended for the water they needed for their work. For toilets, though, they still had to choose between using the two narrow and unsanitary pit latrines (at great personal risk, since they were unsafe) or indulging the goodwill of neighbors who had better latrines. In April 2021, under the SRWSSP, construction of six new toilets—including two for staff, one toilet and bathroom for expectant mothers and one toilet for persons with disability—was completed.

“In addition to the positive impact on our health and hygiene, having such facilities has really improved our image and dignity as healthcare workers,” said Dr. Njinile. “As part of our job, we do not only advise our patients on health and hygiene risks, but we are also expected to lead by example. We are now more credible giving such advice than before when we had to knock on our neighboring doors to request to use their toilets.”

Such is the fresh appeal of the facilities today that some mothers will try to do anything just to be able to give birth at Mlowo. “As a dispensary, our guidelines do not permit us to handle mothers who have had four children already nor those who have had a previous C-section, as these are automatic referral cases,” explained nurse Catherine Ngailo. “But they keep coming and begging us to allow them to have their babies here. We explain to them the risks involved and they understand eventually.” She added that before they had the new sanitary facilities, they registered up to 12 deliveries a month, but this has risen to between 35 and 40 over just the past year. 

“Sanitation contributes directly to the human capital by protecting early childhood development,” said Ruth Kennedy-Walker, World Bank Co-Task Team Leader of the SRWSSP. “Improved hygiene during labor and the early years of a child’s life is critical through improved access even in healthcare facilities. But in addition, we expect knock-on effects of such initiatives at home and within communities as patients continue experiencing the benefits of improvements at their dispensaries and schools.”

It Takes a Village

Beyond the increasing numbers of people and households directly benefiting from the construction and upgrading of sanitation and hygiene facilities in public schools and health clinics as part of its Sanitation result area, the SRWSSP’s theory of change also envisages incentivizing, catalyzing and sustaining behavior change that supports the goals of the government’s National Sanitation Campaign (NSC), which are to encourage households to build improved sanitation facilities and to make communities open-defecation free (ODF).

Launched in 2012, the NSC, whose slogan is "Nyumba ni Choo" (Swahili, meaning: "Home is incomplete without a toilet"), has been financed by the UK’s Foreign, Commonwealth and Development Office since 2017, and has been a catalyst in changing behaviors and driving ODF targets, as well as interest among households in constructing improved sanitation and practicing improved hand hygiene practices. Though the target of the NSC was to achieve 75 percent coverage of the rural population with access to sanitation by 2022, by April 2022, the campaign had already attained 72 percent. Going forward, phase 2 of the NSC will be supported using SRWSSP financing.

The campaign incentivizes an integrated approach that motivates districts to tackle the lack of household access to improved sanitation, poor hand hygiene, and open defecation through a mix of mass media promotion and on the ground demand creation and supply-side activities. As access to sanitation in schools and health facilities improves, the districts are further rewarded for combining these improvements through the SRWSSP so that villages achieve the greater health benefits of Community-Wide Sanitation (CWS). As sanitation coverage increases, the health of the rural population also improves due to the reduction in the prevalence of waterborne diseases and chronic malnutrition in under-5s. 

Open Defecation Free Villages

Iringa, in the agriculturally rich southern highlands, is one of the 17 administrative regions that are implementing the SRWSSP. In addition to the other components of the program, the SRWSSP has supported the region’s implementation of various aspects of the NSC in the three districts of Kilolo, Mufindi and Iringa. The impressive results so far show an overall increase in access to improved latrines from 78 percent in 2020 to 88 percent in 2021. In addition, the number of ODF-certified villages increased from 31 in 2020 to 189 villages in 2021.

One of those villages is Ipalamwa, nestled in the wooded, rolling hills of Kilolo district. When the campaign kicked off there in 2018, only one household out of 274 had an improved toilet. Given the abundant supply of wood in this hillside village, the quintessential toilet structure was a hut walled with leftover bark (“mabanzi”)—or with old banana trees roped together—sitting atop a drop-hole in the middle of the earthen floor. Sometimes the roof was thatched; oftentimes it was bare.  

“If yours wasn’t thatched, you would not go during the rain,” said Valentina Magulilo, the Village Executive. “But these structures were also seasonal as they weakened quite fast with the rains, and when an owner felt it had become a safety hazard, they would break it down and construct another one.” 

As a result of the NSC, the village leadership broke down their own office latrine at the start of the campaign to set an example. Working against the district-issued deadline for ODF inspection, the leaders held meetings with villagers to explain the benefits of improving their toilets. “Some had concerns because of the cost per toilet structure, and we discussed options with them, including splitting costs with neighbors,” said Magulilo. 

“With a Sh500,000 [$215] budget, we can build an improved toilet consisting of a superstructure, cement floor, piping, door, and iron roofing,” said Magulilo. Eventually, the village met the 2018 deadline with the majority building not only their own household toilets but also contributing to the fund for their local teachers’ households as well. 

“Many people have been motivated to improve their overall home environment and are even adding a proper bathroom next-door to the toilet,” Magulilo added. 

As Ipalamwa village has consistently maintained its ODF status, with new households also adhering to these requirements—their efforts were acknowledged by USAID who awarded them Sh80 million ($35,000) that went towards the construction of 11 toilets at the village primary school. They are currently ranked 12th out of 400 villages that participated in the 2021 NSC Competition. 

“Everything starts with education,” said Enock Mpalanzi, an elderly resident who has built not only a toilet but a bathroom also for his six-member household. “We always built good houses but didn’t think much about the accompanying toilet because the mabanzi is what we were all accustomed to. But now everybody here appreciates the benefits; the safety, convenience, and freedom from all the stomach diseases we had in the area.”