Appropriate Approaches to Hygiene and Environmental Sanitation in Remote Communities of Mugu and Humla Districts, Western Nepal

Will Tillett January 2008 Technical Department WASH sector, ACF-France

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Executive Summary

Mugu and Humla are among the least developed of the 75 districts of Nepal; which itself is one of the poorest countries in the world. The mountainous districts are remote and drought prone, and the prolonged conflict in the area has impaired local governance, social organisation, and community based services. Action contre la Faim (ACF), has been operating water supply, sanitation and hygiene activities in the area since 2006, and launched this study, in association with the University of Cranfield (UK), to investigate the most appropriate approaches to sanitation and hygiene for the remote communities in the districts. The research, undertaken over 2007-2008 included over 80 qualitative interviews with communities and key informants, along with meetings to build on the experience of a diverse range of sanitation and hygiene ‘actors’ operating across Nepal. A range of approaches to sanitation and hygiene have been piloted, and applied across the country, but little research as been undertaken in Mugu and Humla; districts with some of the lowest sanitation coverage of the nation.

Open defecation is prevalent in the area, and poor hygiene and environmental management practices create serious public health risks. Diarrhoea is the biggest cause of mortality in the districts, and there is a widespread prevalence of intestinal worms, skin infections, and child malnutrition. Personal and clothes washing is infrequent, and child hygiene is an area of particular concern. Although hygiene and sanitation may be the priority of the outsider, they are lower priorities to the communities, particularly in light of uncertainties of food and water supplies. Whilst not necessarily health related, interviewees perceive issues with their current situation, and barriers to attaining improved practices, such as soap, external material and water access, time availability of mothers, and the ‘dirtiness’ of the villages. Children are deemed autonomous for their hygiene and sanitation needs from an early age, and there is limited parent to child teaching on these topics. The post-conflict communities experience a lack of social cohesion, leadership and initiative, although the recent emergence of Mother’s groups hold potential to drive change. The few sanitation ‘actors’ in the area mention issues of poor coordination of activities, and conflicting policies for community incentives and subsidies are leading to increasing community demands and expectations. Due to material and transport costs, ‘conventional’ latrine designs incur both high per-capita costs, and hold poor potential for replicability without assistance. Due to restricted field access, many projects have taken a ‘hardware’ focus, with limited ‘software’ activities of mobilisation, participation and demand building; limiting the uptake and usage of latrines, and the future sustainability of interventions.

Future approaches in the area could take on longer-term, ‘software’ orientated activities, building demand, and empowering communities to drive change by themselves. Strong mobilisation and sustained follow-up support is crucial. Projects could strengthen the local private sector and supply chains, build up the local skills base, and develop partnerships with local institutions for ongoing sustainability.

The issue of sanitation should be addressed as a community initiative, through participatory mobilisation techniques, driving for 100% coverage, and usage . Projects offering no material subsidy for latrines may be ineffective in this context. Therefore a basic (minimal) subsidy is suggested, augmented with sanitation marketing for households aspiring for higher standards of latrines. Local government could play a key role in coordinating sanitation approaches and for the ongoing support for community driven sanitation in the area.

Hygiene promotion (HP) should be prioritised to address the key risk practices, and relevant to the communities perceptions of the issues. Community level mobilisation and problem identification, should be followed by more targeted HP sessions, and enabling factors should be addressed. Low-cost solutions for environmental sanitation hold strong potential to contribute to improving food security, and should be promoted as such. Child hygiene is a complex issue, and could be addressed through a multi-channel approach, including; improving environmental sanitation, developing child care practices and direct HP to children, through schools and community based activities.

Implementing sanitation and hygiene projects in the area is challenging. However, change can occur, albeit with time, and should be driven by the communities themselves. In light of national targets and financial constraints, approaches to hygiene and sanitation in the area need to be coordinated, low-cost, replicable, and sustainable. A holistic and integrated approach should be taken to work towards the common goal of reducing mortality and morbidity through malnutrition and sanitary related diseases.

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Acknowledgements

I would like to extend my gratitude to both ACF and Cranfield University for giving me the opportunity to take part in this study.

Thank you to Richard Carter and Jean Lapegue for all their support, knowledge and insights in this research, and for their time spent reviewing a gigantic draft.

Thanks to all the NGOs and sector workers who contributed to this research, particularly to Oliver Jones of WaterAid, and the team at NEWAH, from whom I learnt a great deal.

Thanks to all the staff of ACF Nepal for your insights, assistance and company over the study period, particularly the logistics team, who seem to make miracles happen. Thanks to all the French expatriates for keeping up stocks of wine and pate, in a sea of rice and lentils.

My gratitude, as always, extends to my parents, for their constant encouragement, support and understanding.

Finally, my gratitude extends to the inhabitants of Mugu and Humla districts, for their kind hospitality, and for their openness to discuss at length about their defecation habits to a strange looking ‘outsider’.

Will Tillett Water, sanitation and Hygiene Researcher [email protected]

The photographs in this manual were taken by and are reproduced with the permission of Will Tillett.

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Presenting ACF-IN Approaches and Programmes

Action Contre la Faim (ACF) (formerly Action Internationale Contre la Faim) is an independent, a-political non- governmental humanitarian organisation which is internationally recognised as one of the world's premier organisations in combating hunger. ACF intervenes in humanitarian situations involving war, famine, natural disasters and other crises to bring help to displaced people, refugees and any other populations in danger. After the emergency is over, continuity of action helps affected people recover their independence through medium and long-term programmes. The prevention of disasters is also one of its objectives. ACF developed an international network with the opening of Accion Contra el Hambre in Madrid and Action Against Hunger in London and New York and recently an office in Toronto. ACF-IN has 350 international volunteers and 4,000 national staff working in over 40 countries and responds in all four areas involved in the fight against hunger and malnutrition: nutrition, health, food security, and water, sanitation and hygiene.

The Charter Action Contre la Faim (ACF) is a non-governmental organisation. Private, non-political, non-denominational and non-profit making, it was set up in France in 1979 to intervene in countries throughout the world. ACF vocation is to save lives by combating hunger, disease, and those crises threatening the lives of men, women and children. ACF intervenes in the following situations: • In natural or man-made crises which threaten food security or result in famine, • In situations of social/ economic breakdown linked to internal or external circumstances which place particular groups of people in an extremely vulnerable position, • In situations where survival depends on humanitarian aid. ACF intervenes either during the crisis itself, through emergency actions, or afterwards, through rehabilitation and sustainable development programmes. ACF also intervenes in the prevention of certain high risk situations. The ultimate aim of all of ACF’s programmes is to enable the beneficiaries to regain their autonomy and self- sufficiency as soon as possible.

ACF respects the following principles: INDEPENDENCE - ACF acts according to its own principles so as to maintain its moral and financial independence. ACFs actions are not defined in terms of domestic or foreign policies nor in the interest of any government.

NEUTRALITY - ACF maintains strict political and religious neutrality. Nevertheless, ACF can denounce human rights violations that it has witnessed as well as obstacles put in the way of its humanitarian action.

NON DISCRIMINATION - A victim is a victim. ACF refutes all discrimination based on race, sex, ethnicity, religion, nationality, opinion or social class.

FREE AND DIRECT ACCESS TO VICTIMS - ACF demands free access to victims and direct control of its programmes. ACF uses all the means available to achieve these principles, and will denounce and act against any obstacle preventing it from doing so. ACF also verifies the allocation of its resources in order to ensure that the resources do, indeed, reach those individuals for whom they are destined. Under no circumstances can partners working together with or alongside ACF become the ultimate benefactors of ACF aid programmes.

PROFESSIONALISM - ACF bases the conception, realisation, management and assessment of its programmes on professional standards and years of experience, in order to maximise its efficiency and the use of its resources.

TRANSPARENCY - ACF is committed to respecting a policy of total openness to partners and donors and encourages the availability of information on the allocation and management of its funds. ACF is also committed to providing guarantees of proof of its good management.

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Table of Contents

Executive Summary...... 3 Acknowledgements...... 5 Presenting ACF-IN Approaches and Programmes...... 6 Glossary of Abbreviations ...... 10 1 Introduction ...... 11 1.1 Nepal...... 11 1.2 Humla and Mugu Districts ...... 12 Aims and Objectives ...... 15 2 Literature Review...... 16 2.1 The Importance of Hygiene and Sanitation ...... 16 2.2 Sanitation in Nepal...... 17 2.2.1 The Sanitation Status...... 17 2.2.2 The Provision of Sanitation in Nepal...... 18 2.2.3 Strategies and Policy in Rural Sanitation and Hygiene Promotion...... 20 2.3 Approaches to Sanitation ...... 23 2.3.1 Conventional Approaches...... 23 2.3.2 Subsidies...... 23 2.3.3 ‘Subsidy or Self Respect’: Community Approaches ...... 24 2.3.4 CLTS in Nepal ...... 25 2.3.5 Community Led Basic Sanitation for All (CLBSA)...... 26 2.3.6 School Sanitation & Hygiene Education & School Led Total Sanitation...... 26 2.3.7 Revolving Funds and Loans...... 26 2.3.8 Sanimart...... 27 2.3.9 The ‘Model’ Approach...... 27 2.4 Hygiene Promotion...... 28 2.5 Summary ...... 28 3 Methodology...... 29 3.1 Field Research...... 29 3.1.1 Community Selection...... 29 3.1.2 Interviews ...... 29 3.1.3 Interviewee Selection...... 30 3.1.4 Style and Topics for the Interviews...... 31 3.1.5 Structured and Non-Structured Observation...... 32 3.2 Coordination with Other Sector Workers...... 32 3.3 Research Limitations...... 32 3.3.1 Logistics, Coordination and Planning...... 32 3.3.2 Timing of the Field Research...... 33 3.3.3 Interviews ...... 33 4 Findings & Analysis ...... 34 4.1 Context and Community Descriptions...... 34 4.1.1 Community Habitation, Location, Distribution and Orientation...... 34 4.1.2 Society, Culture and Religious Beliefs...... 35 4.1.3 Livelihoods and Economy ...... 36 4.1.4 Roles, Responsibilities and Gender...... 36 4.1.5 Community Organisation, Leadership and Local Governance...... 37 4.1.6 Health and Healthcare ...... 38 4.1.7 Transport, Local Supply Chains and Consumption Practices...... 40 4.1.8 High community expectations...... 41 4.2 Environmental Health in the Communities: Practices, Perceptions, Aspirations and Barriers...... 42 4.2.1 Environmental Health Situation from Observations...... 42 4.2.2 Interviewee Perceptions of Environmental Health Issues in the Villages ...... 44 4.2.3 Defecation Practices and Latrines...... 44 4.2.4 Experiences of Latrine Ownership and Usage...... 47

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4.2.5 Future Aspirations for Latrines ...... 51 4.2.6 Locations of Latrines...... 51 4.2.7 Institutional Sanitary Facilities ...... 53 4.3 Environmental Sanitation...... 53 4.3.1 Solid waste disposal ...... 53 4.3.2 Roof and Greywater disposal...... 54 4.3.3 Livestock and composting practices...... 55 4.3.4 Road Paving...... 56 4.4 Personal Hygiene...... 56 4.4.1 Personal washing ...... 56 4.4.2 Clothes Washing...... 58 4.4.3 Hand Washing...... 58 4.5 Child Hygiene & Sanitation...... 59 4.5.1 Parenting, Responsibilities and Care Practices ...... 59 4.5.2 The Role of the School...... 61 5 Discussion...... 63 5.1 Overall Approach ...... 63 5.1.1 Community Approach...... 63 5.1.2 Community Based Organisations...... 64 5.1.3 Coordination of Activities...... 64 5.1.4 Developing Local Capacity...... 65 5.1.5 Timescales and Donor Funding...... 65 5.2 Options Available for Environmental Sanitation and Hygiene Approaches...... 65 5.2.1 Sanitation ...... 65 5.2.2 Hardware Approach & Appropriate Technologies ...... 68 5.2.3 Software Approach ...... 72 5.2.4 Replicability and Future Sustainability ...... 73 5.2.5 Latrine Locations ...... 75 5.3 Promotion of Hygiene and Environmental Sanitation ...... 75 5.3.1 Prioritising Interventions...... 75 5.3.2 Enabling Factors...... 77 5.4 Hygiene Promotion...... 78 5.4.1 Current Approach ...... 78 5.4.2 Future Approach...... 78 5.5 Child Hygiene Improvement ...... 79 5.5.1 Environmental Sanitation and Enabling Factors...... 79 5.5.2 Parent to Child Care Practices ...... 80 5.5.3 Hygiene Promotion Directly to Children...... 81 6 Conclusions & Recommendations ...... 82 7 References...... 86 8 Appendix...... 89

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Table of Figures

Figure 1.1. Human development status by eco-development region. Source: UNDP (2004) 11 Figure 1.21. Maps identifying ACF Nepal’s intervention areas of Bajhang and Mugu and Humla. Source: www.googlemaps.com 14 Figure 1.22. A Map of the study area in Mugu and Humla districts. Developed from basemap, Source: GoN & Helvetas (2000) 14 Figure 2.11. The ‘F Diagram’.Source: Almedom et al (1997) in Tabiri (2005) 16 Fig. 2.12. Coverage of Improved Sanitation in 2002. Source United Nations (2005) 17 Figure 2.212. Percentage of households with access to toilet facilities by District. Source: (CBS/ICIMOD 2003). 18 Fig. 2.22 Simplified Organisational arrangements for the provision of rural sanitation in Nepal. Based on Ockelford & Shrestha (2002), modified and updated by Taylor et al (2005) 19 Figs 3.121 & 3.122. Demographic and caste divisions of 87 interviews. 30 Fig. 3.2. Division of the 44 coordination meetings and interviews. 32 Fig. 4.111, 4.112, 4.113. Terrace houses in Jamaldara; Melcham Village; Macinmella (seasonal high altitude settlement). 34 Figure 4.114. The layout of houses in the study area. 35 Figures 4.162, 4.163. Understanding of disease transmission. Source: KAP Survey 2007 39 Figures 4.164, 4.165, 4.166. Interviewees response to diarrhoeal incidence (KAP Survey 2007); a traditional healer in Libru village; a child showing signs of stomach scarring from traditional ‘medicine’ in Nerah village. 39 Figures 4.171, 4.172, 4.173, 4.174. Mugu district’s airport; A ropeling river crossing in Mugu; district stores in Gamghadee (Mugu’s capital); a village shop in Purumeru village (Mugu district) 40 Figure 4.175. Household Cash for Work Scheme Expenditures. Source: ACF (2007f) 41 Figures 4.211, 4.212, 4.213, 4.214. Pictures of the status of environmental status of the communities visited. 42 Figure 4.215. Water sources used in the area. Source: KAP Survey. 43 Figure 4.22. Major Issues in Village Relating to Hygiene & Sanitation, as Perceived by Interviewees 44 Figure 4.231. Defecation sites, Results from the KAP Survey 45 Figure , 4.232. Defecation sites, Results from this research 45 Figure 4.233. Collection & Disposal of Faeces 46 Figure 4.234. Methods of Anal Cleansing (Adults) 46 Figure 4.235. Issues with current defecation practices, as perceived by interviewees 47 Figures 4.241, 4.242. Reasons for building a latrine in the past, and the location of the latrine. 47 Figure 4.243, 4.244, 4.245, 4.246. Examples of pan designs and water containers in local latrines 48 Figures 4.247, 4.248, 4.249, 4.2410. Examples of local functional, child and derelict latrines. 49 Figures 4.2411, 4.2412. Issues with, and reasons for stopping using the latrine. Findings from this research and the KAP Survey. 50 Figure 4.26. Perceived Issues of Sharing a Latrine, from the KAP Survey. 52 Figures 4.311, 4.312. Solid Waste Management Practices from this research, and the KAP Survey, respectively. 53 Figures 4.321, 4.322. Domestic greywater management practice findings from this research, and the KAP Survey, respectively. 54 Figures 4.323, 4.324, 4.325, 4.326. Pictures of the environmental sanitation situation in the villages 55 Figures 4.411, 4.412. Frequency of Personal Washing Results from this Research, and the KAP Survey, Respectively. 57 Figure 4.413. Issues with personal washing, as perceived by interviewees 57 Figure 4.43. Box Y. Findings from the KAP Survey Regarding Hand Washing 58 Figures 4.511, 4.512, 4.513, 4.514, 4.516. 12 day-old baby given birth, and kept in the cattle shed; a child left alone unsupervised at home; a child covered in flies in Humla district; baby washing with cold water; elder sister taking care of younger sibling whilst mother works the fields. 59 Figure 4.517. Issues and barriers in child hygiene perceived by interviewees 60 Figure 4.52. School Enrolment Trends in Mugu District 2006-7. Created from data obtained in 'District Education Office Gamgadhee, Mugu. Schools, Students, Teachers, Students of Mugu District 2064-65’ 61 Figure 5.21. Cost of sanitation financing modalities in a typical Nepali community of 99 households (33 ultra poor, 33 poor and 33 medium). Source: WaterAid 2007. 67 Figure 5.223. Improvised, pan structures integrating cement pan with pipe. Lower Rhimi village, Humla. 71

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Glossary of Abbreviations

ACF Action Contre la Faim ADB Asia Development Bank ARI Acute Respiratory Infection CBO Community Based Organisation CBWSSP Community Based Water Supply and Sanitation Project CFW/FFW Cash For Work/Food For Work CHAST Children's Hygiene and Sanitation Training CLBSA Community Led Basic Sanitation for All (NEWAH) CLTS Community Led Total Sanitation COPD Chronic Obstructive Pulmonary Disease DALYs Disability-Adjusted Life Years DDC District Development Committee DEO District Education Office/Officer DHO District Health Office/Officer DMC District Management Committee DoLIDAR Department of Local Infrastructural Development Agricultural Roads DTO District Technical Office FCHV Female Community Health Volunteer FGD Focus Group Discussion GFS Gravity Flow System (Piped water supply systems) GoN Government of Nepal HDI Human Development Index HP Hygiene Promotion IEC Information Education and Communication (visual hygiene promotion materials) INGO International Non-Governmental Organisation iPRA ignition Participatory Rural Appraisal KAP Knowledge, Attitudes and Practices (Survey) LNGO Local Non-Governmental Organisation MDGs Millennium Development Goals MoU Memorandum of Understanding NEWAH Nepal Water for Health (National NGO) NGO Non Governmental Organisation NPR Nepalese Rupee OPD Out Patient Diseases PHAST Participatory Hygiene and Social Transformation PRA Participatory Rural Appraisal QIP Quick Impact Project RWSS Rural Water Supply and Sanitation RWSSFB Rural Water Supply and Sanitation Fund Board SLTS School Led Total Sanitation SMC School Management Committee SSHE School Sanitation & Hygiene Education VDC Village Development Committee VIP Ventilated Improved Pit (latrine) WASH Water Sanitation and Hygiene WATSAN Water and Sanitation WFP World Food Programme WHO World Health Organisation WSUC Water and Sanitation Users Committee

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1 Introduction

1.1 Nepal

Nepal covers a total land area of 147181km 2, which is split into 3 geographical zones; the southern plains of the Terai bordering India; the middle ‘hills’; and the mountains of the Himalaya range. The population of Nepal stood at 23.2m in 2006, comprising of over 60 ethnic groups, and with an annual growth rate of 2.24% (NIDI 2006). Nepal has been in political turmoil for some time, with the last decade seeing royal massacres, popularist uprises against an increasingly authoritarian king, and the establishment and ongoing insurgency of a radical left group (Maoists), aimed at abolishing the monarchy and establishing a people’s republic (Ockelford 2007). Administratively, there are 5 development regions of Nepal, (see Fig. 1.1). and the country is divided into 75 districts, each divided by 9 Village Development Committee areas, or VDCs.

Figure 1.1. Human development status by eco-development region. Source: UNDP (2004)

Nepal is one of the poorest countries of the world, ranking 142 out of 177 countries in the UNDP world poverty index (UNDP 2007). There are large geographical disparities in terms of human development indices, with the lowest HDI in the mountains, and mid and far western development regions (UNDP 2004). There are also strong disparities in development and empowerment within societies. The UNDP (2004) note that ‘discriminatory practices rooted in the ethno-caste system have dominated Nepalese culture for centauries’. The mid and far western mountains show the largest ‘mismatch’ of empowerment, which became a source of bitterness to be exploited by the Maoists, and the areas became the stronghold for their insurgency into the rest of Nepal (UNDP 2004). Progress towards development in these areas has been slowed by Maoist activities, who limited the access and activities of local authorities and NGOs outside district headquarters, and disrupted community and VDC level governance structures (Ockelford 2007). Education and health were the two government sectors allowed to continue, but due to pressure from the Maoists, many healthcare staff chose to leave the area (ACF 2007d). Action contre la Faim (ACF) is an International NGO, organized in 1979 with the aim of saving lives by combating hunger, disease, and assisting in crises that threaten the lives of men, women and children. ACF operates in 40 countries worldwide, and began operations in Nepal in 2005, initially in the far western district of Bajhang, and in Mugu and Humla districts in the mid-western mountains in 2006. The Bajhang intervention was phased out in 2007, whilst activities in Mugu and Humla were continuing into 2008 (see map on Figure 1.21.).

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1.2 Humla and Mugu Districts

According to 2001 data, Humla and Mugu districts are ranked 68 th and 75 th respectively out of Nepal’s 75 districts in terms of the Human Development Index (UNDP 2004). There are no motorable roads in either of the districts, and infrastructure in the area such as river crossings were subject to attack during the Maoist insurgency, limiting market access and economic growth. Mugu and Humla rank 74 th and 75 th for both the percentage of usually economically active children (10-14 years), and literacy rates. (CBS & ICIMOD 2003). Table 1.2. presents a range of social, economic and health indices for the area, showing the two districts consistently ranking at the bottom end of the 75 districts in the country.

Table 1.2. Select statistics for Nepal, and Mugu and Humla Districts

District Statistic Nepal Mugu Humla Total Population* 43,937 40,595 23,151,423 Average Household Size* 5.32 5.84 5.44 Population Density (Person/km2)* 12 7 157 Percentage Hindu/Buddhist* 86/14 84/16 81/11 Life Expectancy at Birth** 44.07 58.37 60.98 Infant Mortality** 173.83 81.37 68.51 % Malunourished Children under 5 (stunting) 68.7 90 50.5 Adult Literacy** 24.1 (5.2% female) 19.6 (4.8% female) 48.6 (34.9% female) Mean Years of Schooling** 1.4 (0.34 female) 1.25 (0.4 female) 2.75 (1.95 female) Proportion of Labour Force Employed in Non-Agricultural 10.83 10.84 31.33 Jobs** Population Without Access to Safe Water** 44.83 35.8 20.48 Population With Access to Sanitation** 14.4 18.3 39.22 Nepal Global Human Development Rankings (Out of 75 Districts in Nepal)** Ranking*** Human Development Index (HDI) 75 68 142 / 177 Human Poverty Index 73 75 25 / 128 Gender-Related Development Index 75 68 134 / 156 *2001 Population Census (NIDI 2006), **Nepal Human Development Report (2004), ***UNDP Country Fact Sheet (2006)

In addition to issues of the Maoists, the Karnali zone (within which both districts are located) is also drought prone, making food security particularly precarious (ACF 2007d).

ACF undertook a nutrition and mortality survey in the Mugu and Humla in 2007, and the findings on food security are presented in Box 1.21.

Box 1.21. Overview of the Food Security Situation in Mugu and Humla. Source: ACF (2007e)

There are chronic food shortages in Mugu and Humla: these districts have been experiencing cereal deficits since the 1970s, and agricultural production is insufficient to cover the needs of a growing population. Hunger periods are usually in February–April (before harvest of winter crops as wheat and barley) and around August (before harvest of summer crops of mainly rice and millet). The most important food gap is the one that follows the winter. The low agricultural production in Mugu and Humla mainly results from the lack of arable land, the poor climatic conditions, the lack of irrigation, the absence of any mechanization, the poor quality of the seeds, the very poor management of the soil in terms of fertility and the absence of management of crop pests and diseases.

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The incidence of under 5 child malnutrition is high across Nepal, and was found to be particularly high in rural communities of Mugu and Humla (ACF 2006, 2007e). Research by ACF indicated that the causes of malnutrition in the area were ‘multi-factoral’, related not only to problems of access to quality and quantity of food; but also to poor child-care and feeding practices; low access to health services; poor hygiene and sanitation situation; and poor hygiene practices (ACF 2006, 2007e). Indeed, sanitation coverage in the Humla and Mugu are way below the national average, standing at 18.3% and 14.4% respectively in 2001, ranking them 66 th and 72 nd out of Nepal's 75 districts (CBS & ICIMOD 2003). Box 1.22 presents results from another ACF survey, undertaken in the area 2007.

Box. 1.22. Findings of the KAP Survey undertaken in Mugu and Humla in May 2007. Source: ACF (2007b)

Out of 240 randomly selected households in rural communities of Mugu and Humla District: •Less than 10% of households used latrines •Only 28% of respondents washed hands after defecating, of which only 24% used washing agents (soap or ash) •36% of respondents collected water from unsafe* sources, and only 2% treated water prior to consumption •70% respondents wash themselves only on a monthly (or more) basis in winter months •97% and 93% of households indiscriminately dispose of domestic greywater and solid waste •97% of households keep livestock in the ground floor of their dwellings •31% of respondents didn’t know what kind of disease could be transmitted by water and 26% thought that cold is the main water-borne disease •Only 28% of the families interviewed had not experienced any diarrhoea cases within 1 month of the survey

* Untreated surface water sources

ACF launched operations in selected VDCs of Mugu and Humla in 2006, in response to worsening conditions of malnutrition, particularly following the drought and Maoist activities. Through 2 consecutive project cycles (2006- 08), the following programmes and activities have, or will be undertaken: • Food Security . Activities of; irrigation rehabilitation; improved farming techniques; greenhouses; and seed distribution • Nutrition . Activities of; outreach therapeutic care; training community health workers in malnutrition detection; community education; establishment of an in-patient therapeutic feeding centre • Water Sanitation and Hygiene (WASH) . Activities of Gravity Flow System (GFS) water supplies; community hygiene promotion; training community health workers in hygiene promotion; and latrine construction.

The WASH programme has been funded by ECHO through two, one-year donor cycles, and at the time of inception for this research, ACF had intentions to move towards multi-year projects and donors for future activities in the area. An evaluation by the ACF WASH technical department highlighted a number of key issues in the ACF intervention area, including; livestock practices and environmental sanitation; child hygiene; and barriers for household latrine construction. The evaluation concluded that the current ACF hygiene and sanitation strategy should be developed in terms of its coherence, effectiveness, sustainability and appropriateness (ACF 2007c).

In response, a 4 month study was launched in September 2007 by ACF, in partnership with the University of Cranfield (UK), to find the most appropriate approaches to hygiene and sanitation improvements in the communities of Mugu and Humla Districts.

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Figure 1.21. Maps identifying ACF Nepal’s intervention areas of Bajhang and Mugu and Humla. Source: www.googlemaps.com

Figure 1.22. A Map of the study area in Mugu and Humla districts. Developed from basemap, Source: GoN & Helvetas (2000)

*The study area incorporates the 10 WASH beneficiary communities, as planned at time of field research (October 2007), and Ruga village (north west of Gamgadhi), which is not an ACF beneficiary community. The Study area does not directly correspond to the total ACF intervention area, especially those under non-WASH programmes.

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1.3 Aims and Objectives

Aim: To investigate appropriate and effective approaches to hygiene and environmental sanitation for communities in Mugu and Humla Districts, North West Nepal

Objectives : • To investigate the priorities, needs and barriers for achieving improved environmental sanitation and hygiene standards of the communities and local amenities (schools and health posts) in the ACF intervention areas • To investigate and evaluate environmental sanitation and hygiene promotion strategies applied by ACF Nepal and other organisations (governmental and non-governmental) • To identify the most appropriate software and hardware approaches to safe excreta disposal, with a focus on sustainability, replicability, impact, coherence and effectiveness. • To make practical recommendations for ACF's environmental sanitation and hygiene promotion strategy, for future long term development projects in the area.

Specific Focus of the Research Following consultation with the ACF technical advisor (Jean Lapegue) and the researcher's observations in the field, the research was focused on the following specific areas: • Promotion, design, financing, logistics, location and management of household latrines • Improved environmental sanitation regarding livestock practices, solid waste management and grey/storm water drainage. • Improved personal hygiene of children

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2 Literature Review

2.1 The Importance of Hygiene and Sanitation

Whilst the world is on track for meeting the Millennium Development Goal (MDG) targets for drinking water, on current trends, it will miss the sanitation target by more than half a billion people (WHO & UNICEF 2006). In 2004, 1.1 billion people were without access to safe water, however, 2.6 billion lacked adequate sanitation (JMP 2006). Sanitation is often regarded as the ‘poor brother’ to water supply, holding less political weight, receiving far less sectoral investment, and often not subject to its own government department or programme (WaterAid 2007). Franceys et al (1992) state that sanitation is one of the first, fundamental, basic steps towards ensuring a safe environment for human habitation. Inadequate faeces disposal can lead to a number of communicable health issues, such as diarrhoea, cholera, dysentery, typhoid, helmiths and schistosomiasis (Harvey 2004). UNICEF estimates that around 2.2 million people, most of whom are children under five, die each year from diarrhea, often related to poor hygiene and inadequate sanitation (JMP 2006). Indeed, diarrhoea accounts for around 21% of under-five child mortality in developing countries (Kosek 2003), claiming around 5000 children’s lives every day (WaterAid 2007) There is an explicit link between malnutrition and diarrhoeal disease (Franceys et al 1992) and intestinal worm infections, by inhibiting normal consumption of foods and nutrient adsorption, leading to impaired physical growth and cognitive development, and reduced resistance to reinfection (Classen & Cairncross 2004). Diarrhea accounts for the annual loss of 62 million DALYs (Disability-Adjusted Life Years); a standard measure of disease burden calculated from the number of years lost of productive life from morbidity and premature mortality (WHO 2004). While sector professionals, policy makers and many donor organisations often focus on service level of source water quality, without adequate hygiene and sanitation practices and facilities, the quality of the water deteriorates rapidly through to the point of consumption. In terms of reducing diarrhoeal disease incidence, Esrey (1996) suggests that interventions in water quality and quantity reduce incidence by approximately 15% and 20%, whilst interventions in hygiene and sanitation by 33% and 35% , respectively.. Figure 2.11. The ‘F Diagram’. Source: Almedom et al (1997) in Tabiri (2005)

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One gram of human faeces can contain 10,000,000 viruses, 1,000,000 bacteria, 1000 parasite cysts, and 100 parasite eggs (WaterAid 2007). The ‘F diagram’ presented in Figure 2.11 shows various pathways of how faeces in the environment can reinfect individuals via the faecal-oral route, and the barriers to reinfection that can be put in place through hygiene and sanitation measures. In 2004, only 59% of the world’s population had access to an improved sanitation facility. This global average masks strong geographical disparity in coverage, with South Asia attaining only 38% coverage, second only to Sub-Saharan Africa with 37%. There is also a clear disparity in coverage between urban and rural areas: out of the 2.6 billion globally unserved, 2 billion live in rural areas (WHO & UNICEF 2006). Only 26% of people have access in rural Southern Asia (UN 2005).

Fig. 2.12. Coverage of Improved Sanitation in 2002. Source United Nations (2005)

2.2 Sanitation in Nepal

2.2.1 The Sanitation Status As in the rest of South Asia, progress towards sanitation coverage in Nepal (39%) lags severely behind that of water supply (81%) (UNDP 2005). Every day, seventeen million people defecate in the open, causing a loss of 4%GDP in Nepal (WaterAid 2006). Health data from 2001 suggests that as much as 41% of total morbidity in Nepal is due to poor sanitary conditions (Taylor et al 2005). Table 2.211. Morbidity due to sanitation related ailments in Nepal. Source: Department of Health Services (2001/2002) in Taylor et al (2005)

Diseases Mountain Hill Terai Total Diarrhoeal diseases 10.4 9.7 9.0 9.4 Intestinal worms 9.9 7.9 7.1 7.7 Skin diseases 11.9 13.6 19.7 16.1 Gastritis 7.0 6.8 5.3 6.2 Typhoid 1.9 2.5 2.1 2.3 Total due to poor sanitation 41.1 40.4 43.2 41.7 Others diseases 58.9 59.6 56.8 58.3 Total 100 100 100 100

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There are sanitation coverage disparities between the rich and poor, with the richest quintile attaining 79%, while the poorest quintile attaining only 10% (UNICEF, 2006), and urban and rural areas, at 81% vs. 30%, respectively (UNDP 2005). Sanitation coverage is particularly low in the mid and Far Western Development Regions of the country, with Humla and Mugu ranking 66 th and 72 nd out of the nation’s 75 districts (CBS & ICIMOD 2003).

Figure 2.212. Percentage of households with access to toilet facilities by District. Source: (CBS/ICIMOD 2003).

The MDG target for sanitation in Nepal is 53% coverage by 2015, but far more ambitious is the national governmental target of 100% coverage by 2017, under the National Water Plan 2002-2017 (UNDP 2006). Opinions are mixed regarding whether Nepal will meet the MDGs (ADB.org 2007), UNDP 2006). An assessment by WaterAid (2004) noted that there was a resource gap for financing the MDG sanitation targets in Nepal of $89 million, meaning $6 million per annum. The report continued to state that 13,677 additional households would need to be ‘served’ for sanitation each month between 2000 and 2015, requiring an acceleration of provision by 235% relative to the actual 1990-2000 performance. A further report by WaterAid (2006) describes how only 60% of the funds committed to sanitation are actually dispersed, and despite the clear gap between sanitation and water supply coverage, only 8% of sector spending in Nepal is allocated to sanitation. Around 65% of financing sanitation in Nepal is externally sourced, meaning the government contributes only 35%.

2.2.2 The Provision of Sanitation in Nepal

The provision of sanitation and hygiene promotion in Nepal is undertaken by a range of stakeholders, including several governmental departments, 2 international development banks, numerous international, national and local NGOs and thousands of users committees (WaterAid 2007b). The diverse range of actors can bring confusion as to who is responsible, and the lack of co-ordination at all levels is ‘one of the most frequently voiced concerns in the sector’ (Ockelford & Shrestha 2003). Figure 2.22 represents the complexity of the arrangement of provision of water and sanitation in rural Nepal. See Appendix 4 for a map of the distribution of key agencies involved in sanitation.

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Fig. 2.22 Simplified Organisational arrangements for the provision of rural sanitation in Nepal. Based on Ockelford & Shrestha (2002), modified and updated by Taylor et al (2005)

Office of the National Planning Ministry of Donors Prime Minister Commission Finance

Overall priorites/ Funds allocation Funds and technical targets support

MPPW MLD

Fund DWSS DOLIDAR Board

NGOs Executive WSSDO DDC

DTO

CBOs SOs WSSDO VDC

Schemes implemented on behalf of WUSCs

WUSCs

Within the Government, two main agencies are responsible for rural sanitation; the DWSS and DOLIDAR. The Department of Water Supply and Sewerage (DWSS), is a centralised department for national level planning, coordination, programming and evaluation, whilst district and community level activities are undertaken by sub-division offices at the district level (dwss. gov.np 2007). The Department for Local Infrastructural Development Agricultural Roads (DoLIDAR) is also involved in funding projects that are implemented through the technical division (DTO) of the District Development Committees (DDCs). The broad division of responsibilities between the two departments is based on the size of the project ‘scheme’, where it is that of DoLIDAR for schemes of less than 1000 beneficiaries, and the DWSS sub-offices for larger schemes. The Finnish Government is also working in partnership with DoLIDAR to provide rural WATSAN in districts in mid and far western Nepal (rvwrmp.org.np 2006). The two largest programmes of the sector are run by autonomous governmental institutions (WaterAid 2007b), namely; the World Bank supported Rural Water Supply and Sanitation Fund Board (RWSSFB) and the Asia Development Bank funded Community Based Water Supply and Sanitation Programme (CBWSSP). International development agencies such as FINNIDA, CIDA, SNV, DFID, UNICEF, WHO, Helvetas, along with INGOs such as WaterAid, Concern, Care, Plan, Oxfam are also supporting sanitation in Nepal. ‘Partnership modalities and bilateral relationships among donors, INGOs, national NGOs and local NGOs are diverse, with some organisations implementing the programmes unilaterally and others working in a wide range of partnerships, cooperative and contractual relationships varying in the number of parties’ (WaterAid 2007b). Research undertaken by WaterAid (2007b) suggests that the geographic distribution of programmes incorporating sanitation in Nepal is not necessarily focussed in the areas of least coverage. In the mid- western region, 5 to 6 agencies were found to be working simultaneously in districts that show more than 50% sanitation coverage, while only one or two agencies were promoting sanitation in the districts with the lowest sanitation. The report continues to suggest that with integrated WASH programmes, communities may be selected based on water, not sanitation needs, and that many agencies may be reluctant to undertake projects in more remote areas. In Mugu and Humla districts, key organisations involved in sanitation provision are the CBWSSP, RWSSFB, FINNIDA’s RVWRMP (Humla), the DTOs, UNICEF and their partners; Saapros and Deppros, KIRDAC, UMN, Concern, ACF, and, in the coming years, SNV.

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2.2.3 Strategies and Policy in Rural Sanitation and Hygiene Promotion

When undertaking WASH programmes, it is essential to understand, and operate within the national and international legislative framework, whilst striving to contribute to national strategies, and acting in line with your one’s own organisation and donor’s policies. This section explores the international, national and ACF policies and strategies relevant to sanitation and hygiene, but omits a review of donor policies, due the uncertainty of which donor(s) will support future activities.

International Standards

Unlike for water supply, there are no globally applicable and ratified standards for minimum service levels for sanitation or hygiene. The only such international standards have been developed by the Sphere project; however these were developed for application in disaster response contexts. These standards are progressively becoming a standard reference point for minimal service standards provided by INGOs in their interventions throughout the world. The following standards have been developed relating to sanitation:

Standards for hygiene promotion and relevant sections relating to domestic and personal hygiene from water supply interventions are presented below;

Box 2.231. Sphere Standards for Hygiene Promotion and Water Use Facilities and Goods. Source: Sphere (2004, Revised Ed.)

Hygiene promotion standard 1: programme design and implementation

All facilities and resources provided reflect the vulnerabilities, needs and preferences of the affected population. Users are involved in the management and maintenance of hygiene facilities where appropriate.

The indicators state that; key risks to public health should be identified; there should be representative

participation in scheme and facility design; access to facilities should be equitable for all groups; user groups should participate in planning, implementation, monitoring and evaluation of promotion.

Water supply standard 3: water use facilities and goods

People have adequate facilities and supplies to collect, store and use sufficient quantities of water for drinking, cooking and personal hygiene, and to ensure that drinking water remains safe until it is consumed.

Key Indicators;

•Each household has at least two clean water collecting containers of 10-20 litres, plus enough clean

water storage containers to ensure there is always water in the household.

•Water collection and storage containers have narrow necks and/or covers, or other safe means of storage, drawing and handling, and are demonstrably used.

•There is at least 250g of soap available for personal hygiene per person per month. •The participation of all vulnerable groups is actively encouraged in the siting and construction of bathing facilities and/or the production and distribution of soap, and/or the use and promotion of suitable alternatives.

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Box 2.232. Sphere Standards for Excreta Disposal. Source: Sphere (2004, Revised Ed.) For a more complete list of standards, see Appendix 3.

Excreta disposal standard 1: access to, and numbers of, toilets People have adequate numbers of toilets, sufficiently close to their dwellings, to allow them rapid, safe and acceptable access at all times of the day and night. Key Indicators:

•A maximum of 20 people use each toilet •Toilets are no more than 50 metres from dwellings.

Excreta disposal standard 2: design, construction and use of toilets Toilets are sited, designed, constructed and maintained in such a way as to be comfortable, hygienic and safe to use.

Although useful as a benchmark reference point, it is not felt that all the standards outlined by Sphere are relevant, or useful for application in context of the study area; with relatively stable populations, and chronic issues rather than being in a state of emergency or disaster.

Action Contre La Faim International Network WASH Policy

The ACF-IN WASH policy document (06-2006) sets out to standardise the various approaches of ACF WASH programmes, and develop a technical strategy for the sector (ACF 2007a).

Box. 2.233. Global aims and objectives of ACF-IN WASH programmes. Source: ACF (2007a)

The global objective of water and sanitation programmes is to guarantee, through access to water and sanitation, survival or socio-economic development, especially acting as preventative care to malnutrition, and finally impacting on the reduction of mortality. Specific Objectives: 1. Covering the minimum requirements necessary for life 2. Reducing the risk of the spread of water, sanitation and hygiene related diseases 3. Guaranteeing access to water as a necessary resource for food security and socio-economic development

Regarding standards and guidelines, ACF-IN policy (2007a) states programmes ‘should ensure minimal standards are reached (e.g. Sphere)’ although ‘in specific contexts….those standards may be reconsidered and adapted’ and ‘where national standards are above international standards (WHO, Sphere), ACF-IN should at least reach national standards’. In this, the policy document does not apply its own set of standards, either in minimal service level or construction/technologies, but strives to comply with international and national standards. The policy details the criteria for beneficiary or target group selection, and intervention priorities, and goes on to define the ACF-IN WASH intervention modalities.

The Rural Water Supply and Sanitation National Policy & Strategy 2004

Nepal’s first National Sanitation Policy was produced in 1994. Replacing this, in 2004, was the integrated National Rural Water Supply and Sanitation (RWSS) Policy and Strategy, produced with assistance of the ADB and UNICEF (WEDC 2005). The policy had a strong focus on water supply, and does not address sanitation to the detail of the 1994 policy (Shrestha et al 2005). Two further documents named the ‘National Guidelines for Sanitation and Hygiene Promotion’ and ‘Guidelines for Planning and Implementation of

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Sanitation Program’ have apparently been produced, but neither were available at the time of research. Within the RWSS policy 2004, the Government of Nepal (GoN) reaffirms its commitment to the target of 100% water supply and sanitation coverage by 2017, as described in the tenth plan document (GoN 2004).

Box 2.234. Key features of the Rural Water Supply and Sanitation National Policy & Strategy 2004. Source: GoN (2004)

Overall RWSS Policy and Strategy •Capacity of local bodies, NGOs and users committee should be developed as per the decentralised approach, the local empowerment and management of RWSS facilities and schemes •Local resources and skills and ‘know-how’ are utilised and developed in the projects •Representative participation in decision making of gender, caste and disadvantaged ethnic groups •Infrastructure and entrepreneurship will be developed to produce RWSS materials and equipment at the local level •Selection is based on poverty or hardship; willingness to pay; cost-benefit ratio; prevalence of waterborne/related diseases; existing facilities •Appropriate technologies are to be used that are affordable and manageable to the users, while informing them about all available technical options. •The poorest groups in the communities will be identified, and supported with ‘specific target grants’. There is a formalised identification criteria. •Only plans and schemes selected through a participatory DDC/VDC planning process will be implemented •WSUCs will be organised for the implementation of all RWSS systems, irrespective of the source of development assistance, and should be representative of gender, caste and disadvantaged groups, and at least 30% women. Specific Hygiene & Sanitation Points •Health education and sanitation activities will be conducted in water supply programmes NGOs or partner organisations will train the community level health volunteers (FCHVs) •If the community demand, a stand alone sanitation project may be implemented •At least 20% of sanitation construction costs should be contributed by the community •Community managed revolving funds will be allowed, with special subsidies for the construction of latries for poor households •100% of the operation and maintenance costs of household sanitary facilities will be borne by the households

Although national guidelines have been developed regarding minimal standards of water supply service delivery, like ACF-IN, there are no technical standards on latrine construction, designs or materials that can be applied for sanitation in RWSS projects. This is evident, as the DWSS has had active involvement in CLTS schemes, where there is no minimum design or service standards. The national RWSS policy is discussed further in section 5, and the main features, in comparison with the ACF-IN policy, are presented in Appendix 5.

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2.3 Approaches to Sanitation

Sanitation projects are commonly integrated into WASH programmes, but may also come as ‘stand alone’ sanitation and health promotion programmes, the latter being on the increase in Southern Asia, where there are such disparities in water and sanitation coverage. A summary of the various approaches to sanitation undertaken in Nepal is detailed below;

2.3.1 Conventional Approaches

Conventional approaches to sanitation are normally orientated around health based promotion of latrines, followed by subsidy, either in cash or materials (hardware), which is distributed directly to individual households, or managed by a water and sanitation user’s committee (WSUC). The individual household approach can mean slow progress or uptake, and less than 100% sanitation in the target community. Therefore, whilst, for example, 70% take up latrines, 30% of the community may still be defecating in the open, limiting the health impacts of the intervention for all in the community.

2.3.2 Subsidies

The subsidy of materials is a common practice of external agencies to support the development of sanitation, although there is currently a debate in the sector as to whether this is appropriate or necessary (WaterAid 2007b). The degree to which materials are subsidised is generally decreasing, with full subsidy being a rarely practiced approach. Subsidy to households in the form of cash is also a rare practice, due to the potential misuse of funds (WaterAid 2007b). Global norms for rural sanitation projects are that the implementing agency support the community with some form of external materials and skilled labour, whilst the community are expected to contribute local materials and unskilled labour (except in cash for work schemes). The superstructure construction and materials is commonly left to the household to organise and finance (Franceys 1992). Within Nepal, it is a common practice to subsidise ‘up to pan level’ (WaterAid 2007b), with basic packages of cement, a ventilation or drainage pipe, and a toilet pan, and will commonly be accompanied by a limited amount of skilled labour. Some NGOs may also provide rods and wire for concrete reinforcement, metal sheeting for roofing, buckets and brushes for maintenance. Major arguments against material subsidy are that it can undermine the sense of ownership that the users bestow on the facility, therefore jeopardising sustainability in the long term, it can be at a high per capita cost approach (depending on the degree of subsidy), and that it can stifle local initiatives and technological innovations (WaterAid 2007b). Subsidy for latrine construction or materials can be flat rate; that is, the same subsidy level is provided to all households within the community, regardless of economic (or other) status; or graduated. The flat rate can range from; a ‘minimum subsidy’, where the households are provided with only a small amount of external materials, whom then have to organise skilled labour and all other materials themselves (also termed an encouraging subsidy) (WaterAid 2007b); to full material and skill provision. The concept of graduated subsidies is to enable all members of the community to be able to access sanitation facilities, with a clear poverty focus. This graduated subsidy may be in the amount of materials provided to each household, or the amount of cash contribution expected from them. This also allows the potential for cross-subsidy within the community to finance materials or skilled labour for the more vulnerable households. Within Nepal, communities may be ranked and categorised into socio-economic groups, either by the community themselves, the implementing agency, or, most commonly, a combination of the two. For example, NEWAH categorises households into; the ‘ultra poor’, ‘poor’ and ‘medium’; through a so-called well being ranking (NEWAH 2007). However, in countries such as India, the government has set objective and clear identification criteria for those ‘below the poverty line’ (WaterAid 2007b). Experiences from two INGOs operating in Nepal have found implementing graduated subsidies can be challenging; as some communities are egalitarian in nature, and attempt to divide all provisions and costs equally. In contrast, in some communities the well being ranking was hijacked by the richer, more powerful households, and in some

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circumstances, all households in the community demand support, and raise issues of equity if they are provided with less than others (Plan, WaterAid 2007 pers comms ). ‘Community categorisation is a difficult process that needs to be well facilitated and requires representation from all groups’ (WaterAid 2007b).

2.3.3 ‘Subsidy or Self Respect’: Community Approaches

In 1999, a new approach to sanitation was trialled in a rural community in Bangladesh. This approach was based on a community level initiative to stop open defecation, and develop basic sanitation, using strong Participatory Rural Appraisal (PRA) techniques, in the absence of external subsidy (Kar & Pasteur 2005). This approach was found to be a great success, and has subsequently evolved, and been scaled up to be applied in numerous countries throughout Asia and Africa (Plan Nepal 2006). The approach is termed ‘Community Led Total Sanitation’ or ‘CLTS’.

Box. 2.33. The Main Differences of CLTS to Traditional Approaches. Source: WaterAid (2006)

CLTS differs from traditional approaches in that:

•CLTS focuses on stopping open defecation rather than just building latrines.

• CLTS harnesses traditional collective community action to stimulate hygiene behavior changes.

• CLTS gives no subsidies to build latrines.

• CLTS promotes low cost homemade toilets made from local materials which are easily constructed by the households themselves.

Rather than targeting individual households, CLTS uses a ‘total sanitation’ approach, promoting sanitation as a public good that the whole community must attain, showing that as long as their neighbour is defecating outdoors, their family will still become sick, regardless of whether they have a latrine. The total sanitation approach aims at 100% of the community using some method of safe excreta disposal, thus enabling the community to attain the status of being ‘open defecation free’. The approach involves strong community mobilisation through ‘ignition PRA’ techniques, which aim to facilitate the community members to realise the problems in their community by themselves, and develop a plan for change. These PRA activities include community walks to identify defecation areas in the presence of visitors; faeces mapping; volumetric calculation of faeces in their environment; and identifying potential contamination pathways from faeces to water or food supplies (WaterAid 2006). The PRA techniques ignite a sense of disgust and shame in the community, as they collectively realise they are ‘literally ingesting one another’s shit’ (Kar & Pasteur 2005). Following ‘ignition’, the community develop their own strategy to stop open defecation, which involves the construction of basic latrine facilities, and vigilant monitoring within the community by individuals and children’s groups, who place flags in open defecation, and literally whistle blow at continual open defecators. In this sense, it is self monitored and driven by shame, self respect, and community level initiative, and vigilance. The community can eventually attain the status of ‘open defecation free’, which may include some form of NGO or Government supported reward (Sakthivel, undated), and recognition, such as public notices/certificates at the entrances of the village. A key feature of this approach is that it does not involve external subsidy to assist latrine construction. The input of the NGO or implementing agency is that of a facilitator, and is therefore referred as a ‘software’ approach, rather than the more traditional approach, with more of a ‘hardware’ focus of latrine construction and coverage.

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With CLTS, households build basic latrines initially, using whatever local materials are available, to prevent open defecation as the primary target, and subsequently upgrade their facilities through time, as funds become available. This is the concept of slowly moving up the ‘sanitation ladder’. The approach promotes the use of appropriate technologies and innovations, whilst fostering a strong sense of ownership over the facilities, which the traditional approach of material subsidy, can undermine (WaterAid 2007b). As the CLTS approach puts the community in control of the process, with external input mostly restricted to initial mobilisation and ‘software’ support, experiences have shown the communities find innovative ways to work around their constraints, and meet their new demand for sanitation (Kar & Pasteur 2005).

2.3.4 CLTS in Nepal

In 2003, WaterAid Nepal, and its partner Nepal Water for Health (NEWAH) visited Bangladesh to observe CLTS projects, and subsequently decided to pilot the approach in Karki Danda of Dhading district (CETS 2007). Success led to further piloting by NEWAH and the adoption of the technique by numerous other INGOs, including CARE, Plan Nepal and Oxfam, and national NGOs such as RRN (WaterAid 2006). Optimism and expectations for the new approach were high in Nepal, particularly given the low national sanitation coverage, temporal and financial challenges attaining the MDGs and more optimistic national targets of 100% by 2017. CLTS showed the potential for relatively rapid increases in coverage in the intervention areas, with strong possibilities for multiplier effects in the local area, and at a relatively low unit cost. The progress of CLTS has been encouraging, and by March 2006, 14 villages spread across six districts have been declared open defecation (OD) free and a further 18 villages spread across seven districts were put under a CLTS programme (WaterAid 2006). These programmes are spread over the Terai and Hill areas (see WaterAid 2006 for a list of areas), but no evidence was found by the author at the time of research to suggest it had been applied in the mountain context. Experiences with the approach have yielded success, although there have been instances where NGOs have claimed that CLTS ‘failed’ in certain communities (CETS 2007, Plan 2006). Success was found greatest in small, homogenous communities and weakest where there was poor follow-up on the part of the NGO (Plan 2006). An assessment of NEWAH’s CLTS pilot found that; the costs of implementing CLTS per household was 1689 NPR in comparison to non-CLTS approach, at 2626 NPR; CLTS was largely sustainable; and that it helped expand sanitation coverage within the shortest period of time (CETS 2007). NGOs implementing the approach comment on the need for strong facilitators, the challenges of allowing the community to fully take ownership of the process, and the need for intensive, and regular ongoing follow-up support for the communities. Plan Nepal (2007 pers comms ) found that as there was no provision for subsidy, CLTS should be integrated with other activities, not as a stand-alone activity, as the communities expect material or financial support/ gain from the NGO’s presence within the community, and do not seem satisfied with the purely ‘software’ subsidy. The community desire for ‘permanent’ latrines (i.e. with cement and pans) has been found to be a challenge in implementing CLTS, and the concept of ‘climbing the sanitation ladder’ has not been observed widely in practice. NGOs such as RRN and Plan are attempting to work around this issue through the provision, or linkages with microcredit. NEWAH and Plan found that implementing a ‘dual approach’ in one area, that is, a graduated subsidy approach in one community and CLTS in a neighboring one, led to resistance from the CLTS community, who argued the case of inequity of material provision (CETS 2007, Plan pers comms ).

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2.3.5 Community Led Basic Sanitation for All (CLBSA)

Through the piloting of CLTS, and based on its previous experience of graduated subsidy, NEWAH developed its own hybrid type of approach, essentially a combination of the two, termed ‘Community Led Basic Sanitation for All’ (CLBSA). This approach attempted to merge its previous ‘dual approaches’ to sanitation, and also included the provision, in line with national policy (GoN 2004), for a supporting mechanism for the most poor and vulnerable members of the community. For more information on CLBSA, see NEWAH (2007).

2.3.6 School Sanitation & Hygiene Education & School Led Total Sanitation

School Sanitation & Hygiene Education (SSHE) was an approach developed and applied by the IRC and UNICEF in the 1990s. It was piloted in 1997 in Nepal, to be scaled-up to cover the 15 UNICEF supported districts of Nepal (DWSS & UNICEF 2006a). SSHE uses a child-child approach, designed to ‘promote water and sanitation facilities in schools, transform student’s behavior, and promote community sanitation through child club’s mobilisation’ and to build the school-community relationship (DWSS & UNICEF 2006b). The approach utilises children as the agents of change within the community, and the school as a focal point of activities and management of the process, and success of piloting led to its incorporation into the national strategy for rural water supply and sanitation in 2004. SSHE has subsequently evolved in Nepal, to be combined with the ignition PRA techniques of CLTS, and capacity development activities, to form a new approach termed School Led Total Sanitation (SLTS). This approach is analogous to CLTS, but as the name suggests, uses the school as the entry point to the community, and uses the school catchment boundary to delimit the area of activities (DWSS & UNICEF 2006b). SLTS was pioneered by UNICEF, and has been applied widely by them, and piloted by NEWAH and the Nepalese Red Cross, and is now also integrated into national strategy. The experiences of SLTS have been based in the Terai and Hill areas; however, a pilot is being trialled in Humla district, in the administrative town of Simikot, although at the time of research, it was too premature to try to derive any findings (UNICEF pers comms ). A WaterAid report (2007b) mentions the benefit of SLTS being linked with permanent institutions, with good prospects for sustainability, but also states that ‘the members of the school are not always representative of the communities around them, with many poorer and excluded groups not sending their children to school and therefore not part of the institution’.

To aid the attainment of ‘open defecation free status’, SLTS commonly includes the provision of an award in the form of a financial grant, or by instigating a revolving fund within the community. A comprehensive guide to SLTS is provided in DWSS & UNICEF (2006b).

2.3.7 Revolving Funds and Loans

Another approach to financing sanitation is through the provision of microcredit and revolving funds, to enable households, generally following broad sensitisation or hygiene promotion, to access sufficient funds to construct toilet facilities.

The World Bank RWSSFB project utilises a revolving fund technique. In this, the RWSSFB provide the community with ‘grant money’ to begin latrine construction. Initially, funds for 25% of the households in the community, (at a rate of 2000 NPR per household) are supplied to the WSUC bank account. The WSUC provide these funds as a loan to 25% of the community’s households to build their latrines, but on the condition that they pay it back within a certain period, normally 3-6 months. Once the first 25% of households have paid back the loan, the funds are released to the next 25% to construct, and so on, until 100% of the community has constructed latrines. The funds remaining in the account may be used to support the more vulnerable members of the community to construct the latrines, or reserved for ongoing operation and

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maintenance needs (RWSSFB 2006). All households of the community are expected to construct ‘permanent’ latrines within a 2 year period, and the RWSSFB has certain design criteria for latrines that must be followed. A report by WaterAid (2007b) identified a number of key issues associated with the revolving fund system, presented in Box 2.37.

Box. 2.37. Key issues with revolving funds for Sanitation. Source: WaterAid (2007b).

•Long repayment periods slow the revolving process but too short or unrealistic repayment periods cause households to default on payments.

•Disadvantaged households often do not take revolving loans, as they are unable to repay them.

•Due to the fund having to be revolved three or even four time to cover the whole community the implementation periods for this approach are often longer than other approaches.

•Generally, the amount lent is not sufficient to build a latrine and therefore some households have to take additional loans from private moneylenders or relatives to complete construction of the latrine.

The 2004 National Policy acknowledges revolving funds as an available option to finance sanitation (GoN 2004), and the approach is being applied across the country, including in Mugu and Humla districts. However, implementing NGOs mention that the remoteness and access of the communities in these districts, and the requirements of consultants, often based in Kathmandu, to validate the progress of the projects before releasing funds, can lead to long delays and poor monitoring (RWSS, Saapros 2007 Pers comms ).

2.3.8 Sanimart

Whilst hygiene promotion, community sensitisation and ‘ignition PRA’, and microcredit aim to develop the community and household demand , and ability to obtain sanitation facilities, Sanitation Marketing, or Sanimart, aims to address the supply of sanitation materials to the communities. Potential barriers to households constructing toilets are the lack of material and skill availability locally. Households in more remote areas may have to travel large distances to obtain sanitation materials, spending time on transport and overnight subsistence, whilst loosing time doing their normal income generating activities (NEWAH 2004). The concept of a Sanimart is to bring a range of sanitation materials and skills to be accessible and affordable to the community consumers and sold through local shops or outlets, staffed by a trained sanitation promoter. These ‘outlets’ or ‘sanitation centres’ may also be involved in local production of sanitary materials, and produce a range of demonstration latrines. Sanimarts are being promoted and supported widely throughout the world, with much activity in South Asian countries of Bangladesh and India (Kar & Pasteur 2005). A pilot project undertaken in Nepal by NEWAH proved effective; with households constructing latrines with very low financial input from NEWAH. However it was noted that even with subsidised materials, the ‘ultra poor’ in the communities could still not afford to purchase the materials available (NEWAH 2004).

2.3.9 The ‘Model’ Approach

Another approach is that of using communities, VDCs or even entire districts as ‘model areas’, whereby funds are focussed to enable 100% sanitation, and may be extended to other activities including environmental sanitation, water supplies and tree planting, to make the ‘model’ a reference point for which other communities aspire to be like (WaterAid 2007, RVWRMP 2007).

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2.4 Hygiene Promotion

So far, a strong focus has been placed through this document on the importance, and modalities of promoting sanitation. While this is of utmost importance, it should not be forgotten that hygiene behaviour holds a significant influence on the health of communities. A study by Curtis (2003) found that the simple act of handwashing with soap can reduce the risk of diarrhoeal disease by 42-44%, and interventions that promote handwashing ‘might save a million lives’. Evidence is now also mounting that handwashing can significantly reduce the other ‘major killer of the developing world’; Acute Respiratory Infections (ARI) (Cairncross 2003). Statistics from a national study by UNICEF indicate that in rural areas of Nepal, 37% of people wash their hands with water only, and only 12% use soap (BCHIMES/UNICEF, 2000 in Taylor et al 2005). The relatively low figure for washing with soap and water suggests a need for an increased focus on hygiene promotion. However, there are no associated targets for addressing hygiene awareness, unlike water supply or sanitation (Taylor et al 2005). Hygiene promotion is commonly integrated into water supply and sanitation programmes, although programmes are often criticised for ‘bolting it on’ at the end of the ‘hardware’ activities, rather than incorporating it from the project inception. Traditionally, hygiene promotion has been undertaken in the form of a ‘top down’ lessons based approach where an outside ‘expert’ trains the community through health based messages, often using visual Information Education Communication (IEC) materials. Increasingly, more interactive and imaginative ways of message conveyance have been practiced, using song, drama, puppetry, street theatre and even community radio. PRA techniques are now widely used in hygiene and sanitation promotion, and perhaps the best known set of tools developed for the purpose are that of the Participatory Hygiene and Sanitation Transformation (PHAST). More child-orientated approaches include child-child techniques, where (as mentioned in SSHE) the children are used as the agents of change in the communities, taking an active role in teaching siblings, friends, peers, in addition to the elder members of their family. The training of the children in this approach is through practical education, either in the school, in community kids clubs, or a combination of the two.

Hygiene education is essential to help to identify and tackle key risk practices within the communities. However, without access to enabling factors, such as an adequate water supply, toilet facilities and soap, the impacts of the intervention can be strongly limited (WHO 2005).

2.5 Summary

In summary, poor sanitation and hygiene practices are acute and chronic problems in Nepal. A variety of approaches exist to address both, each with their own strengths and weaknesses, and particular contexts where they may be effectively applied. There is no single, universal approach or ‘silver bullet’ to rural sanitation and hygiene.

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3 Methodology

The project was undertaken in Nepal over a period of four-and-a-half months between September and February 2008. The sequence of activities was as follows:

Table 3. Activity schedule for research project

Week Activity 1 2 3 4 5 6 7 8 9 101112131415161718 Briefing in Paris/Nepal Coordination Meetings (Kathmandu, Mugu) Field Research Analysis of Findings Coordination Meetings (Kathmandu, Nepalgunj, Mugu, Humla) Report Writing Translation of Report to Nepali Presentation at Sector Workshop in Kathmandu Dissemination of Report in Nepal Presentation at ACF Paris and Cranfield University

The research was undertaken through a combination of community interviews and site visits; coordination and lesson sharing with other sanitation and hygiene ‘actors’; and a bibliographic review.

3.1 Field Research

Seven weeks were spent undertaking field research in rural communities within the ACF intervention areas of Mugu and Humla districts. See Fig. 1.22 for a map of the study area.

3.1.1 Community Selection

Thirteen communities were visited in Mugu and Humla; representing all 10 beneficiary communities that ACF has, or plan to implement WASH activities in, and 3 further (non-ACF-WASH beneficiary) communities of interest. The rationale for community selection is presented in table 3.11. In addition to communities, 4 secondary and 6 primary schools, along with 2 health posts were also visited in the area, although due to various reasons, only 3 of the institutions were open at the time of the visit. A list of the institutions visited is presented in Appendix 1.

3.1.2 Interviews

A total of 87 interviews were conducted in the field with community members (61) and key informants, such as traditional healers (2), teachers (7), priests (1), shop keepers (3), community health workers (6), CBOs (3), Maoists and local leaders (4).

Figures 3.121 and 3.122 show the caste and demographic characteristics of the 87 interview respondents.

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Figs 3.121 & 3.122. Demographic and caste divisions of 87 interviews.

Table 3.11. Community selection for field research

Number of Community Name VDC District Rationale for Selection Interviews Undertaken

Nerah Photu Humla 15 Taza Photu Mugu Received a GFS from ACF in 4 Nathapu Nathapu Mugu 2006-07. Planned for Latrines 15 Jamaldara Nathapu Mugu 2008* 9 Rati Melcham Humla 3 Nachara Nathapu Mugu 5 Pumeru Jima Mugu 11 Planned for a GFS and Jima Jima Mugu 7 potentially latrines over 2007-8* Melcham Melcham Humla 7 Lower Rhimi Darma Humla 2 Specific environmental health Libru Photu Mugu characteristics, in ACF 3 intervention area Seasonal settlement for Masinmela Nathapu Mugu 3 residents of Nachara Accompanied visit to sanitation Ruga Ruga Mugu 3 project of LNGO Total 87 * According to the provisional community selection at the time of field research planning (October 2007)

3.1.3 Interviewee Selection

The initial aim of a fully randomised sampling methodology was found to be inappropriate for the study. Due to the timing of the field research (during the harvest and festival preparation period, and daytime interviews), many villagers were very busy, particularly the lower castes and women, and often absent from the village, working the fields. Therefore, interview selection was sometimes, unavoidably, a case of who was available and willing to partake at that time. The following approach and criteria was applied: • Aim to get proportional representation of castes, gender and age within the communities • Aim to get a geographic-spatial spread of households throughout the communities • Aim to speak to key informants from each community where available.

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Basic mapping of the settlements and caste distributions helped this selection, and, coupled with community walks, allowed the identification, and targeted selection of households with particular relevance to the research, such as vulnerable and landless households, those with latrines, those with particularly unclean children, and so on. Therefore the selection process was flexible and adaptable to the context, whilst striving to obtain social, economic and demographic representation. The total sample size was limited to time constraints in the field.

3.1.4 Style and Topics for the Interviews

Two other pieces of research influenced the style of interviews and data collection, and the topics covered in this research project.

The KAP Survey

A Knowledge, Attitudes and Practices (KAP) survey was undertaken by the ACF WASH team in the study area in May 2007. This involved the collection of quantitative data on respondent’s knowledge, attitudes and practices relating to water supply, sanitation and hygiene, through questionnaires in 240 households. The respondent households were randomly selected throughout ‘clusters’ in 4 VDCs in Mugu and 6 in Humla Districts, where ACF have or had activities. For the full methodology, see ACF 2007b)

Investigation into Child Care Practices

This research was conducted at the same time as an investigation led by Psychologist Aurélie Bardouit, into parent-child care practices. Aurélie’s methodology was both qualitative and quantitative using questionnaires and Focus Group Discussions (FGDs), and there was a degree of overlap with topics regarding the responsibilities and practices for child hygiene and sanitation. Questions for both researches on these overlapping areas were developed in coordination between the two researchers.

As this research aimed to identify barriers, aspirations and perceptions of respondents regarding hygiene and sanitation, a qualitative approach was deemed to be more appropriate than quantitative. This decision was also in light of the wealth of quantitative data collected on hygiene and sanitation obtained by the KAP Survey. The human resources available for the project also limited the possibility of collecting large, statistically valid quantitative datasets.

An informal, semi-structured interview style was selected, using predominantly open questions that allowed for elaboration, and allowing the answers given to guide the interview sequence, and the questions asked. Therefore a wide range of qualitative information could be collected, not confined to the scope and structure of pre-determined questionnaires, or multiple choice answer options. Given the constraints on respondent’s availability at the time of field research, and the challenges of isolating individuals for personal interviews, interviews were flexible in style, undertaking individual, multi-person, and focus group interviews (such as mothers or children groups).

The topics for interviews were developed so as to add quality assurance, but not duplicate the KAP Survey findings, and were tailored to the specific areas of relevance for this research. Questions included the following broad themes: • Interviewees priorities and perceptions of environmental hygiene and sanitation issues • Current defecation habits • Previous experiences, and future aspirations for latrines • Latrine location issues • Environmental sanitation and household management • Personal, hand and clothes washing • Child hygiene and child hygiene promotion (including responsibilities within the family and the role of the school) • Community organization, leadership, and appropriate approaches for sanitation and hygiene improvements.

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For a full list of questions, see Appendix 2.

Asking all questions developed for the research took around 2 hours, and some topics were not relevant to some interviewees. Therefore a flexible approach was taken, to allow answers to initial, open questions regarding general hygiene and environmental sanitation issues, to shape the relevant topics selected and the opportunity to elaborate to areas outside the questions selected if appropriate. However, if time allowed, interviewees would be led through all questions, to develop the degree of quantitative information available for analysis. This was achieved in 44 out of the 87 interviews. Topics covered in interviews with key informants depended on the context, and their role in society. Therefore no standardised questions were developed for these interviews.

3.1.5 Structured and Non-Structured Observation

To aid the researcher’s understanding of the community, and to inform interviewee selection, basic mapping of settlements, which identified house and infrastructure layout, and caste distribution, was undertaken as a first priority upon arriving in the communities. This was followed by a community walk, accompanied where possible by community members, to undertake a broad environmental health assessment, and identify key points of interest and their respective interviewees.

3.2 Coordination with Other Sector Workers

A total of 44 interviews were conducted at the national, regional and district level, to learn from the experiences, strategies and policy of different actors involved in sanitation, child hygiene and general community health. Figure 3.2 shows groupings to which these 44 respondents belonged to.

Fig. 3.2. Division of the 44 coordination meetings and interviews.

ACF Staff Local/National NGOs Donor s/Funding organisations

National Gover nment INGOs

Local Government

A full list of names, positions and contacts of those spoke to can be found in Appendix 1.

3.3 Research Limitations

3.3.1 Logistics, Coordination and Planning

Repeat delays were incurred with recruiting the translator and attempting to incorporate an additional consultant’s study, in addition to delays in the field with organizing porters and irregular flights. This made project planning and coordination with other ACF staff challenging, and, in addition to turnover of staff, meant that time spent with ACF (and partner) WASH implementation staff in the field was very limited. Requirements to renew visas also limited the researcher’s time in the field. The repeat delays and last minute cancellation of the consultant meant that avenues of his research, particularly on the social appropriateness of CLTS and graduated subsidy were left uncompleted.

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3.3.2 Timing of the Field Research

The research was conducted during harvest time, and generally during the day, meaning that community members at this time, particularly the lower castes and women in general, were often too busy to partake in the research. This was mitigated to some extent by holding evening time focus group discussions (FGDs). In total, gender and caste representation is felt to have been achieved (see Figures 3.121, 3.122). As the field research also coincided with two of Hindu’s biggest festival periods (Dashain and Tihar), many government departments, schools and health posts were closed for holidays, and many staff were unavailable for interview. This was mitigated by a return visit to district towns 3 weeks after festivals had finished, although many local government staff were still absent from their post.

3.3.3 Interviews

The field research was undertaken by the researcher and a translator, both of whom are males. This posed issues of undertaking individual interviews with unmarried females, due to cultural acceptability, and timidity. This was mitigated by holding group discussions with females, in public places, and with constant encouragement for their contribution. The males of the community often tried to participate, and even dominate women’s group discussions. This was unavoidable in some circumstances, but reduced by holding male interviews first, giving them their own time to contribute to the research.

Respondent’s answers may have been influenced by the fact that both the researcher and translator represented ACF, which is widely perceived by the communities as a rich NGO with lots of resources.

Gauging respondent’s feelings regarding the appropriateness of various technical and social solutions was also challenging, as enthusiasm for assistance or new ideas may come before the evaluation of whether it is truly appropriate. Questioning on this topic also had to be cautious as to avoid building expectations for future assistance on each of the solutions proposed.

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4 Findings & Analysis

Throughout this section, findings from this research are presented along side findings from the KAP survey for the area. This is to capitalise on the breadth of research that has been undertaken on hygiene and sanitation in the intervention area. However, significant differences exist between the two methodologies, in terms of interviewee selection, sample size, style of data collection, topics covered, and temporal differences of the research. The results should not therefore be directly compared, but are presented here to maximise the information available for analysis. Where findings are presented that were not directly collected by the author, it is clearly marked in the text, and all photos presented in this report were taken by the author. Where possible or applicable, findings from this research have been represented graphically and quantitatively, but often it is misleading to represent qualitative findings in such a way. In such instances, qualitative findings have been summarised into relevant sections.

4.1 Context and Community Descriptions

The communities in the study area were found to be heterogeneous in size, orientation, demography, social organisation and environmental health status. However, common characteristics were observed, and are presented below.

4.1.1 Community Habitation, Location, Distribution and Orientation

Communities visited ranged in size between 13 and 110 households, with the average household size in the area calculated at 7.7 people (KAP Survey 2007). Most communities in the area are highly nucleated and dense, with houses built in complex terraced arrangements, with up to 13 households per terrace, intersected by narrow public paths, grain pounding areas and livestock pens. Some of the higher altitude seasonal settlements and smaller mid- altitude communities however, are more dispersed, with single households or smaller terrace units of 2 to 4 households. In both circumstances, there is generally spatial groupings and clustering of households according to caste.

Fig. 4.111, 4.112, 4.113. Terrace houses in Jamaldara; Melcham Village; Macinmella (seasonal high altitude settlement).

Households located within the interior of the settlements were commonly surrounded by other buildings and paths and therefore had little house ‘frontage’, whereas those households located on the settlement periphery, or in more dispersed communities, often had frontage to land plots directly outside their house or just the other side of a path.

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The size of the houses varied according to settlement dispersion, and also generally correlated with caste status. Houses consisted of 2 or 3 floors, and were generally arranged as follows;

Figure 4.114. The layout of houses in the study area. Side View of an Average House

• There may be a small storage room for the third floor, generally used for keeping grains. Grain Store • The roof is flat, except in a few high altitude exceptions, to allow for grain drying and processing.

• The first floor is the living space for the family. This may consist of Family Living Space multiple rooms for bedrooms/storage and kitchen, but is generally one room for all purposes. There is normally an external overhang or balcony for this floor.

Cow Shed Buffalo Shed • The ground floor is for livestock shelter (cattle shed), generally with internal wall divided chambers for cows, buffalos and occasionally goats.

Settlements were located on valley slopes, plateaus, ridges and alluvial fans, surrounded by terraced agricultural land. Land ownership patterns can be complex, but, generally, the more proximal and productive land is owned by higher-caste families of the village or surrounding area, and the more distal land owned by the lower-castes.

4.1.2 Society, Culture and Religious Beliefs

Society within the communities is stratified by the caste system. Within the study area, the following castes are present, listed here in descending order of social hierarchy: Brahman, Thakuri, Yogi, Chhetri, Magar, and Dalit. Generally only 3 different castes were present per community, with Chhetris, Takuris and Dalits being the most commonly occurring castes. Members of different castes were observed to socially mix, and attended and contributed at the same focus group discussions. However, it was explained that taboos do exist, particularly with sharing facilities and commodities with lower castes (Dalits). Older generations generally regarded caste division as more important than the younger, relatively more educated generation in the communities. There is an obvious disparity of resource access, land ownership, material wealth and living conditions between Dalits and the other higher caste families in the communities.

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4.1.3 Livelihoods and Economy

Livelihoods in the study area revolve around subsistence agriculture. Major crops include rice, millet, maize, wheat, pulses, and, to a lesser extent, vegetables. Livestock such as buffalo and cows, and occasionally goats and chickens are also reared. The annual cropping cycle dictates the seasonal activities of the farmers, with harvest times being particularly busy periods. See Appendix 6 for an annual social and cropping calendar. Lower castes (Dalits) often have very little land for farming or low productivity plots, and are consequently unable to produce sufficient food for their families. They often work on higher caste land in exchange for food, or to service previous debts (commonly related to last year's food transactions). Aside from agriculture, there is little in the way of job opportunities in the area apart from occasional local porterage or labouring on a cash/food for work development project in the area. Seasonal economic migrancy is practiced by males over approximately 15 years, going to India over the winter to undertake unskilled labouring posts for between 4 and 7 months. It was stated that the migrant workers are able to save around 2200 NPR per month. Financial (cash) resources and flows are seasonal and low. Transactions between households were often based on quantities of crops instead of cash. However, it was difficult to determine cash ownership and flows during the field research, as answers were often sceptically believed by the author to be distorted, in an attempt to gain maximum benefit from projects or to make minimal contributions. The area is drought prone, and food security is perceived as both a major issue and priority.

4.1.4 Roles, Responsibilities and Gender

The daily family chores and responsibilities are traditionally allocated to different family members. Findings from two focus group discussions (backed by observations) on task responsibility are as follows:

Table. 4.14. Traditional task responsibilities according to gender.

Traditional Task Responsibilities (Findings from 2 FGDs) Task Gender Responsibility Economic migrancy to India ♂ Plough the field ♂ Milk cow/buffalow ♀ ♂ Take cattle to field ♀ ♂ Collect wood ♀, occasionally ♂ Collect water ♀, occasionally ♂ Harvest crops ♀, occasionally ♂ Cook food ♀ Supervise, clean and feed children ♀ Pounding rice ♀ Grinding grains for flour ♀ Clean the house ♀ Wash dishes ♀ Clean families clothes ♀ Carry compost to field ♀ Children Go to primary school (up to around 11 years) ♀ ♂ Go to School > around 11 years ♂ Supervise cattle ♂, occasionally ♀ Wood collection ♀ ♂ Collect water ♀, occasionally ♂ Help mother clean house ♀ Supervise younger brothers/sisters ♀ Cut grass/collect leaves for composting ♀

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The disparity in tasks is reflected in the daily burden of the women, who regularly complained about the limited free time they have during the day. Despite this, it was generally stated that men have dominant control over the financial and material resources of the family.

When possible, children are sent to school at primary age, however, during harvest time, or when the father leaves for India, the elder children can be pulled out of school to assist at the home or in the fields. The preference is to remove the girls before the boys. Girls were explained by parents to be sent to school until the age of 10 or 11, but then often removed. This was reasoned by 3 interviewees by stating ‘they (the girls) will grow up, marry and leave the family, why should we invest in their education?’ Boys, in contrast are perceived as a potential economic asset for the future.

4.1.5 Community Organisation, Leadership and Local Governance

Due largely to the Maoist activities in the area, local services, governance and leadership have been impaired. At the district level (in Mugu), the District Management Committee (DMC), who normally make decisions such as community or VDC selection for development projects, is on-functional, and the responsibility has fallen on meetings between political representatives. The operational capacity of the Village Development Committee (VDC) level governance has also been affected, as work and travel outside of district capitals was constrained by Maoist operations, and local services such as schools and health posts have suffered. However, many of the district officials interviewed were optimistic of an improving situation in the area. At the community level, many of the interviewees remarked on the current lack of leadership, social cohesion and unity. A common answer to enquiries on leadership was ‘no one listens to anybody anymore’. This was attributed to the remnants of the Maoist oppression, which actively undermined the authority and reputation of formally recognised local leaders and VDC government, and caused some leaders to flee the area. Willingness, self mobilisation and initiative for individuals to work on community projects have been depleted. Previous Maoist forced labour projects (such as path construction), cash for work/food for work schemes (CFW/FFW) by NGOs and Government for community projects, along with family priorities for food security, limited time availability and the lack of leadership were all mentioned to be influencing factors for this.

Box 4.15. The Case Study of Nerah Mothers Group

In 2 communities next to ACF field base (Nerah & Taza), mothers groups have been relatively active. The groups were formed during the monsoon, whilst ACF were not present in the community, and it was unclear from interviews exactly how or why they formed. Some interviewees stated the idea came from a local teacher, with a friend in a locally operating NGO, others said it was an idea originating from the community itself. Nethertheless, the group was formed and received no formal training from any project. It is headed by a socially active 50 year old Chettri mother from the community, and has around 48 members, of different castes. Their focus at the time of research was to address problems of male gambling and drinking on the street, and 'cleaning up the village'. Activities undertaken by the group (unassisted or pushed from an external project) have included mobilising and undertaking community meetings, and effectively promoting the construction of child latrines and household greywater soak pits.

Despite the aforementioned issues in leadership, key figures still exist, and have varying influence within the communities, such as; ex. ward and VDC presidents, former and current Maoist (and other political party) leaders, traditional healers and priests. Out of the 12 communities visited, 7 were stated to have Community Based Organisations (CBOs) in the form of Mothers or Women’s Groups. In 2 of the communities, the CBOs had been created by a local NGO to promote and drive social change. In these instances, attempts by the CBOs at social mobilisation were unsuccessful, and the CBOs were not

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provided with follow-up support. The initiatives lost momentum, leaving a sense of fatalism (observed in 4 interviewees from the CBOs), where they felt unable to change their situation. In 3 of the communities, women/mothers groups were said to have been recently formed (in 2007), and in two instances legally registered at the DDC. However, the presidents or secretaries of the groups were unsure of the true purpose, or goal of the CBO, and stated that they had not yet undertaken any activities. They were formed following suggestions from local teachers and health post staff, and stated that they were waiting for support, training and direction from external projects to drive some form of change in the communities. However, the villages of Nerah and Taza had more promising experiences with CBOs, outlined in Box 4.15.

4.1.6 Health and Healthcare

Problems, Knowledge and Beliefs

Health problems mentioned by interviewees were seasonally variable, with diarrhoea, fevers and eye infections predominating in the summer (March-May) and rainy season (May-September), and pneumonia, common colds, respiratory and joint problems in the winter. Other ailments mentioned by interviewees and the District Health Officers (DHO) were; dermatological problems such as scoriasis, scabies, fungal infections, fleas/lice in clothes and blankets, infected wounds; parasites such as roundworm, hookworm and tapeworm; stomach/digestion problems such as gastritis, food poisoning, vomiting, abdominal pains and malnutrition. The DHOs of both Humla and Mugu stated that diarrhoea was the biggest sole cause of mortality in the districts.

Table 4.161. Top 10 outpatient diseases in Humla District during 2006. Data obtained from the DHO in Simikot, Humla in November 2007.

Rank Males Females 1 Diarrhoea Diarrhoea 2 Acute Respiritory Infection (ARI) Acute Respiritory Infection (ARI) 3 Intestinal Worms Intestinal Worms 4 Skin Diseases Gastritis 5 Abdominal Pain Skin Disease 6 Eye Complaints Abdominal Pain 7 Chronic Obstructive Pulmonary Disease (COPD) Eye Complaints 8 Arthritis Ear Infection 9 Toothache Chronic Obstructive Pulmonary Disease (COPD) 10 Ear Infection Toothache Data refers to patients diagnosed in Humla Health Posts and District Hospital only

Under local belief, the concept of ‘purity’, and the belief that gods will become displeased if an ‘impure’ activity occurs within the house, means that women have to spend time in the cattle shed during menstruation, and during and 15 days following childbirth.

All four interviewees questioned on the topic stated that their own family had experienced infant mortality rates of over 50%, and knew of women within the communities that had died during childbirth in the cattle sheds; however, no data was available on this from the DHOs at the time of research.

The KAP Survey identified that out of 240 interviewees, ‘45% to 67% of respondents knew that smoke, flies or food can carry diseases. Concerning water, 31% of respondents didn't know what kind of disease can be transmitted by water and 26% thought that cold is the main water-borne disease’.

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Figures 4.162, 4.163. Understanding of disease transmission. Source: KAP Survey 2007

Do you think that smoke, flies or food can Do you think that w ater can carry diseases cause diseases 1-No 7% 2-I don't know food 20 35 45 26% 3-Respiratory 1-No 4-Eyes flies 7 27 67 2-I don't know 31% 1% 5-Diarrhoea 3-Yes 6-Fever 6% smoke 18 18 64 6% 7-Worms 9% 13% 8-Skin 1% 0% 20% 40% 60% 80% 100% 9-Cold

Although not a strong focus of this research, 2 of the following explanations from interviewees give an interesting insight into some of the traditional beliefs about disease cause and effect held in the area: • Swollen stomachs are a product of too much millet rotis (bread) or from eating cold food • The cause of baby diarrhoea was a result of feeding it hot milk from the breast due to the mother being exposed to the sunlight in the fields.

When a member of the family falls sick, they are often taken to a ‘dhami’ or ‘lama’ (traditional healer). The healers may explain that the ailments are related to displeased gods, and, upon the sacrifice of a chicken, perform a ritual to please, or expel ‘the gods’ from the patient.

Common treatments from the healers includes using coals to burn stomachs (to exorcise the gods) for diarrhoea, and rubbing herbs to reduce the swelling of children's stomachs (malnutrition caused). Figure 4.164 shows the KAP Survey interviewees response to diarrhoeal incidence.

Figures 4.164, 4.165, 4.166. Interviewees response to diarrhoeal incidence (KAP Survey 2007); a traditional healer in Libru village; a child showing signs of stomach scarring from traditional ‘medicine’ in Nerah village.

If one gets diarrhoea what do you do

1-Nothing 9% 9% 2-Traditional medicines 23% 3-Buy drugs

40% 4-Health center/Hospital 19% 5-Give ORS

Services and Practices

Findings from interviews with the Humla and Mugu DHOs are as follows;

The district hospital and health posts were generally affected by high turnover and regular absence of qualified staff and chronic shortages of medical supplies, reducing their ability to function or operate effectively. The more serious cases are often referred to regional hospitals, but due to costs of flights, this is normally only an option for the more affluent families. Transport difficulties and the uncertainty of whether the local health post is operational often means cases are left until they are perceived as critical before making

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the journey to the district hospital. The effect of the traditional healers means that the family wait to see if the patient will get better following traditional ‘treatment’, before they take them to the hospital. For both these reasons, cases brought to the hospital are often in their advanced form, and beyond the capacity of the district team.

Within each ward is (or should be) a Female Community Health Volunteer (FCHV). These are members of the community, trained to varying extents by the Ministry of Health through DHOs, and, more recently occasionally by NGOs. Their main functions are to provide community level basic care, disseminate health and hygiene messages to the community, ad-hoc distribution of vitamins and supplements, and remind mothers about dates for child immunisation.

The FCHVs are often well regarded by the DHOs and NGOs who incorporate them into their projects, for their effectiveness at the field level, noting that the only problem in using them being rising demands for incentives for attending training sessions.

However, there were discrepancies in interviews in 3 communities between the activities that the FCHVs stated that they have undertaken in the community (such as holding monthly ward-level mothers group education sessions, and household visits), and those which the community members said that they had done, which was far less.

The 6 FCHVs interviewed stated that they are generally listened to and respected by the community, particularly by the younger mothers, but the younger FCHVs said that the elder mothers may be reluctant to listen to their advice, as a combination of respect for age, and their limited experience. Three mothers within the communities stated that they would not visit the FCHVs for advice or assistance, stating that they did not believe they were capable, or trained enough.

4.1.7 Transport, Local Supply Chains and Consumption Practices

For an understanding of the potential for the sustainability of access to materials, and sanimart viability, an assessment of local supply chains was undertaken.

The study area is remote, with no road access within 4 days trek, narrow and landslide prone tracks and river crossings using ‘ropelings’ (see Figure 4.172). A combination of the infrastructure and low household income means that the ownership and use of mules or other animal-based transport is limited, with most materials being portered on people's backs.

There is little in the way of external materials, particularly large or bulky commodities in the communities, except that which are brought in specifically for use in development projects (such as tin roofing, cement and pipes etc). There is no manufacturing industry locally.

Figures 4.171, 4.172, 4.173, 4.174. Mugu district’s airport; A ropeling river crossing in Mugu; district stores in Gamghadee (Mugu’s capital); a village shop in Purumeru village (Mugu district)

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Formal and informal ‘shops’ exist within settlements exceeding around 40 households, which stock a limited range of hygiene consumables. More expensive items, such as buckets and building materials are not stocked, due to the high capital expenditure required, and respective financial risk. Soap in these shops is generally sold for 15-25% more than at the district towns from where it is sourced.

Consumption patterns of hygiene products, particularly for soap, were stated by village shopkeepers as seasonal, peaking during the summer months and over festival times. Interviewees stated that they generally purchased higher priced commodities in the district towns or Kolti, to avoid mark-up costs from village stores. External materials were also purchased in India by the seasonal migrants, commonly bringing back clothes and shoes.

Figure 4.175 presents results from a survey on spending habits from incomes from a Cash for Work (CFW) scheme, undertaken by the ACF Food Security team in June 2007, indicating trends and priorities for cash expenditure in the area.

Figure 4.175. Household Cash for Work Scheme Expenditures. Source: ACF (2007f)

4.1.8 High community expectations

Due to a number of reasons, expectations of the level of support to be provided by external projects can be fairly high in the communities. This finding is from anecdotal reports from many other locally operating NGOs, ACF implementation staff and the researcher’s own experiences. This was mainly linked to; previous activities and promises of materials or levels of subsidies, from NGOs (including ACF); pro-active, non demand-driven community selection for projects; and the programmes utilising CFW schemes. ACF’s experience in the area has seen instances of increasing or changing community demands, and renegotiations of community contributions. This is common to the experiences of other NGOs in the area, of what one LNGO termed ‘bargaining tactics’. This may be understandable in the area, considering the recent history and low level of employment in the area.

Box. 4.18. Experiences of communities actions and perceptions with development projects.

Anecdotal evidence from a Mugu based NGO: The NGO selected, and then launched a water supply (GFS) project in a community, using cash for work (CFW) scheme for unskilled local labour. Upon scheme completion, the NGO left the community. Some of the community members then sabotaged the GFS, and then applied to the NGO for assistance to rehabilitate, to get repeat employment from the CFW scheme. In this, the benefit of scheme was seen (by some) as a mode of employment, not necessarily for the end product (a functional GFS). Answers from 3 Interviewees regarding Operation & Maintenance (O&M) of potential future latrines: ‘If the toilet (pan) breaks, an NGO or the Government will come and fix it for us’

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This is not to discriminate or condemn activities, or to suggest that all members of the community act in this way (which would be quite misleading), but just to reflect ACF, and other NGOs experience that they can be challenging communities to work in.

4.2 Environmental Health in the Communities: Practices, Perceptions, Aspirations and Barriers

4.2.1 Environmental Health Situation from Observations

The environmental health situation of communities was variable spatially, and, it is predicted, seasonally. This section provides a broad overview of the situation from observations, before presenting findings from community interviews and the KAP Survey. At the community level, the heterogeneity of issues was linked to the relative size and dispersion of the settlements, the distance to public, vegetated land (common defecation areas), water availability, natural drainage, and the relative standard of development and education of the village.

Many settlements are densely populated and nucleated, holding strong potential for rapid disease transmission. Within, and on the paths leading into many communities, human, dog and livestock excreta is noticeable, often in significant volumes. Poor solid waste management and livestock/composting practices result in high quantities of debris on the paths outside homes, and domestic grey water is commonly poured indirectly onto this, with no system of effective drainage. Most paths are unsurfaced, and the effect of livestock ‘trampling’ creates a thick organic slurry, or ‘quagmire’. This is remedied short term during harvest periods by applying rice husks and other drying debris; however this decays and adds to the accumulation of debris in the street. Flies are prevalent, and food is often left uncovered. The prevalence of excreta in the paths holds a strong potential for mechanical vector transmission into households and food preparation areas, by insects, rodents and on the soles of feet. Many people walk through the village without shoes, posing strong potential for soil based helmiths. Children are left unsupervised to play in the street, putting hand to mouth, with limited handwashing practices.

Figures 4.211, 4.212, 4.213, 4.214. Pictures of the status of environmental status of the communities visited.

Within the household, there are few water containers, which are often left uncovered, and used for multiple practices. Many of the communities do not have improved or ventilated stoves, utilising instead open fires in the centre of the kitchen, with few windows or vents to allow smoke to disperse. Livestock are kept within the ground floor of dwellings.

Inhabitants of the communities often choose to defecate near sources of water, such as streams, protected springs and irrigation canals, for anal cleansing purposes. For groundwater sources such as springs, this is estimated to be only a significant risk during rainy periods, when faeces in the immediate spring catchment get leached into the groundwater. However, many communities in the area collect water from surface water (streams and irrigation canals) downstream of other settlements, and household drinking water treatment is not commonly practiced.

Will Tillett, 01-2008 42

The area is seasonally drought prone, and water supply shortfalls are common. Out of 12 communities visited, 10 had GFS systems, of which; 3 were totally non-functional; 5 were in a state of disrepair, 6 are observed to be at risk from surface contamination; and 6 were subject to permanent or seasonally low yields or source failure. Distances from households to water sources ranged between 10-500m from in- village tap stands, to river valley sources, with between 0-200m altitude difference. Water collection, storage and consumption practices were not routine areas of inquiry for this research, but the following results were collected by the KAP Survey:

Box 4.21. Water source, collection, consumption and use findings from the KAP Survey

Out of 240 Interviewees: •43% of respondents travelled less than 15 minutes to fetch water while 39% travelled between 15 and 30 minutes •68% of respondents waiting more than 15 minutes to fetch water •Animal faeces are present in 56% of water points during the rainy season, and 61% of them during the dry season. Animals share the same water points in 40% of cases • Collection of water is generally the responsibility of women (72%) •The total water consumption per household by day was 44.5 litres [15 to 175] •84% of household water storage containers were not covered. Almost all water containers were laid on the ground •Only 2% of respondents claimed to treat their water prior to consumption •52% collect water from storage containers by dipping a cup or hand into the vessel

Figure 4.215. Water sources used in the area. Source: KAP Survey.

Drinking water sources

2 10-Mill channel 2 4 9-Irrigation channel 4 2 8-River 1 5 7-Stream 5 11 6-Spring with protected intake 10 rainy season 4 5-Spring with unprotected intake 4 dry season 24 4-Spring without intake 26 12 3- Tap stand (irrigation channel) 12 9 2-Tap stand (stream catchment) 12 26 1-Tap stand (spring catchment) 24

0 5 10 15 20 25 30 %

Personal hygiene and clothes washing is visibly an issue, particularly with the children of the communities.

The environmental health status, and relative risk importance is estimated to vary temporally. For instance, in the rainy season, the environmental sanitation, roof and greywater drainage is likely to be an issue, as is the quality of water consumed. In the winter when yields are low, queuing times are high and sources fail, there is likely to be less water consumed. Also during the winter months, individual’s personal hygiene is likely to deteriorate due to the cold weather and subsequent unpopularity of bathing.

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4.2.2 Interviewee Perceptions of Environmental Health Issues in the Villages

At the beginning of 41 interviews, interviewees were questioned on the main issues present in the village relating to hygiene and sanitation. The question was asked in an open, non-check box style, to gauge the perceptions and priorities of the main issues, without the prompts of a multiple choice. Answers have been grouped, and results are presented in Figure 4.22.

Figure 4.22. Major Issues in Village Relating to Hygiene & Sanitation, as Perceived by Interviewees

Major Issues in Village Relating to Hygiene & Sanitation, as Percieved by Interviewees

Open Defecation/ lack of latrine Access to soap Education of the people Greyw ater drainage Roads follow ing rain Livestock road trampling Water supply distance Domestic w aste disposal Water supply shortages Livestock excreta Population Density

0 5 10 15 20 25 30 35 Number of Respondents Who M entioned the Issue

Respondent’s answers may have been tailored in some instances due to what the community expected from ACF (knowing the NGO’s WASH remit of provision of GFS and latrines). Nethertheless, it shows that 75% of respondents remarked on indiscriminate defecation within the village, particularly by children, and lack of latrine as an issue. 36% of respondents mentioned problems relating to the reliability or yield, and to a lesser extent, distance to water. Interestingly, no respondent mentioned water quality, or the prevalence of flies as an issue.

This should not be misleading to suggest that sanitation is the main priority in the communities. Through numerous interviews, it is apparent that food security is the major, overriding issue perceived by the communities. This is followed by reliable water access and commodities such as clothes.

4.2.3 Defecation Practices and Latrines

Current Defecation Practices: Locations, Collection & Disposal

Figures 4.231, 4.232.shows results from both this study and the KAP Survey regarding locations for defecation selected by the interviewees.

Will Tillett, 01-2008 44

Figure 4.231. Defecation sites, Results from the KAP Survey

Defecation sites

6-Neighbours latrine 1 1 8 5-Private latrine 7 4-Irrigation channel 1 5 Children of family 6 Adults of family 10 3-River side 32 34 Interviewee 2-In the fields/forest 32 53 53 48 1-Near the house 12

0 10 20 30 40 50 60 %

Figure , 4.232. Defecation sites, Results from this research

Current Defecation Practices

Jungle near w ater source Sickness - Severe 1 11 1 Jungle not near w ater source Sickness - Mild 2 1 2 Fields Children > 3 21 1 2 Street or near house Children < 3 1 5 Cattle shed Adult Night 7 16 3 In the house/ anyw here Adult Day 11 15 3 3 Container 0 5 10 15 20 25 30 35 Latrine Number of respondents

Open defecation is prevalent, with a low coverage, and even lower usage, of latrines. The results consistently show the practice of adults to visit the ‘jungle’ by day, and through interviews it was clear that if there was a source of water near the village, they would choose this area. The ‘jungle’ generally refers to public land on the periphery of the village. Common reasons for choosing the jungle were; the fact there is often water sources for washing; vegetation provides privacy; the land is public, therefore they are not defecating on their own, or others land. Being caught defecating on other’s land was shameful, and mentioned to be a fairly common source of dispute within the communities. People may also defecate whilst out of the village working the fields during the day. The adult respondents who claimed to defecate in the village by day were relatively elderly citizens, reasoning impaired mobility and vision and incontinence prevented them travelling far from the house.

During night time, locations differed, with 61% of respondents claiming to defecate on the street or close to the house. Reasons for this included; fear of animals (such as bears) or spirits in the jungle or paths; lack of light, and distance to the jungle. In addition to this, at night they are not seen defecating in the village, and therefore not shamed. Women claimed to be generally more afraid to travel to the jungle at these times, and almost invariably go in the street or garden near the house at these times. Those who owned and claimed to use latrines, used them during night time.

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Figure 4.233. Collection & Disposal of Faeces

Collection & Disposal of Faeces Pick up w ith hands/leaves Basket and husks Sickness faeces disposal 5 3 1 Multi purpose pan Sickness faeces collection 7 3 Street Child faeces disposal 7 2 2 2 3 Bushes in village Child faeces collection 8 Bushes outside village

0 2 4 6 8 10 12 14 16 18 Latrine Number of respondents Eaten by Dog

For children, location for defecation was related to age. Respondents claimed that less than around 3 years of age (exact aging challenging in the research), children were stated to defecate anywhere, including in the house. In this case, the mother normally collects and discards it, or the dog eats it. Potties are generally not used. When the child is older than around 3 years, up until around 8, they commonly defecate in the street or near to the house, after which they start to visit the jungle. When a family member is sick, and not able to leave the house, faeces is commonly collected in a domestic container, which is used for other food-related purposes, and discarded either indiscriminately in the street, or hidden in a bush in, or on the edge of the village, where others would not see it.

Anal Cleansing The KAP survey stated that ‘almost all the respondents (99%) used water for anal cleansing’. However, this research yielded different results.

Figure 4.234. Methods of Anal Cleansing (Adults)

Method of Anal Cleansing Take w ater w ith them

Day 4 6 1 5 9 Wash w here defecate (e.g stream, spring) Night 14 1 2 2 4 Wash after at home

0 5 10 15 20 25 30 Wipe then w ash Number of respondents Wipe only

There was variability with night time and daytime practices. In daytime, the practice by adults was dependent on the availability or proximity to water, with 5 out of 25 respondents claiming to use stones, twigs and leaves to wipe, then washing after if close to water, and 9 out of 25 only wiping. By night, many more respondents claimed to take water from the house, as suggested in the KAP survey, as they were normally not travelling far from the house. One interviewee stated they did not take water with them by day, as ‘everyone would know where he was going’.

Children often defecate in the street, then return to the house to wash themselves or a family member washes them, often using water from the drinking water container. Those interviewed who claimed to take water did not normally have a designated container, and said they used between 0.5-1.5l per time.

Will Tillett, 01-2008 46

Perceived Issues with Current Practices

A number of issues with the defecation practices were mentioned by interviewees. Commonly mentioned problems are presented in Figure 4.235. Other issues mentioned included the fact children get scolded by adults when they go in the street, and it is a common source of dispute between households. In Natharpu village, two female interviewees stated that the ‘jungle’ area generally used as the village defecation area was a ‘man’s place’, but there was no ‘women’s’ place, hence they had no choice to defecate in the street of nearby fields.

Figure 4.235. Issues with current defecation practices, as perceived by interviewees

Issues with Current Defecation Practices, as Percieved by Interviewees

Animal attacks/bites Distance/time to defecation area No w ater w here they defecate Thorns in feet Privacy Rain/cold Defecation area is 'dirty' Hassle of finding a new location No torch for nighttime defecation Smell/makes village 'dirty' Fear of visiting the jungle at night Step on faeces and bring into the Health impacts

0 2 4 6 8 10 12 Number of Respondents Who M entioned the Issue

4.2.4 Experiences of Latrine Ownership and Usage

Reason for Construction Open defecation is the norm in the study area, and the use of latrines limited, estimated by the author to range between 0-15% of the population of the communities visited. The KAP Survey suggested less than 10% usage from respondents. Latrines do exist in the communities, but are generally derelict, dismantled, or used for storage. The dominant reason for the existence of these latrines is due to previous Maoist campaigns, which, among other initiatives, violently forced inhabitants to construct latrines. Figure 4.241 shows the reasons for latrine construction given by 56 respondents:

Figures 4.241, 4.242. Reasons for building a latrine in the past, and the location of the latrine.

Side of the Reason for Building a Latrine in the Past Location of Previous or Current house/under (56 Respondents) Latrine (56 Respondents) balcony Pre-Maoist self- Public land initiative

Due to Maoist Garden next to pressure the house

Pre-Maoist Land w ithin the Development village Project Mothers group Land ow ned pressure (for outside the child latrines) village

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A small number of respondents built latrines before the Maoist pressure, generally following exposure and experience of latrines in the district towns, or in India during economic migrancy. At the time of field research, a growing number of basic latrines were being constructed, or derelict latrines recommissioned for children’s toilets, following advocacy and social pressure by active mothers groups in Nerah and Taza villages (see Box 4.15)

Design

A wide range of designs were observed in the study area, showing local level innovation, with a range of local products, and limited input of external materials. Designs seen that were being used included:

• Pit Latrines Pits were generally, but not exclusively, shallow and unlined. Squatting areas were constructed by laying logs and stone slabs, and finished by covering with packed soil. Few direct pits had fly control measures, or plugs/lids for the squatting hole.

• Offset Pour-Flush Latrines This design type was the most common in the area. Pits seen were both cubic and cylindrical, generally lined, with logs, and/or stone slab lids, covered with soil. All designs were single pit type, and the distance of offset ranged from 30cm (just outside the superstructure) to 2m. In two instances, the chute discharged to the land surface, as the pits were full. A variety of materials were innovatively used for the chute and pan. Chutes were often HDP pipes salvaged from derelict GFS, in original form, or opened up and beaten to shape to combine pan and chute. In other instances, there was simply a sloping stone slab or wooden plank to defecate on, and pour/push the excreta with a designated stick into the pit. Carved basic wooden pans, folded plastic from broken jerry cans and rolled tin sheets were also used for pans. In a village subject to a pre-Maoist government project (Lower Rhimi), designs included HDP pipes, and graduated cement pan structures (Figure 4.255). No household latrines visited utilised ‘ubend’ water seal designs.

Figure 4.243, 4.244, 4.245, 4.246. Examples of pan designs and water containers in local latrines

• Water Storage and Maintenance Materials in the Latrine In some instances, no water was stored within the latrine, with the user carrying it from the house. However, most functional latrines had designated water containers. These ranged from glass bottles, to buckets, screw lid containers and even broken jerry cans, laid on their side and opened up for access (see Figure 4.246). One latrine owner was even utilising rainwater harvesting to augment the toilet water supply. In addition to water, many latrines contained a designated ‘pushing’ stick, to dislodge stools from the pan and chute, and one owner kept ash, to aid handwashing, and for periodic application into the latrine pit to mitigate odours.

• Superstructure The superstructures were often small and cramped, built with local stone, and roofed with wooden planks covered with soil. Some were constructed using wood planks. Ingenuity was observed with the doors, using tin sheeting, grain sacks, and more commonly, wooden planks on basic hinges. Many included a small, glassless window, and the stones were generally unmortered, allowing natural ventilation. Figure 4.248 shows the common occurrence of cramped superstructures built to minimal standards for compliance to Maoist pressures.

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Figures 4.247, 4.248, 4.249, 4.2410. Examples of local functional, child and derelict latrines.

Location of Latrines

Figure 4.242 shows the different locations of latrines that have been built in the villages. This was variable, often upon population density, and land ownership. Where communities were relatively dispersed, latrines were placed close to the houses, and in more dense settlements, on the periphery of the village, and on areas of land owned within the village itself. In villages where Maoist pressure for latrines was particularly focussed, such as Pumeru, latrines were built on public land on the roads leading into the villages.

Access to, and ownership of land to build the latrines was stated by inner-village households to be a major reason for not constructing latrines during the Maoist pressure.

Pre-Maoist governmental initiatives had been undertaken in two communities (Rati and Lower Rhimi) leading to coverage of around 50%, many of which were still being used. Innovation was seen on the part of technical low-cost design, and latrine location. Locations included; under the balcony, with offset pit under the village path, and on the side of the house.

Out of 56 interviewees questioned on the topic, only 4 claimed to have previously shared a latrine with another household.

Usage Trends

This was difficult to effectively evaluate, as many interviewees claimed to use their latrine daily, but upon inspection, the toilet obviously had not been used for months, or years. Many interviewees stated that their whole family use(d) the latrine at all times. However, the following points regarding usage were discovered in different interviews; • Toilets may be reserved for use only at night or in emergencies by adults, choosing to go to the jungle by day, as they do not want the pit to fill too quickly. • The toilets are for use only by children, as adults can go to the jungle. • Conversely, children may be prevented from using them for fear of them making it dirty. • Use may be restricted to the father, or males of the family.

Experiences of Latrine Ownership, Use and Maintenance

Positive experiences and perceived benefits of the latrine use mentioned by interviewees included; convenience through proximity to the house; and hence time saved not visiting the jungle; ease and safety of use for nigh time defecation; privacy; improved environment and reduced ‘pollution’ on the village paths; shelter from the rains and less distance to walk in the snow; they do not have to send their children far from the house to defecate; children are not scolded by adults for defecating in the street; they can take water with them, or keep it in the latrine, for anal cleansing. Despite the benefits mentioned by former users, most had reverted back to open defecation, and the latrines had become derelict. This was stated to be linked to many reasons. Common issues presented in Figure 4.2411.

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When the Maoists undertook their forced latrine programme, they provided no financial, material, and limited- no technical support to the communities. Because of this, latrines constructed were generally of poor technical standard, with inadequate materials. The community were also, in many instances, building for compliance, not because they perceived a benefit, and hence in some circumstances, did not build it with the thought of actually using it. Little investment was made in the latrines, building to minimum standards, and the designs were ‘temporary’ in most instances.

Figures 4.2411, 4.2412. Issues with, and reasons for stopping using the latrine. Findings from this research and the KAP Survey.

Issues with, and Reasons for Stopping Using Old Latrine

Smell Pit Collapse Temporary' design Lacked w ater storage in the latrine Why did you stop using Village w ater shortages (KAP Survey) Decame dirty w ith improper use 3 1-Pit was full Difficult to clean 28 Not habituated to use 2-Damaged 3-No habit to Pit filled rapidly 38 use Leaking roof 4-Forced Latrine w as used publicly to build Cramped superstructure 31 Superstructure collapsed Insects/flies

0 5 10 15 20 Number of Respondents Who Mentioned the Issue

The designs were generally made from local materials, such as wood and unpolished stone, with rough, difficult to clean surfaces, and as it was many user’s first time to use a latrine, often became fouled and malodorous. This was a particular issue where the latrines were located within the village, but did not have a padlock, as the latrine would be used as a public toilet.

Latrines that were shared by more than one household complained of other family’s children fouling the toilet, and their parents not cleaning after them, causing inter-house disputes.

The fact they utilised rough surfaced materials for pan and chutes required relatively large volumes of water to flush and clean. This was stated to be an issue due to annual water shortages in the area (and domestic priorities for the water) and distances to collect, and the lack of adequate and available storage containers for the latrine.

Smell was the most commonly stated issue, understandable, as few pits were ventilated, and the user’s previous experience in the fresh mountain air. Interestingly, flies were not mentioned to be a problem. Pits were commonly shallow and unlined, and interviewees stated that in many cases they collapsed, or overflowed in the rainy season. Logs laid to support the squatting area rotted and failed.

Four current users of latrines of offset pit latrines stated that they intended to revert back to defecating in the jungle when the pit becomes full, for 2 years, by which time they could empty the pit, or it would have settled sufficiently for reuse. They could not dig another pit as they had no more space for a new one, or the pipe was not long enough to allow switching to a new pit.

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4.2.5 Future Aspirations for Latrines

Permanent Latrines Although many interviewees mentioned that they perceived benefits of formerly using latrines, they were reluctant to build another ‘temporary’ latrine. The latrines they previously built had issues, were now broken, and the users were not keen to invest their limited time or resources on another latrine using only local materials that would become rapidly filled, soiled, or collapse. Interviewees stated that they were unable (or unwilling) to access or finance ‘permanent materials’ such as cement, pipe and pan to build a ‘permanent’ latrine. This may well also be linked to the previous promises made to them by ACF and other NGOs in the area about material provision, so households are holding out for assistance until they construct a new latrine.

Design Type & Previous Promises When questioned on the type of latrine they would like to build, answers generally described offset pour flush designs, incorporating a pan, cement and pipe. It should be noted that this is what ACF staff promised in 5 of the visited communities in Focus Group Discussions (FGDs) 6 months prior to this research, and many interviewees in these communities perceived this question as a memory test of what they were promised. It was found that this preference for offset pour-flush pits was for a number of reasons; • The offset pour flush with pan design is the commonly used ‘improved’ design in the district towns and constructed by other locally operating NGOs, and therefore they have had experience and exposure to this design type, and perceive it as ‘modern’, and desirable. • Pit latrines were a common design of Maoist ‘temporary’ latrines, and were found to be malodorous. • There is a general desire to have the pit as far away from the point of defecation to limit odours in the latrine. The functionality of a waterseal is not readily grasped; therefore an offset pit is more desirable than a latrine set above the pit, regardless of a waterseal. When questioned regarding the ability of the interviewees to sustain such external materials as a pan if it became broken, interviewees initially stated they would request external assistance from an NGO. When reasoned that this may not be viable, most respondents conceded a design less reliant on external materials may be more appropriate. Regardless of the exact materials or designs, the following features of a toilet were identified as important to the interviewees; • Easy to clean, without requiring large volumes of water • Water source or storage within the latrine • Not too odorous • It must have a lockable entrance, to stop public use.

4.2.6 Locations of Latrines

When questioned on potential locations for the latrines, interviewees stated they would be keen to build the latrines closer to their houses than the former Maoist latrines, as the ‘permanent’ designs would not be so odorous. In many of the communities visited, land access appeared, and was stated to be a potential barrier to certain households accessing their own latrine. The main households with this potential problem are those located within a terrace inside the villages. When questioned about latrine location, much of the mid-higher caste interviewees stated they had land close to the village which they could use, or that they could probably exchange or purchase land from others for the purpose. Many households stated that for land acquisition, land price is according to area, and lower-caste households will commonly build the maximum size house on their limited plot size, seldom leaving much free, unused space. These households often only own land far from the village, and have the lowest financial resources available to acquire land.

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Community Suggestions and Perceptions of Options Available for Latrine Location Suggestions for the issue of land access included land exchange and purchase at a household to household level, and that a committee should be formed to push the process forward, and to apply pressure on the owners of the land surrounding the village to be willing to sell, even to low castes, at favourable, or at least non profiteering rates. Many interviewees warned that ACF should not interfere in the process of land acquisition, which should be organised within the village itself. A number of options were suggested by the author to interviewees for potential solutions for the issue of land availability. Responses were as follows; • The idea of all households contributing to a central fund, to enable the village to gain ‘total sanitation’ type status, where the funds were accessible for land acquisition, was unpopular. Respondents noted that not all would contribute, and many would try to access the funds, potentially leading to disputes. • The concept of sharing latrines was unacceptable to 32 out of 35 interviewees. This was reasoned by; other family’s children would soil it, and there would be disputes regarding cleaning and maintenance, and those with large families anticipated long waiting times and rapid pit filling. Interestingly, those who found the idea most unacceptable were Dalits. This was explained to be due to the fact that they have very limited physical resources, and generally inherited and shared between brothers. The concept of sharing and joint ownership of a latrine was expected to pose potential for family feuds and conflict. Those few who conceded that they could share latrines stated that it would only be under specific circumstances, generally a direct blood relative and their family. Findings from the KAP Survey suggested that just over 10% of respondents were willing to share latrines, with common concerns of sharing presented in Figure 4.26.

Figure 4.26. Perceived Issues of Sharing a Latrine, from the KAP Survey.

Problem of sharing latrine

1-No 2% 12% 12% 2-Intimacy

3-Cast 24% 4-Cleaning problem 37% 5-Not my family 13% 6-Other

• However, when suggested with using a latrine ‘block’, where each household had a separate cubicle, but utilising the same pit, interviewees did not perceive a problem, as long as all doors were lockable to prevent public use. The sharing of a block with between higher castes and Dalits was generally deemed unacceptable. • The possibility of locating a latrine within the cattle shed took persuasion. Initially respondents claimed that they feared that it would be odorous for the house, and that they did not think that there was sufficient space. However upon inspection, they agreed that in many instances it would be feasible, as long as it was ‘permanent’ and therefore easy to clean and non-odorous, and robust to avoid damage from cattle. An interview with a local priest revealed that, as cows are deemed as gods, locating a latrine within the cow shed was completely unacceptable, and any project that promoted this, he would actively advocate against. However, locating it within the buffalo compartment was deemed as acceptable, as long as it was not in the direct domain of the cows. • Similar initial responses for cattle sheds were received upon the proposition of locating latrines underneath the first floor balcony. It was not thought that there was sufficient space, and there were also doubts about where they would then discharge their domestic greywater, and the fact that it may encroach onto public land or block pathways, but in theory it was stated to be acceptable.

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4.2.7 Institutional Sanitary Facilities

3 out of 4 secondary schools had latrines, although one was ‘under construction’, which had been left for over 1 year since initial construction of the superstructure, as the cement for the overall school rehabilitation was not sufficient, and was not prioritised for the toilets. Out of the 6 primary schools, two had latrines, both were visibly derelict. With the two health posts, one had facilities that were also ‘under construction’ since over 6 months, the other had none. None of the schools or health posts visited had reliable or adequate yielding water supplies, and half of them had no supply at all. Latrines built recently were generally relatively high standard offset pour flush, with waterseal, fibreglass pan and cement finish, built in a block style arrangement. These were either constructed by NGOs Saapros or Deppros on behalf of UNICEF’s Quick Impact Project (QIP), or by the DDC/District Education Office. Without a proximal or adequate water supply, the latrines were commonly blocked due to insufficient water to flush with a waterseal, and rapidly became derelict. At one secondary school, 4 latrines were being constructed, one per gender for teachers and students. This meant 2 latrines for 270 students; 1 latrine for 140 male students. At 3 schools, latrines were locked, for the exclusive use of teachers and visitors, leaving no facilities for the students. This was reasoned by caretakers and teachers as the students do not take care of the latrines, and they become rapidly dirty, particularly as there are so many students to potentially use the latrines and water shortages.

4.3 Environmental Sanitation

In addition to defecation habits, poor practices of solid waste, greywater and livestock excreta management create environmental conditions within settlements that pose high risk for disease transmission, particularly in the denser, nucleated villages.

4.3.1 Solid waste disposal

The production of domestic solid waste was explained to be seasonal both in terms of volumes and type of waste produced. Interviewee’s estimates of volumes ranged from 1 or more baskets per week (approximately 35 l baskets) in the harvest periods, mainly consisting of waste from grain processing, to quarter of a bucket or less in the winter. Outside of harvest periods, solid waste generally consists of small volumes of organic waste, such as vegetable peelings and corn cobs. Inorganic waste is produced, but in very small quantities. Current domestic waste disposal practices are presented in Figure 4.31.

Figures 4.311, 4.312. Solid Waste Management Practices from this research, and the KAP Survey, respectively.

Domestic Waste Disposal Practices (32 How does the family manage the refuse respondents) Indiscriminate/

onto street Inorganic 03 97

Compost 1-Dumping 2-Pits Vegetale 016 93 Feed to cattle 3-Compost 4-Anyw here Burn Animal 01 59 41

Throw onto 0 20 40 60 80 100 garden directly %

The results from both researches show that indiscriminate disposal, generally by throwing waste onto the street or garden from the balcony is the most common method of disposal. Few respondents remarked that the practices were a major issue (See Figure 4.22), and generally only when pushed did they mention issues, such as smell, rats and the fact it made the street ‘dirty’.

Will Tillett, 01-2008 53

When suggested with digging a pit for refuse disposal, respondents were generally not enthusiastic, and commented that the volumes of waste were low, and their constraints in terms of time and available land. Mixing with composting was not commonly practiced, and respondents stated that they were not aware of the true benefits, but saw potential, with some mentioning the lack of an available container as a potential barrier.

4.3.2 Roof and Greywater disposal

No settlement visited outside the district towns had community level drainage systems, and domestic drainage caused village paths to become slippery, with areas of stagnant greywater and mud encouraging flies and vermin. Water drains from the roof onto the street paths, and tapstand drainage is an issue.

Figures 4.321, 4.322. Domestic greywater management practice findings from this research, and the KAP Survey, respectively.

Gre yw ater Dispos al Practice s (32 How does the family manage the waste respondents) Indiscriminate water disposal/ drains to street 3% 1-Kitchen garden Onto garden 0% (drainage pipe or 2-Emptied near toss) the house Designated pit 3-Drained 97% anyw here

At the domestic level, greywater was predominantly drained onto the street from a designated dishwashing area on the balcony, causing localised areas of stagnant water. In less dense areas, or houses with direct frontage to cultivated land (or just the other side of the path), some households have incorporated a basic kitchen-garden irrigation system, using pipes salvaged from derelict GFS.

One of the activities of the aforementioned Mothers Groups of Nerah and Taza villages was to promote the construction of basic greywater pits, to contain the extent of saturation, shown on Figure 4.325

Roofwater from households is often drained to one or two corners of the roof, and drained by a long HDP pipe or traditional carved wood chute to offset the drainage to fall in the same location as the greywater, or to a neighbouring field or garden plot. No integrated grey and roofwater domestic drainage systems were observed.

Again, drainage was not widely stated as a major issue in the village, but when probed, interviewees mentioned problems of; paths becoming slippery to walk on (often causing disputed between households); the ‘quagmire’ situation that results from poor drainage, solid waste, excreta and livestock trampling; and occasional odours.

Options suggested to interviewees such as building improved, gravel filled soakaway pits, or extending coverage of kitchen gardening were received well, but mentioning potential barriers of time availability and HDP pipe access. Community level initiatives such as village drainage channels were suggested by 3 interviewees, but they conceded that ongoing maintenance may be difficult, and channels were likely to become blocked, or damaged by livestock.

Will Tillett, 01-2008 54

Figures 4.323, 4.324, 4.325, 4.326. Pictures of the environmental sanitation situation in the villages

4.3.3 Livestock and composting practices

The community’s livelihoods are intricately connected with agriculture, to the point that they share their homes with their cattle. Generally, buffalos and cows are taken to the highlands to graze in the summer and brought increasingly closer to graze in the colder months, and are kept largely within the cattle shed in the winter. During the times the livestock are in the settlements, by night they are almost invariably kept in the ground floor of dwellings (in 97% of cases according to the KAP Survey), and by day often kept in front of the house, or tethered to designated posts within the village. Livestock excreta within the shed is commonly composted in-situ; mixed with leaves and pine needles brought from the jungle, but it is not a common practice to frequently collect the faeces from in front of the house or on the street. One interviewee mentioned that one reason for this was a lack of a shovel. The manure in the shed is brought out once or twice per year, and heaped outside the shed, or on the street, to ‘mature’ for one month, before being taken to the fields. The responsibility of composting and ‘mucking out’ the cattle sheds is generally that of the daughter in law, or children.

Issues with the current livestock and composting practices were not commonly mentioned by interviewees unless probed. Regarding animals in the village, the main problem was that of them trampling and churning up the paths, and that the compost heaps can take up space and block pathways. When pushed, some interviewees conceded that the; ‘dirtiness’ caused by the animals in the village can be a problem, as children play in the street, then walk in the house, bringing dung with them; and that, mixed with stagnated greywater, dung can omit a gas that can cause fevers. Answers were, in some instances defensive, with one interviewee stating that ‘it (composting and livestock practices) may be an issue, but it is the compost that keeps us with food, and alive’.

The knowledge or perception that livestock excreta had the potential to cause ill health was not widely understood. Indeed, livestock (cow) excreta was found to have a wide number of applications, presented in Box 4.33.

Suggestions regarding alternative practices were not forthcoming, but 2 interviewees stated that a committee could be formed, and equipped with shovels to clean the livestock excreta from streets, on rotation. The suggestion that the animals could be kept outside of the village was overwhelmingly unpopular, with respondents defensively stating that the cold conditions would kill the animals, and that keeping them on the ground floor in the winter was a source of household heating. Besides this, interviewees stated that land acquisition, the costs of building another cattle shed, and the requirement for constant monitoring, even in winter months, made the proposition difficult as well as unpopular. The concept of composting the manure outside the village, or far from the house was also unpopular, as it would require daily transport to the field, which was laborious, and deemed to the interviewees as unnecessary.

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Box. 4.33. Perceptions of, and Uses for Cow Excreta

Cows are believed to be gods, and therefore ‘pure’. In this logic, cow excreta is also deemed to be ‘pure’, and used for a wide range of applications. However, buffalo or other animal excreta is understood to be ‘impure’ and therefore not used for practices aside from manure. A list of the applications for cow dung in the study area is presented below:

•Mixed with leaves and used to wash hands, body and face for exfoliation properties •Mixed with water and used to wash dishes •Mixed with red mud and used to clean the floors of the house •Mixed with water and a lower quantity of mud and water and applied to the roof to create a • hard surface upon which to dry/process grains •Used as a cement-like 'filler' to fill holes in the house walls or roof •Mixed with leaves or pine needles and used as compost •Mixed with water, and smeared on general purpose transport/storage baskets to reinforce them •Used in the plastering and mortar to bind stones in wall construction

Handwashing is not perceived to be a high priority after handling the dung, and fresh dung is often collected, transported and stored in plates or bowls used for eating from by family members.

4.3.4 Road Paving

In addition to latrine building, another forced Maoist initiative in 4 of the communities visited was weekly street clean-ups and path paving with local stone slabs. Although most interviewees stated that the communities were cleaner at this time, they also mention that now no-one is currently willing to work on these types of projects for free.

4.4 Personal Hygiene

Due to a number of factors, the personal hygiene of inhabitants of the study area was generally extremely poor, particularly that of the children. This section outlines current practices, perceived issues, barriers and future aspirations of interviewees regarding their own, and family’s personal hygiene.

4.4.1 Personal washing

The frequency of personal bathing varied between interviewee, and was stated to be influenced by the season and temperature, water availability, and access to washing materials. It was observed that there were trends within the village, often with lower castes having a lower state of personal hygiene, and between villages, thought to be related to the remoteness of the village and number of visitors, relative level of education of inhabitants, and proximity/yield of the water supply.

The major reason for the seasonal difference in washing frequency was the temperature of the air and water in the winter, and, to a lesser extent the reduced source yields at these times. Women generally claimed to wash at least monthly, regardless of the season, believed to be related to menstrual cycles, and corresponding rituals of ‘purity’. There was a broad trend amongst the answers to indicate that the older

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generations spend longer periods without washing, with one 50 year old male respondent claiming not to wash at all during winter; a period of at least 2.5 months.

Figures 4.411, 4.412. Frequency of Personal Washing Results from this Research, and the KAP Survey, Respectively. Frequency of Personal Washing How often family members are taking shower

Once per week Children 1 41 57 Frequency Winter Child Father 0 26 73 Once per fortnight Frequency Winter Adult Mother 2 19 79 1-Never Once per month 2-Weekly Frequency Summer Child Children 1 86 13 3-Monthly Once per two Frequency Summer Adult Father 0 78 23 months Summer Winter 0 5 10 15 20 Less than once per Mother 0 68 32 two months Number of respondents 0% 20% 40% 60% 80% 100%

A wide range of washing agents were used by interviewees. Soap use was desirable, but generally only infrequently used, when it was brought back from a family member’s visit district towns or India, or when the household had spare financial resources. However, the more affluent households used soap at all times.

Natural cleaning products were also used, including ground-up (locally available) ‘Senu’ and ‘Utenu’ roots, ground walnut shells, mustard seed fibres, ‘kumeru’ (leached white mud), and even fresh cow dung mixed with leaves. Aside from the cow dung, the materials were only generally used only for washing hair, and normally only used by women. The use of these materials was seasonal, and subject to the user having sufficient time to collect and prepare them.

Figure 4.413. Issues with personal washing, as perceived by interviewees

Issues with Personal Washing

Privacy/ not able to w ash fully Soap access Village w ater shortages Cold w ater or w eather Only ow n 1 pair of clothes Dirty conditions of village Tap stand crow ding Smoke in homes Distance to w ater source

0 2 4 6 8 10 12 Number of Respondents Who Mentioned the Issue

Issues mentioned by the respondents regarding their current bathing practices are presented in Figure 4.413. Privacy was mentioned as a major barrier for adults and children of both genders, but seemed to be a bigger issue for the women. Women complained of having to cover at least their lower halves with a sarong whilst washing, limiting the effectiveness and extent of bathing the whole body. The fact that many interviewees only had one pair of clothes meant that they had to put on dirty clothes after washing themselves, and some also reasoned that the benefit of washing frequently was limited, as the village environment, smoke in the

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house, and agricultural activities make them rapidly dirty again. Water supply yield and proximity was also a common problem, mentioning that in times of scarcity, personal hygiene is less of a priority than water for drinking or cooking purposes. Scarcity of time to wash was also commonly identified. Interviewees, particularly women, were very enthusiastic about the concept of some form of privacy structure next to water points, such as public bathrooms, stating that with this, they would be likely to wash more frequently. They felt that they could be managed by some form of village committee. Interviewees generally stated that they could share facilities between genders (with use at different times), but certain interviewees said they would not be willing to share facilities with Dalits, and feared waiting times and potential misuse without effective monitoring. 5 Interviewees who either never, or intermittently used soap claimed that if it was made more affordable in the village shop, between 12-16 rupees per bar (normal price 20-25 at village stores) they would use it at all times. Female interviewees were also enthusiastic about the potential to produce improved washing products at the domestic level.

4.4.2 Clothes Washing

Clothes washing was commonly mentioned to be the responsibility of the mother, although many children were observed to wash their own clothes. Frequencies generally ranged from fortnightly in the summer months, to less than once per month in the winter. However, women cleaned their own clothes monthly, likely to be related to the menstrual cycle, particularly as sanitary towels or other products are not widely used in the area. More affluent families may use laundry soap, but the predominant washing agent for clothes in use is ash. Often, clothes are boiled in large cooking pots in an ash-water mix, helping to remove ingrained dirt, lice and fleas.

4.4.3 Hand Washing Handwashing was a strong focus of investigation in the KAP Survey, and therefore not a particular focus of this research. Findings from the KAP Survey are presented below:

Figure 4.43. Box Y. Findings from the KAP Survey Regarding Hand Washing Key findings When do you usually wash your hands from the KAP Survey regarding 8-After w orking 9 handwashing:
53% of 7-After touching animals 0 respondents wash their hands after 6-After cleaning a child 11 defecating to remove smell, 5-After defecate 28 21% to prevent 4-After eating 17 disease
66% use only 3-Before eating 16 water to wash, 18% ash, and only 2-After cooking 11 6% use soap 1-Before cooking 9
85% stated they did not use soap as 0 5 10 15 20 25 30 it was either too % expensive or unavailable.

It was found in this research that the use of ash was unpopular as it caused the hands to dry and become cracked, and that for ingrained dirt, leaves, mud and cow dung was may be used to aid cleaning. As with personal washing, in times of water scarcity, handwashing is placed at a lower priority than water for drinking and cooking.

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4.5 Child Hygiene & Sanitation

The status of the children's hygiene in the study area is generally extremely poor. It was found to be variable between families, and villages, and expected to deteriorate during the winter months for reasons previously mentioned for adult hygiene. This section presents findings from interviews with children, parents, teachers, District Education Officers (DEO) and District Health Officers (DHO), regarding current practices, responsibilities, barriers and opportunities for child hygiene and sanitation.

4.5.1 Parenting, Responsibilities and Care Practices

The supervision of the children is related to the age of the child, time constraints of the mother, and availability and willingness of another family member to supervise. Young children are often left to be taken care of in the house or village by the mother in-law, and to a lesser extent father in-law (the grandparents of the child), an elder sibling, or the father. In the case of the elder sibling taking responsibility, it is predominantly the responsibility of the older sister, and not the elder brothers. This was rationalised by interviewees as the boys are more careless, and less attentive to their siblings well being. The extent to which the fathers were observed to be involved with supervision varied between families, with no clear trends in caste group. Father's supervision could range from constant play and contact, to passive supervision whilst sat discussing or smoking with other males. Many fathers, particularly from lower caste households work in India for up to 6 months per year, and are therefore unable to supervise. Regardless of responsibility, the sight and sound of a child screaming alone in the street, or filthy and covered in flies is common throughout the study area.

Figures 4.511, 4.512, 4.513, 4.514, 4.516. 12 day-old baby given birth, and kept in the cattle shed; a child left alone unsupervised at home; a child covered in flies in Humla district; baby washing with cold water; elder sister taking care of younger sibling whilst mother works the fields.

The upkeep of the cleanliness of the child was generally mentioned by interviewees (most of which were parents) to be responsibility of the mother, and, to a lesser extent, both parents. 92% of KAP Survey respondents said it was the mother. However, from observation, it is clear that elder siblings, invariably females, are often the people taking the children to bathe. It is traditionally the role of the women to wash the child, and 2 fathers who were interviewed whilst supervising their child commented on the deplorable state of the child's cleanliness, but were not themselves motivated to wash them.

Before the children can walk, they are normally cleaned by pouring cold water from a jug or held under the tapstand in many instances using soap, and sometimes following washing with rubbing mustard oil or ghee into their skin. Children of this age do not seem to enjoy the experience of washing, possibly due to the water temperature, commonly screaming and kicking in the air.

Once the child is old enough to walk, it is sent to the tapstand to wash themselves at the order of a parent, occasionally accompanied by siblings or parents, but often alone. Indeed, the interviewees perception of being 'responsible for the upkeep of the child's hygiene' was often limited to the person who tells the child to wash.

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With defecation practices; the children who cannot walk defecate anywhere, or are held by a family member over the balcony. Potties are seldom used in the area. When the child is old enough to walk, he or she is told to go ‘a bit far from the house’, and later to the jungle. Younger children often do not wear clothes on their lower half, or the seat is cut out of them to allow them to defecate at any time without (in theory) soiling their clothes. In very few circumstances did the concept of teaching the child about how and where to defecate or wash extend beyond verbal instructions and commands. Few interviewees stated that they accompanied their child to teach them practically about defecation or washing.

Nethertheless, many interviewees (parents) stated that it is their responsibility to teach their child, and generally that of the mother. However when children were asked where they learned how to wash or other hygiene and sanitation activities, they would commonly say that they learned more at school, from elder siblings, or merely from observation at tapstands. Figure 4.517 presents results from both parents and children.

Children in the study area are deemed by parents to be largely autonomous for their own cleanliness and defecation practices from a very early age. The age mentioned by parents ranged from 7-8 years down to ‘when they can walk’. One Dalit family interviewed stated that once the child can crawl it looks after itself’. The exact ages of children was difficult to determine in the field, due to limited accuracy of the researcher’s estimations, and vague estimates parents had for their own children.

Figure 4.517. Issues and barriers in child hygiene perceived by interviewees

Issues and Barriers in Child Hygiene as Percieved by Interview ees (Parents)

Soap access

No time to supervise

No time to teach

Dirty environment

Water supply shortages

Not enough clothes

0 2 4 6 8 10 12 14 Number of Respondents Who Mentioned the Issue

The major reason for this early age of autonomy was blamed on the time availability of the mother. Many interviewees also remarked that (due to poor family planning) once the child is at walking age, another child has been born that requires the mother’s attention. One Dalit mother explained that she stops washing the children when they begin to crawl, rationalising that after this age, it is up to chance, stating 'if they survive they survive, if not they die'. This women and her mother had experienced particularly high infant mortality rates.

From observation, many of the children in the study area aged approximately between 2-10 years are particularly unclean. Before this age the parents generally take more responsibility, and after around 10 years, the children seem to be more aware or responsible for their own cleanliness. When asked if their children were as clean as they would like them to be, 14 out of 30 respondents stated their current status was sufficient, not perceiving it as a big problem. However, the other 16 stated that they were unable to bring their children to the desired cleanliness for a number of reasons, presented in Figure 4.517.

The lack of access to enabling factors such as soap, spare clothes and adequate water supply, along with the mother’s lack of time were the most common problems. 6 respondents also noted that the children play in the streets which are dirty, and that it is impossible to constantly supervise them, so they soon become dirty after being washed.

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4.5.2 The Role of the School

Although many of the schools were closed for festival holiday at the time of research, interviews were carried out with students, parents, local teachers and the DEOs from Humla and Mugu. The schools, like health posts and local governance, are suffering from low functionality, poor staffing, under resources, in addition to poor monitoring and accountability of teachers.

Although there is little in the way of formalised hygiene promotion campaigns in the schools, topics are taught at both primary and secondary level which include messages on personal hygiene and environmental sanitation. These are, however, only lessons based, with no practical exercises, and little-no visual materials. Indeed, many of the schools do not have water or functional/accessible toilet facilities with which to undertake these activities.

At 5 of the schools, the teachers actively and routinely monitored the hygiene status of the students (normally checking nails, hands and face), telling ‘dirty’ children to wash before they next come back to school. In 3 schools, there was an annual prize for the cleanest student, the winner receiving hygiene products like soap, in addition to stationary and books. Both the monitoring and competitions are the initiative of the schools, and are not part of a government education strategy.

The teacher’s remark that the students’ hygiene generally improves due to the monitoring and competitions, and students remark that there is a certain degree of peer pressure not to be too dirty at school.

Student interviewees mentioned that the messages about improved hygiene practices from the teacher, such as wearing slippers when going to defecate, using a latrine and washing daily with soap were generally unattainable due to a lack of enabling factors. Parents of the students stated that their children bring the messages such as to construct latrines back to the home, but do not follow their requests, due to lack of time and money. All teachers interviewed agreed there was a general trend for students to be particularly unclean until the latter years of primary school, and, in general, Dalit children tended to have relatively worse hygienic conditions.

School attendance varies seasonally, depending on labour demands in the home and fields, with harvest time being particularly quiet, and girls are often removed from school to help in the home during the father’s absence in India. In areas where there are seasonal settlements, children may only visit the school for half of the year. Along with sickness absences, another key problem for attendance in the area is the presence of the teacher, whom may be absent over long periods, and even have alternative jobs.

Figure 4.52. School Enrolment Trends in Mugu District 2006-7. Created from data obtained in 'District Education Office Gamghadee, Mugu. Schools, Students, Teachers, Students of Mugu District 2064-65’

School Enrolment Trends in Mugu District 2006-07

100 Boys % 80 Girls % 60

(%) 40

20

Gross Enrolment Rate Rate Enrolment Gross 0

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According to local government statistics for Mugu District, attendance is relatively good for primary level, but drops significantly for lower secondary (10-12 years) and secondary (12 plus), with the proportion of girls falling from 43% in primary, to 25% and 20% for lower secondary and secondary respectively. A similar story is seen for total Dalit attendance, with Dalit girls accounting for 15% and 11% for total Dalit lower secondary and secondary attendance.

The Karnali Zone has various governmental strategies to boost school attendance, which, according to the Mugu DEO includes payment for primary school attendance of 350 NPR per year for Dalit boys, and 100 NPR per month for all girls, regardless of caste. These payments increase for lower secondary and secondary, and the scheme is applied in all schools within the zone. Other initiatives include a pilot food-for education in 70 schools, and free textbook distributions. It remains to be seen whether this will significantly boost attendance, particularly for girls above primary level.

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5 Discussion

This section discusses appropriate approaches for sanitation and hygiene, in light of the context, findings of the filed research, and meetings with over 40 sector workers. The discussion refers to the current ACF approach, but focuses more on appropriate strategies for future, longer term development projects in the area.

5.1 Overall Approach

Previous assessments of ACF’s intervention strategies have suggested a weakness in community orientation and mobilisation (ACF 2007c, Ockelford 2007). This mirrors to some extent other actor’s activities in the area, where due to multiple factors, particularly security and field access, projects have taken a more ‘hardware’ or construction focus, with limited software activities.

The area is challenging in which to undertake WASH activities; where supply chains are long and costly, local and district governance and services impaired, field access challenging, and communities may be demobilised, relatively uncohesive, with alternative priorities and high demands for external assistance.

It is suggested that these challenges, through appropriate, effective, long-term coordinated activities, could be worked around, to sustainably improve hygiene and sanitation conditions, and to empower the communities to develop their own situations. Section 5.1 discusses important overall components for future projects in the area, before entering into detail on sanitation and hygiene in subsequent sections.

5.1.1 Community Approach

Many NGOs acting in other areas of Nepal operate projects that include up to one year dedicated to initial social ‘preparation’ or community ‘mobilisation’ . In this phase the community is sensitised, and through participatory activities, demand is built for the services and infrastructure that will follow. The community may be actively involved in developing ‘community action plans’, and Water and Sanitation Users Committees (WSUCs) are trained. In this, it is argued that an appropriate approach for the area would be to sequence activities to begin with software activities, followed by technical interventions and hardware activities.

Following an initial needs assessment, broad sensitisation of communities in the area can be undertaken to inform beneficiary communities as to the mandate and services available from the NGO. This should be followed by a transparent and if necessary, assisted application process to the NGO for support. This would help to gauge community motivation, but also, as a pre-requisite, requiring the communities to mobilise themselves to some degree to develop community plans for the application. This approach would also build on the sense of ownership the community has on the process. This demand-responsive approach is in contrast to the commonly practiced pro-active selection, where NGOs may be seen as rich outsiders coming into the villages and pushing their ideas onto the village. This is of particular relevance in this situation, where communities may see projects as a mode of material or financial gain, not necessarily so bothered about the end product of the project (such as the example of the community dismantling the GFS for CFW employment, Box 4.18).

The high expectations and, in some instances, dependency mentality observed in the area may be, in part, related to strong pro-active approaches with limited community orientation or participation. It is recognised that long term development approaches incorporating participatory techniques, has been challenging to implement in the area, especially due to the conflict, reducing many projects to more rapid ‘quick impact project’ approaches, with a hardware, infrastructural focus. However, as the security situation in the area seems to be progressively improving, there is an opportunity to build up the capacity , and empower the communities to help themselves.

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Initial impressions are important and strong facilitation and rapport building is essential in the early stages of the project, to gain the community’s trust, and develop their ownership and active involvement in the project.

Expectations for material or financial gain from projects can be high in the area, and experience has shown that demands can increase through time, with some community members ‘bargaining’ with the NGOs for the best deal. To mitigate this, roles, responsibilities and even budgets should be made clear , and if necessary publicly displayed, and Memorandums of Understanding (MoUs) should be signed by the NGO and community in the early stages of the project.

The context of the area is essentially post-conflict, and many communities have suffered from a breakdown of social cohesion and leadership. In such circumstances, individuals may have a depleted sense of self-worth (WaterAid 2007, pers comms ), and not feel able to change their situation. This may be confounded by some individuals’ previous unsuccessful attempts at social mobilisation, through previous, poorly planned and supported NGO or Government projects.

A clear potential exists, with good capacity building and regular support, to empower the community, and build up social capital, initiative and leadership through community projects such as WASH interventions.

5.1.2 Community Based Organisations

Many of the communities have pre-existing Community Based Organisations (CBOs), such as mothers groups. In two communities they have been observed to have capacity to drive significant change in the villages, whereas in others CBOs have been formed but lack direction. These groups hold strong potential for agents of change in the village, and are essentially pre-mobilised units within the community which NGOs could utilise in their projects. Experience in 3 communities visited showed that initial failures of CBOs to mobilise the community, and the absence or inadequacy of follow-up support from the NGO that created the CBO, can lead to the CBO members feeling they are unable to drive change, and a sense of fatalism can prevail. In this, mobilisation and failure may be worse than no mobilisation. Any activity in the area using CBOs should dedicate sufficient time and resources for adequate training in areas such as conflict resolution and decision making, and, most importantly, periodic follow-up support visits, to assist them to overcome barriers faced, and refresh and re-motivate the members. This is especially important, as communities may be weak, with challenges managing projects or activities especially in the post conflict scenario. Seeing is believing, and to help communities and CBOs realise that change is achievable, CBO visits to ‘success’ villages should be encouraged.

Due to the sensitive political situation in the area, NGOs should be careful not to inadvertently support CBOs that may have ulterior political intentions or bias. In addition, to increase accountability and transparency, and potentially gain future support, CBOs should be encouraged to legally register at the district level. This latter point is a requirement for all WSUC created according to national RWSS policy (GoN 2004).

5.1.3 Coordination of Activities

The active involvement and coordinated selection of projects with the DDC and VDCs is not only a mandatory requirement for RWSS projects (GoN 2004), but essential to avoid overlapping projects or conflicting approaches (offering communities differing levels of incentives and subsidies) in the implementation area. This involvement allows the project to be coherent with district, regional and national development strategies.

Regarding decisions on subsidy to be provided, salaries for local staff, incentives for involvement in project activities, and porterage rates, it should be borne in mind that all activities undertaken set a precedent for future activities in the area, for future ACF operations, other implementing NGOs and local government.

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5.1.4 Developing Local Capacity

Projects should, where possible, utilise and involve local government and institution’s (teachers, health workers) staff. This would have the benefit of; bringing district officials to the field; reaffirming or empowering their positions; strengthening links with more remote VDCs; benefit from their local knowledge and understanding, and develop the capacity of local services. The involvement of local institutions from the beginning holds potential for post-project sustainability by linking the project and CBOs to more permanent structures and support networks. The involvement of local staff, in addition to local recruitment and training for posts within the NGO is more sustainable long term, and could mitigate the high turnover of national staff, many of whom are sourced from Kathmandu and may not be accustomed to the living conditions of the area. It is recognised, however, that working with local government can be a slow, bureaucratic process, and the current low-functionality of local governmental departments and services make this approach uncertain in the current political climate. In addition, available human resources in the area for recruitment are limited in terms of capacity. However, the investment of training local staff is a more sustainable option than continual external sourcing, and maximises the potential economic benefits the project has on the area.

The project should involve the local private sector and supply chains wherever possible, especially for procurement of materials, to strengthen supply chains, ensure the ongoing availability of materials and skills, and to maximise the local economic benefit of the project.

Many of the National NGOs have developed their own strategies and approaches based on their experiences. INGOs could benefit from their local knowledge and experience, whilst developing the capacity of the partner through its international experience. In this, the INGO could strive to move away from using the local partner as an implementing ‘contractor’, towards a ‘win-win partnership’ .

A move towards more participatory development, with the community taking control of the process, and empowering the local partner to have autonomy for decision making, would require the NGO to vanquish control , and be less prescriptive over its activities, and move towards the role of the ‘facilitator’ .

5.1.5 Timescales and Donor Funding

A Key constraint of ACF Nepal’s past and present activities is the fact it has been trying to work in an essentially development context, within humanitarian timeframes (Ockelford 2007). If the type of development approach outlined in section 5.1 was to be undertaken, it is argued that multi-year development projects, with corresponding donors should be approached. This would allow the community to drive change at a pace that may be more appropriate to their time and resource constraints, and to allow flexibility for potential delays involved in local material procurement, and the involvement of local authorities. The sustained presence of the NGO would aid ongoing follow-up support, in the realisation that behavioural change in the community may take time.

5.2 Options Available for Environmental Sanitation and Hygiene Approaches

This section discusses the current ACF approach, and possible future, long term approaches to improving sanitation and hygiene in the area.

5.2.1 Sanitation

The Current Approach

The approach to sanitation currently employed by ACF in Mugu/Humla is that of a flat rate subsidy, with the additional provision of skilled labour. Although the design standards, and volume of external materials

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provided for the latrines have reduced significantly since the Bajhang project, per household costs remain very high, at around 67 Euros (external materials and skilled labour).

Without transport, the material subsidy and skilled labour costs are not excessively high by Nepali standards. However, current procurement and transportation systems involve procurement of all materials in Nepalgunj (in the Terai), followed by road, and then helicopter transportation, and finally local porterage to ACF field stores. Transportation accounts for 64% of total financial input from ACF, of which 95% is on helicopter transport. Transportation costs are based on weight, and 75% (around 31 Euros) of transport costs are spent on the 25kgs of cement provided to each household.

Table 5.211. A breakdown of current costs, materials and contributions for household latrine construction in ACF A1D project. Data from ACF Procurement Lists, Logistics and WASH PM estimates.

Unit Cost Cost Component Quantity Unit (Procurement ACF Community in NPG) Materials (Procurement Costs) Cement (25kgs) 0.5 Bag 500 250 HDPE pipe 110 mm (4Kg/cm2), dark coloured, 2,5 metre length1 Piece 860 860 Latrine pan with footrests 1 Piece 600 600 Siphon 1 Piece 60 60 Elbow Pipe 1 Piece 70 70 Local Materials (sand, stones, wood - No cost to procure) - - - Subtotal 1,840 Labour* Skilled Labour 0.5 Days 700 350 Unskilled Labour (Pit digging/lining, collecting local materials,12 buildingDays superstructure)180 2,160 Subtotal 350 2,160 Transport of Materials Local Materials (cost covered in unskilled labour days) - - - External Materials (NPG-Field Store) 33.5 kgs 116 3,886 Total Costs (NPR) 6,076 2,160 Total Costs (Euros) 67 24 Relative Contributions (%) 74 26

Two clear potentials for cost reducing this system exist:

• The first is to reduce the total weight of external materials provided to the beneficiaries, with the biggest cost reduction potential being on reducing the quantity of cement. For example, reducing the quantity of cement to 12.5kgs per household would reduce costs by 27%, from 67 to 49 Euros.

• The second would be to alter the transportation system, using local supply chains, procuring materials from district outlets and retailers, who could porter or mule-transport materials overland to their stores, and then ACF or the community themselves could organise porterage to the communities. This option has the advantage of strengthening the potential of ongoing availability of sanitation materials in the area post project, and maximises the potential economic impact of the project in the area. The drawback of this approach is that ACF would be in less control of the procurement and more important, delivery dates, potentially delaying project activities.

Table 5.212 shows that per capita costs borne by ACF for latrine construction, using current design standards, could be reduced by 15% through local procurement and porterage of materials.

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Table 5.212. Comparison for procurement and transport costs for latrines

Procurement in Local Component Quantity Unit NPG and Air Procurement** Transport and Porterage Materials (Procurement Costs) Cement (25kgs) 0.5 Bag 250 1,500 HDPE pipe 110 mm (4Kg/cm2), dark coloured, 2,5 metre length1 Piece 860 1,288 Latrine pan with footrests 1 Piece 600 875 Siphon 1 Piece 60 80 Elbow Pipe 1 Piece 70 80 Subtotal 1,840 3,823 Skilled Labour Skilled Labour 0.5 Days 350 350 Transport of Materials* External Materials 33.5 kgs 3,886 1,020 Total Costs (NPR) 6,076 5,193 Total Costs (Euros) 67 57 * Transport from point of purchase to Mugu field store (Nerah) ** Procurement in Mugu district town stores

Research undertaken by WaterAid (2007b) found that approaches in Nepal undertaking flat rate, hardware subsidies up to pan level, as ACF is utilising, leads to far higher per capita costs than other approaches, particularly ‘software approaches’ such as CLTS. Based purely on costs, an approach that provides very little, or no material subsidy, such as CLTS would bring the highest coverage of household sanitation with minimal external financing. However, following negative experiences with ‘temporary’ latrines made only of local materials, and promises of external material support for latrines made to the communities either by ACF or other organisations in the past, many interviewees stated they would be unwilling to construct latrines without some form of hardware subsidy.

Figure 5.21. Cost of sanitation financing modalities in a typical Nepali community of 99 households (33 ultra poor, 33 poor and 33 medium). Source: WaterAid 2007.

400000 350000 300000 250000 200000 150000 100000 50000

Costtheof programme (NRs) 0 Subsidy up Graded Minimum Subsidy + Revolving SLTS CLTS to pan level subsidy subsidy Revolving loan loan

As various other projects exist in the area, supplying communities with hardware subsidies, it is likely, even with strong facilitation, that communities would reject projects without subsidies, and choose to wait, instead for assistance from another organisation.

In the long term, these conflicting approaches may be addressed through proper coordination by the NGOs and local government to delimit geographical areas of implementation, and the national government enforcing thresholds on what organisations can provide. However, in the shorter term, it is argued that due to community expectations and past experiences, a project may not engage or interest beneficiaries without the provision of some form of ‘permanent materials’.

An appropriate approach should therefore seek to provide the minimum materials necessary for the community to be satisfied they have received support, whilst at the same time minimising costs, and avoiding undermining ownership by ‘giving too much’.

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5.2.2 Hardware Approach & Appropriate Technologies

There are no national or international minimum design standards that are relevant to rural sanitation technologies in Nepal. National policy does however state that 100% of ongoing operation and maintenance costs of latrines should be bourn by the household, meaning that materials used for construction should be realistically replaceable by the household, or highly durable. An assessment of the Bajhang programme recommended offering a range of latrine designs, from which the user can choose which is most appropriate to their circumstances (Ockelford 2007).

Table 5.221 (overleaf) evaluates the range of technology options for the context. The offset pour flush design is the most popular with the users, and is appropriate as the vast majority of the users will be anal washers. Using twin pits means the structures can be permanent, and there is a strategy for continual emptying and reuse. There is another advantage that the waste can be safely removed from the pit after around 2 years, and used as a productive soil additive, contributing to food security of the area. However, there are two main drawbacks of a conventional designed twin-pit pour flush: 1. Pour flush toilets commonly utilise a ‘waterseal’ ‘ubend’ or ‘siphon’ to act as a barrier to odours and flies between the pit and defecation point. This structure is reliant on sufficient quantities being available for flushing; otherwise it can become blocked, and subsequently disused. In an area with unreliable water supplies, it may not be wise to promote water-dependent toilets. Many basic offset pour-flush toilets in the area however simply do not use the waterseal, using instead simply a straight pipe at an inclined angle from pan to pit.

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Shallow pit (cat Tabledefecation) 5.221. Appropriate sanitation technology options for the context

BucketTechnology latrines Option and Strengths in context Weakness in context Comments Nightsoil No cost Fly nuisance To be promoted for daytime defecation whilst in the fields. Soil helmiths mitigated by Can be used as fertiliser Transmissionths of soil helmi promoting using stone foot slabs. Low initial cost Malodorous and fly nuisance If poorly maintained, bigger health risk than Low space option Dander to health of collection and disposal open defecation. To be avoided. Likely indiscriminate/irregular disposal Basic pit latrine To be promoted for child and sickness disposal. Provide 20l Jerry cans to be cut in half- half used for latrine water storage, half Potties Low cost (if local design) May be usedposes for other pur Ventilated Improved for potty. Potties could be made in practical Pit (VIP) latrine HP sessions by users. If providing all HDP pipe, better to promote Low cost Previous negative experiences in the area basic VIPs where space and water is limited. Low demand for water for operation or maintenancey nuisance Fl and malodorous To be promoted as an option where water Simple, replicable technologyNeeds certain No optionconditions is fullfor when (prevailing pit winds,terior, dark in supply is unreliable, and no space for pit sunlight on vent) Low-moderate cost switching. Can ventilate pit using basic Control of flies and odour subsidy package. Low demand for water for operation or maintenance option for No when pit is full Can promote as an option where sufficient space but unreliable water supply. Double pit latrine Permanent structure Bigger demand for concrete for 2 slabs/pans Can promote as an option where space is Contents of pit can be emptied and used eras fertilis Bigger demand on space for pits and superstructure limited but unreliable water supply. Without Pour flush direct pit waterseal better to opt for basic VIP. latrine Space saving where not space for twin pitaterseal Requires - dependent w on reliable water supply To be recommended as standard design. Generally anal washers in area No optiont is fullfor when pi Need fly/odour control if no waterseal - Use pan 'plug' or 'stopper' and periodically add Pour flush offset Desired and understood by beneficiaries Requiresce for two spa pits ash. Needs provision of water storage within double pit latrine Low cost (if local design) With waterseal-reliable requires water supply latrine. Permanent- strategy for pit emptying Withoutal- potential waterse malodorous and flies Contents of pit can be used as fertiliser Generally anal washers in area Composting toilet Without waterseal- moderately low water demand Improves food security with fertiliserosts High capita c Integrated solution for solid waste disposalintensive Labour and require significant behaviourale chang Bulking agents (ash and organic waste) readilylable avai Technically complex with urine diversion Anal cleansing (washers) - disturb moisture balance Twin-pit option provides fertiliser with minimal Low demand for additional manure if high maintenance effort and lower per-capita costs.

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Fly and odour control can be improved by the periodic additive of ash into the pit (also improving the productivity of the sludge for fertiliser), and placing a ‘plug’ over the hole. This is less hygienic than using a waterseal, but arguably more appropriate. Users should therefore not be given waterseals in a standard package, but advised of the benefits and drawbacks of waterseals, for them to make their own decision on what is most relevant to them, and purchase one if desired.

The availability of water (stored) within the latrine was seen as a high priority by interviewees for anal cleansing and flushing. Without this, users may be reluctant to use it, or use household containers, such as jugs also used for drinking purposes.

2. Where available space is an issue, twin-pits may not be possible. In these circumstances, direct pits may be more appropriate, although their design life is limited to the size of pit. Where users are anal cleansers, and have a reliable and adequate supply of water, a direct pour-flush latrine with waterseal may be promoted. However, given water supplies may fail, a pit latrine with basic pit ventilation may be a better option.

Basic Package and Technical Design

In light of the appropriate technology options suggested, the following basic subsidy package is suggested, which allows flexibility between a basic ventilated pit latrine and pour-flush.

Table 5.222. Recommended basic subsidy for household latrines

Costs (current Costs procurement (procurement Use (Basic ventilated pit and air transort) locally) Material Use (Pour-flush design) design) Procur Portera Procure Transpor ement ge to ment t GGD* field Forming hygienic surface for Forming basic latrine 'pan' and Cement (12.5kgs) squatting area, and fixing 125 1,450 625 hygienic surface vent pipe** HDPE pipe 110 mm dark Drainage pipe and incorporated coloured, 2,5 metre Ventilation pipe 860 812 1,288 into pan 950 length Elbow Pipe OR Fly Elbow pipe for pit switching Fly net for vent pipe 60 58 80 netting for vent pipe without physical works on pan 20l Jerry can Latrine water supply and potty Latrine water supply and potty 120 29 160 Sub total (NPR) 1165 2349 2,153 950 Total (NPR) 3,514 3,103 Total (Euros) 38.6 34.1 * GGD stands for Gamghadee, the district town of Mugu ** This volume of cement is not sufficient for a solid concrete squatting slab, but to cover laid stone slab arrangement

The basic subsidy omits a pan from its design. This is because fibreglass pans are less durable than cement and HDP pipe, and as 100% maintenance costs would be bourn by the households, it is deemed more appropriate to state the benefits of using pans, and those who can afford, desire, and feel they can replace them, may purchase them.

Many functional latrines were observed in the field that used innovative techniques in the absence of purpose built pans, to achieve smooth, easy to clean surfaces for improvised pan structures.

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Figure 5.223. Improvised, pan structures integrating cement pan with pipe. Lower Rhimi village, Humla.

This basic subsidy package provides the minimum amount of materials to attain ‘permanent’ and moderately hygienic, easy to clean attributes, and encourages innovative designs. The reduced volume and weight enables easier field transportation, reducing costs and making collection, particularly by vulnerable households, more achievable. With current procurement practices, the package reduces costs of material provision by 42% of current costs, down to 38 Euros per household. These costs could be further reduced to 34 Euros (49% less) by procuring materials through district outlets and portering to the field. During sensitisation, households should be given sufficient information regarding the advantages, drawbacks, maintenance requirements and costs for a range of latrine designs and standards, for them to be empowered to make informed decisions based on their own priorities and circumstances.

Sanimart

As there may be households wishing to attain higher standards for their latrines, such as the addition of pans, siphons and use more concrete, a Sanimart system should be developed to make these materials as accessible and affordable as possible. Due to economies of scale, and the high capital required, it is unrealistic to supply such materials through the informal shops in each village. A realistic option could be to work with retailers in the district towns to help them to obtain and supply materials at the minimal price. WSUCs could organise bulk purchases and porterage from retailers to the community, and the NGO could even subsidise materials, by providing the WSUCs with ‘discount vouchers’, and paying the retailers the difference. To make Sanimart a viable option, there has to be sufficient consumer demand. Therefore ACF should coordinate with other sanitation actors in the area (DDC/DTO, DWSS, and other NGOs) and try to get them to support and promote this local supply chain in their activities.

Construction and Skills Base

Current ACF latrine construction activities comprise of an NGO ‘overseer’ based in the communities to supervise and assist in construction. These overseers theoretically remain in the community until all latrines are built, but then leave. A more sustainable approach could be to train local masons sufficiently to be able to construct the latrines, so that the skills base remains in the community, and also reducing the human resource demands on the NGO. If the skills remain within the community, users are not rushed to build latrines under the NGOs timeframes. Masons could be incentivised to participate in the project by providing them a higher subsidy package, such as more cement and a pan. Practical training could be provided to him through the construction of initial ‘model’ latrines in the community. The community can then use these well constructed latrine ‘models’ as reference points for their own construction, and to aid decision making over which design is most appropriate to them.

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Subsidy

It is unclear, given the social dynamics and general high expectations of support from individuals, regardless of socio-economic status in the communities, whether graduated subsidy would be appropriate. Rather, what is suggested here is that basic latrine packages should be available to all, with the more affluent encouraged to upgrade their latrines themselves. National policy states that the ‘ultra poor’ should be supported in sanitation projects through ‘targeted grants’ (GoN 2004). If, following strong community sensitisation and mobilisation, vulnerable households are not assisted by neighbours or relatives for construction and porterage, grants could be made available to assist them. This should be used only as a last resort, as it may cause conflict or be abused, and the vulnerability classification should follow national guidelines (see GoN 2004).

5.2.3 Software Approach

Evaluations of ACF programmes in Bajhang and Mugu/Humla have criticised the relatively low focus on ‘software’ and social mobilisation (Ockelford 2007, ACF 2007c). As the vast majority of the population have defecated outside most of their life, as generations did before them, successful sanitation programmes need to have a strong software component, to drive for significant behavioural change. This ‘software approach’ should be undertaken at the beginning of projects, to sensitise the communities, and build demand for sanitation, before any construction activities begin.

The current approach to sanitation used by ACF in Mugu/Humla is targeting and supporting individual households, and is not likely to achieve 100% coverage. This means that although latrines have been built, the full public health benefits are limited, as open defecation will still be practiced by some households. A total sanitation approach would be more effective at attaining full coverage as the issue of sanitation would be taken from an individual to community initiative and responsibility. By working at the community level, pressure can be placed on those who continue to defecate openly, and barriers faced by certain households (such as land availability or inability to construct) can be worked through as a community. Interviewees suggested that committees and CBOs could be empowered and supported to help manage this process.

Table 5.23. An assessment of various approaches to sanitation for the context of the area.

Approach Strengths in context Weaknesses/barriers in context Community initiative Low social cohesion Strong community mobilisation techniques Needs good facilitators (may not be available locally) CLTS Communities expect material support Communities do not want another temporary latrine SLTS Incorporation and focus on children Low functionality and potential capacity of schools All members of the community expect material Potentially high per captia costs Flat rate subsidy support No specific poverty focus (in line with RWSS Policy) Graduated Potential hijacking by richer households Poverty focus and supporting mechanism for poor subsidy Potentially socially unpopular option Challenges in monitoring, and potential misuse of funds Revolving fund Potential for greater costs borne by households Sanitation a low priority for limited household cash Slow payback as cash flows are limited and seasonal Ensure ongoing material availability Limited purchasing power of households in the area Sanimart Economies of scale and challenges of bringing outlets Maximise local economic benefit from project closer than district towns

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Relevant Latrine Promotion

Past programmes such as the Maoist forced latrine building has shown that if the users do not readily perceive a benefit for themselves of using the latrine, the usage will not be sustained. Due to the traditional beliefs about cause-effect of disease, an approach using predominantly health based messages for promoting latrine usage may not be so effective. However, the interviewees mentioned a number of issues that they perceive with their current defecation habits (see Figure 4.235), which should be drawn upon in promotion and group discussions, so that they see benefits of latrines that are relevant to their lives.

Ignition PRA

The ignition PRA tools utilised in CLTS use an approach based on shame, self-respect and disgust as drivers and motivators for sanitation, justified as health based messages may not be sufficient to drum-up initial momentum for community-level action. Rather the health benefits are realised following the usage of latrines, which is an ongoing motivator for sustained usage.

The application of community approach iPRA tools in the area may be hindered by a number of points: • The currently weak social cohesion and lack of leadership in many communities • The low motivation for self-help community initiatives without incentive in some communities • Low numbers of visitors to the communities and the relevance of shame and self respect approach • The need for strong facilitation skills of the social mobiliser, and the reality of the limited human resource capacity available locally, and high national staff turnover.

This third point could be addressed by local recruitment and strong capacity building, and/or working with partners with proven track record in successful iPRA, such as NEWAH. Ignition PRA tools should be piloted in the area as means of initial community mobilisation, and successes should be scaled up. The piloting would need strong initial facilitation, along with regular, sustained follow-up support.

Children have strong potential to drive social change within the village, and schools should be included in sanitation promotion when they are within the catchment of intervention. However, relying on schools as the main entry point into the communities (as in SLTS) may not be appropriate in the area, due to the low functionality and staffing issues of the schools. Schools should be assisted to have access to latrines and water supplies, and teachers should encouraged students to use them. This topic is discussed further in section 5.5.

The aim of ‘total sanitation’ is to stop open defecation. This takes significant effort, and should be recognised. The involvement of the local health posts can provide feedback to the communities on improving health status, and the DDC or VDCs should be involved in the official recognition, ceremony, and even in the provision of community rewards, for the attainment of ‘open defecation free’ status. In the ceremonies, representatives from surrounding villages should be invited, to disseminate the message, and show other communities what is possible.

5.2.4 Replicability and Future Sustainability

To maximise on public health benefits, communities could be encouraged, and supported to attain 100% coverage of latrines, rather than the NGO trying to spread its activities ‘thinly’ between communities, gaining, say, 60% in each. However, as the sanitation approach suggested in this report involves the subsidy of external materials, it may be difficult for neighbouring communities to replicate the latrines without external assistance, limiting the potential for a multiplier effect in the area from the NGO’s activities.

To maximise the effectiveness and impact from a community intervention in the area, the role of the VDCs and DDCs are arguably critical to support subsequent community-driven sanitation in the area, and for ongoing sustainability of sanitation projects in general.

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• Funding and Continual Support

Each VDC in Mugu should receive an annual budget of 1 million NPR (around 11,000 Euros) per annum (DDC Mugu staff, 2007 pers comms ). This must be divided between the administrative wards and communities of the VDC, but still represents a considerable budget for the area. The funds are channelled from the DDC, and are to be spent on community/VDC infrastructure and services. The VDCs have moderate autonomy of what to spend the funds on, but need to account for the use through annual reporting. With the remoteness of the communities, and subsequent poor monitoring, there is a real danger of corruption and embezzlement. The DDC also has an annual budget from DoLIDAR to fund rural water and sanitation projects. It is suggested that these funds provided to the VDCs from the DDCs could be used for communities wishing to obtain the same the basic subsidy provided by the NGO in the neighbouring implementing communities.

This approach would need the VDCs and DDC ‘on board’ from the inception of the project, with both parties sensitised as to the importance of sanitation in their working areas, and willing to support communities wishing to improve their access to sanitation. Although the VDC funds have the mandate of addressing community, not household issues, the point could be advocated that total sanitation is a community project, with community benefits. Funding provided could cover the procurement costs (at the district level) of basic subsidy materials, and the activities of a social mobiliser/facilitator. Funds could also be made available from the VDC for total sanitation ‘rewards’ to the communities, and the DDC could provide rewards for VDCs, as an incentive for their participation in sanitation development.

This is not to suggest that the NGO provides funds to the local government, but that local government funds are made available for communities outside the NGO’s implementation area to gain support for sanitation.

• Local Skills Base

For sustainability and ongoing accessibility of skills, the NGO should invest in local skill development and capacity building. Using and training local masons in the intervention communities would leave construction skills in the VDCs, and the use (and training) of local government or local NGO staff in community mobilisation and facilitation in the intervention communities, would potentially leave these skills at the district level. Key skills for the local ‘mobiliser’ should include community mobilisation and iPRA, community proposal writing, and capacity building WSUCs.

Additional advantages of utilising local government staff or using local partner NGOs include; maximising the employment and economic gain of the project in the area; benefiting from their local knowledge; and potentially reducing national staff turnover, as staff recruited in Kathmandu often find it difficult to adjust to local lifestyle. Costs for staff transport would also be greatly reduced.

Indeed, partner NGOs need not be national-level NGOs. INGOs could see their potential role of developing the capacity of local (district or regional) NGOs. Skills could be brought from reputable national-level NGOs such as NEWAH, by contracting them to train the local partners in key skills.

• Igniting Local Demand for Sanitation

ACF experience of assisting sanitation in communities in the area, through provision of materials, has seen many other communities outside the intervention area calling for similar assistance.

This local demand could be further increased through inviting members of neighbouring communities to observe the process in the intervention communities, particularly at reward ceremonies. Members of the health posts and CBOs of the intervention community could undertake exchange visits to other communities to disseminate their experiences, and public display boards could be placed in the area. The social mobilisers could be paid by the DDC or VDCs to visit communities, to mobilise them, and help them to develop community action plans and proposals for VDC/DDC assistance for materials and ongoing software assistance. This improved link between community and local government may aid the transparency and accountability of the use of VDC funds. In this respect, further activities in the area would be demand driven, by mobilised communities who know what is, and is not available for their assistance.

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• Economies of Scale

Working at the VDC, and even DDC level would help to increase the ‘economies of scale’ for bulk procurement and transport of sanitary materials by district retailers, and increases the potential viability of Sanimart outlets at the VDC level. It would also help to standardise the approach and subsidy level across the VDC, helping to mitigate conflictory approaches or high community expectations for assistance in sanitation.

5.2.5 Latrine Locations

The lack of free land available for households to build latrines close to the house may be a barrier for some for building latrines. However, it is likely that if there is sufficient community demand and pressure for total sanitation, with pressure groups and good social facilitation, it is likely that the community would overcome these barriers themselves. At the household level, if there is sufficient demand for latrines, innovative solutions to locations and space saving designs will be found. The total sanitation approach should drive the importance as a community responsibility. NGOs should avoid becoming involved in land acquisition for latrines, and leave the process to the community. However, the NGO’s role can be that of a facilitator, suggesting technical and social solutions, and ensuring the process is inclusive, where the vulnerable, landless households are addressed. Below are potential options for those without obvious access to land: • Space saving latrines. Design models with small squatting areas and superstructures that can be located beneath the balcony. Pits could be placed in front of the house underneath public paths. • Locate within the cattle shed. This could involve structural work on the houses, and must not be in the cow compartment. • The use of public land for individual or multi-household latrine blocks. This should be through formal consent of the VDC. • The support and training for saving and credit groups for land acquisition • Establish a committee to act as a pressure group for land owners to set aside/sell land for landless • Advocate sharing latrines between households. If users see benefits of the latrines, and the pans are easy to clean, this may be an acceptable option.

5.3 Promotion of Hygiene and Environmental Sanitation

5.3.1 Prioritising Interventions

In communities with such a wide number of environmental health risk conditions and practices, it unrealistic to expect that an intervention can cover all issues at once. It is necessary therefore to prioritise activities and health promotion on key-high risk issues, ideally those which have knock –on impacts on other issues. However, the key issues highlighted by a WASH professional may not correlate with the risks or issues perceived by the community. For maximum impact and effectiveness, a balance must be made between the environmental health and beneficiary priorities, with the biggest potential for impact and change in focussing on issues that involve a minimal amount of behavioural change or technical input. In this, strategies and approaches to improving environmental health should follow the path of least resistance. This is not to say that certain issues should be avoided, as participatory hygiene sensitisation can help to develop or modify community perceptions of risks. There may be differences between the priorities perceived by different members of the community, or within the family, highlighting the need for the identification and discussion of issues at the community level with representative participation from all ages and genders. In the absence of sufficient epidemiological, health or water quality (particularly at point of consumption) data, the relative prioritisation of the various environmental health issues is unavoidably subjective, as is the assessment between issue (cause) and health problems (effect). More research is clearly required on this topic in the area. Table 5.31 identifies key issues in environmental health in the intervention area, and interventions that could address them.

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Table 5.31. Environmental health priorities and potential physical interventions

Relative EH Priority in the Issue Community Priority Potential Hardware/Physicalventions InterCost*- Area Benefit** Child/sickness excreta disposal Low Latrine construction Low Open defecation in the village High High Potty construction Low Latrine construction Low High Potty construction Low Handwashing facilities Low Lack of handwashing at key times (with oroap) without High s Low Soap distribution or production Low Indescriminate solid waste disposal Low (variable) Remove animals from inside village/houseHigh Presence of livestock excreta in human sh)habitat (fre Moderate/unclear Very low Process manure in fields High Regular collection and containment ofModerate dung Low (only 3 weeks per Process manure in fields High Composting manure outside the houses Very low year) Regular collection and containment ofModerate dung Waste Pits Moderate Low-moderate Compost, potentially with Manure Moderate Poor personal hygiene Moderate-high Moderate-high (variable)Feed to animals Low Soakaways Low Grey/storm/roof water stagnation Moderate Moderate Kitchen Garden Irrigation Low Drainage Trenches High Construct bathing/privacy facilities Low Soap distribution or production Low-moderate Hygiene kit production or distrubition Moderate Improve access/yield of water supply Low-moderate Source water quantity Moderate High Improve environmental sanitation Low-moderate Source water quality Low-high (variable)Low Catchment/system management. Low-moderate Develop multiple/alternative sources. Low-moderate Improve system efficiency Low-moderate Vectors (flies) Moderate Low Improve environmental sanitationLow-moderate Vectors (rodents and pests) Low Lowtal sanitation Improve environmenLow-moderate * Cost in terms of capital economic cost,r andto sustain labou ** These relative cost benefits are the authorsimates only,est and are highly dependent on context

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Hygiene promotion is limited without access to enabling factors. There were various barriers identified during the field research which may limit the beneficiaries’ ability to achieve improved health or hygiene conditions. These are discussed in the following sections.

5.3.2 Enabling Factors

Environmental Sanitation

Hygiene and environmental sanitation are inherently interlinked. With a ‘dirty’ environment, inhabitants are more reluctant to wash themselves, their clothes or their children frequently, as they will rapidly become dirty again. In addition, if all villages or people are of a similar standard of hygiene or sanitation, there is no ‘clean reference point’ upon which to compare one’s own standards. Therefore a more holistic approach to environmental sanitation and hygiene is needed.

Greywater disposal, solid waste management and livestock excreta interventions have a clear potential to be integrated with food security activities. Kitchen-garden irrigation can be promoted and supported for greywater disposal, and as domestic solid waste is dominantly organic, it can be combined with manure in a drive for improved composting. Sweepings from house cleaning can be put in a ‘sweepings pit’ yielding high quantities of potatoes.

Excellent booklets covering basic techniques for composting, livestock excreta management, greywater irrigation, sweepings pits, and improved farming and environmental management have been produced in western Nepal by an INGO called Appropriate Technology Asia. Their contact details are presented in Appendix 1.

The presence of livestock excreta in the villages and around the homes was not generally perceived by interviewees as a major issue, and alternatives to keeping the animals in the ground floor were complex, potentially expensive and overwhelmingly unpopular. However, attempts to manage and contain the excreta could be promoted by providing or locally producing shovels to aid ‘mucking out’ excreta from in front of the house and inner village areas. The heaping and/or containment of the manure could be incorporated with messages of improved composting.

Greywater drainage in inner-village areas where kitchen-garden solutions is not possible could be greatly improved by advising communities on constructing gravel filled soakaways.

Street paving was attempted by the Maoists, bringing significant improvements in street conditions, but were not maintained. Communities agree that path paving would improve the state of the villages but are unwilling to work on such a project without payment. The government has a strategy of ‘one household one employment’, which the community or WSUC could be linked to for financing such a project. Communities could also be linked with local organisations that provide or subsidise improved ventilated stoves.

Personal Hygiene and Handwashing

In addition to the ‘dirtiness of the village’, major barriers interviewees mentioned for improved hygiene were insufficient water supply, issues of privacy for bathing, and access to soap.

Whilst addressing shortfalls in water supply should be standard interventions in WASH projects, privacy for personal bathing is not often addressed. Many interviewees of all ages and genders stated that they were likely to wash themselves more frequently, and, particularly for women, more effectively, if they had privacy whilst washing. As a low cost intervention, semi-public wooden shelters (bathrooms) could be piloted in communities, to be managed at the tapstand-cluster level. Walls could be built near the tapstands to act as basic privacy screens for the same purpose.

The affordability and accessibility of soap is another factor. Soap is sold in the village stores at a 20-25% mark-up price to that which is available in district town stores. A small-scale pilot of cost reducing, or

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subsidising supply chains for soap (at the village shop level) could be worked on, as could workshops to improve the domestic production of soap using local ingredients.

Current ACF strategy includes providing the beneficiary households with 4 bars of soap each. Although this is arguably unsustainable (particularly taking into account the procurement and transportation methods), it could help to ignite demand for soap in the communities. Males generally hold control over the families purchasing habits, and if they can perceive the benefits of soap, they are more likely to prioritise family expenditure on it. The procurement of soap for distribution should, where possible be undertaken through the village shop owners, to strengthen the supply chain of soap and other hygiene consumables to the village level.

Handwashing at key times, particularly after defecating and child/sickness stool disposal, is argued to be the second biggest priority for hygiene promotion after safe excreta disposal. The construction of basic handwashing units such as ‘tippy taps’ for use in the latrine or in the household are low cost, low tech interventions that could prevent individuals washing with the family drinking water jug.

Another major barrier to improved hygiene, particularly that of child hygiene, is the lack of time availability of the mothers. An integrated approach that reduces mother’s daily workload, through interventions such as hydro grain grinding mills may also indirectly benefit hygiene conditions.

5.4 Hygiene Promotion

5.4.1 Current Approach

Hygiene Promotion (HP) in the ACF Bajhang project was criticised as ‘very weak’, with short training sessions covering too many topics, resulting in limited improvements in hygiene behaviour (Ockelford 2007). HP activities were not undertaken in Bajhang or Mugu/Humla until the late stages of the projects, with water supply construction taking precedent over initial WASH activities. The current HP approach currently used by ACF is predominantly health-based lesson sessions, using IEC materials, to community groups (mothers, children and general community) by hygiene promoters of the implementing partner NGO. This is due to be followed by individual household visits by the external hygiene promoters, and the training of community hygiene promoters towards the end of the project.

5.4.2 Future Approach

As mentioned in Section 5.31, with so many issues of hygiene and sanitation to address in the communities, key risk issues and practices should be addressed as a priority. These priorities may vary between communities and groups, and should be tailored accordingly. One or two topics should be addressed per session to avoid saturating the audience.

The IRC (2005) state HP should priorities messages addressing issues of: 1. The highest risk 2. The greatest ease of successful change 3. The greatest possibility of successful change 4. The most interest on the part of the community

As with sanitation promotion, given the commonly held traditional beliefs regarding causes of disease, purely health based messages may not be appropriate. Messages should therefore contain a balance of health messages and education, and highlighting the issues that they currently perceive with their situation, to make beneficiaries perceive the relevance of the HP to their lives and situations. An approach that facilitates the communities to realise the problems of their environment by themselves, and barriers to overcome, rather than being ‘told by an outsider’, may be more effective at driving change. Therefore a participatory approach to HP such as the PHAST technique should be used. It is recognised, however, that as with ignition PRA for sanitation promotion, the effectiveness of PRA tools is determined by the strength of the facilitator.

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Experience of HP during the A1D project has shown that there is a reluctance to attend sessions without incentives, and those who attend sessions, may leave half way through, thought to be because of other commitments, or boredom. HP sessions should be as engaging and participatory as possible to sustain the interest of the audience, and lessons should include practical exercises wherever possible. Incentivising attendance should be well thought through, and coordinated with other development actors in the area. Potential incentives could be providing basic materials for use in practical hygiene promotion sessions, where attendees may be taught to construct enabling facilities such as hand washing facilities (tippy taps), basic child/sickness potties and latrine water containers, and locally produced soap. Attendees would then have to attend the full sessions to gain the materials, and keep the end product, at the end of the session. Other practical exercises could be in the construction of improved soakaways, or enhancement of kitchen garden irrigation. The latter may be taken on through food security interventions.

Experience from locally operating NGOs has shown that running competitions between children, households and even villages for the best hygiene standards has been successful. However, these competitions should be linked to, or run by more permanent structures such as the VDCs, DEOs/schools and health posts, to enhance post-project sustainability.

The skills base within the community and local institutions (FCHVs, health post workers, teachers and community members) to undertake HP should be developed and invested in, as they will be there long after the project finishes. This training should commence at the beginning of HP activities, to maximise the ‘on the job’ training, rather than ‘bolted on’ at the end.

The inclusion and participation of local health posts has proved to be effective in the area, as they can enhance/accredit the authority of external or community hygiene promoters, and provide the community feedback on their improving health status.

Conversely, it is important not to exclude traditional healers and priests from the process. If they feel that their authority is not being acknowledged, or is being undermined, they may try to demobilise HP activities, or discredit the hygiene promoters. The department of health approaches this issue by formally acknowledging the existence and services offered by the healers, and telling them that f they can solve the issue, try, but if they are unsuccessful or unable to cure it, to refer patients to conventional health services immediately.

Whilst many hygiene promotion activities in WASH projects focus on women or mother’s groups, at the relevant demography responsible for household and family hygiene and sanitation, it is important in this context not to exclude males. It is the males who have dominant power over financial resources and decision making in the household and community, and also the males who are likely to build new infrastructure, therefore their participation in the process is essential. Research has shown that domestic violence towards women is widely justified in the implementation area (more so than anywhere else in Nepal) (MoH&P 2006). Although important, and a component of ACF-IN strategy, gender empowerment should be sensitive not to over-empower women to such an extent that may cause domestic violence and subordination.

5.5 Child Hygiene Improvement

The improvement of the children’s hygiene status could be addressed through 3 broad approaches; improvement of environmental sanitation conditions and enabling factors; promoting parent-child care practices; and direct HP to children. Different interventions will benefit different ages of children, where child-care approaches focus more on children less than 5 years, direct HP to children would benefit around 3 years plus, and environmental sanitation improvements would potentially benefit all.

5.5.1 Environmental Sanitation and Enabling Factors

Due to cultural, social and livelihood factors, it is unrealistic to expect that children will be constantly supervised. Children will continue to play in the paths and around the village, and not always wash their

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hands. It is therefore pertinent to improve the general hygiene status (excreta disposal, greywater drainage, and domestic waste and manure practices) of the villages. Cleaning up the environment should de-facto improve children’s hygiene and health.

Interviewees mentioned a number of barriers to attaining improved child hygiene status. These included; the lack of soap; lack of mother’s time to supervise/wash or teach children; shortfalls in water supplies; and the ‘dirtiness’ of the village. Therefore, any intervention that helps to overcome these barriers, such as cost reducing, distributing or locally producing soap; reducing the daily workload of women; and improving water supply and environmental sanitation would potentially improve child hygiene.

5.5.2 Parent to Child Care Practices

The extent of parent to child teaching, supervision and upkeep regarding hygiene and sanitation is limited in the area, due to a number of social, cultural and economic constraints. Whilst parents interviewed perceive that it is their responsibility to teach the children about washing and defecating, children stated they learn more on these topics at school or simply from observation of others.

Interventions should build on parental ability and sense of responsibility, to improve and maintain the hygiene of their children. This concept of responsibility is especially pertinent for males (fathers and grandfathers) who generally have more time available than mothers.

Infant mortality rates are high in the area, and parents should be made to feel empowered about the fact that they can improve the potential for survival of their children; and that it is not simply ‘up to chance’.

Key opportunities exist with the presence of mothers groups and Female Community Health Volunteers (FCHVs) in many of the communities. Group activities could be held to develop and promote basic care practices, whilst building on the parent-child relationship through ‘quality’ or ‘play’ time. These sessions should include practical exercises where possible. An example of such an exercise is baby bath sessions, which could turn bathing from an unpleasant chore to an enjoyable experience for both child and parent (ACF 2006b).

These sessions should be open and accessible to all who partake in childcare in the communities, and could be an ideal opportunity to involve the males in the hygiene upkeep of their children.

FCHVs could be trained to undertake such sessions in the communities, and follow-up household visits. The involvement and training of FCHVs in HP programmes is coherent with national RWSS policy (GoN 2004), although their potential limitations in terms of capacity to educate, credibility, and actual amount of activity in the communities should be taken into account.

There is a clear potential to integrate activities in child care practices for hygiene promotion with future preventative malnutrition programmes. Current ACF strategies involve the training of FCHVs in malnutrition detection, but do not yet include preventative care for malnutrition. A potentially effective mode of future malnutrition preventative care in the communities would be education through mothers groups.

If FCHVs are to be trained, and nutrition messages communicated through mothers groups, it should be fully coordinated by both WASH and Nutrition programmes. A potential issue of this is that there are so many messages to be communicated on both child hygiene and malnutrition prevention; there is a true danger of trying to cram too much in.

Given constraints on parental time, the relatively low priority that some households place on child care and teaching, and poor hygiene practices of the parents themselves, parent to child approaches should not be relied upon as the sole method to communicate hygiene and sanitation messages to children.

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5.5.3 Hygiene Promotion Directly to Children

Children are potential agents of change in the communities, and are often charged with the supervision of younger siblings whilst the mother is working. Once educated, children may actively teach other children (child-child approach), or passively teach, by becoming ‘models’ for other children to watch and learn improved practices through observation. Two opportunities for direct hygiene promotion to children are; in schools; and through child groups.

School Hygiene Promotion

Hygiene education through the schools should be undertaken through coordination with the DEO and other NGOs, particularly UNICEF, who are active in schools in the area. The broad experience of UNICEF in school HP should be capitalised on, and they could also be approached for training and IEC materials. The DEO should be involved to aid sustainability, and to facilitate the scaling up of successes to other schools outside the area of intervention. As with community HP, for messages to be implemented, users must be able to access enabling factors. Therefore all schools within the catchment of project intervention should be provided with water supply and sanitation facilities. Many latrines constructed for schools in the area rapidly became disused in the absence of a water supply for cleaning and flushing. A water supply to the institution would also facilitate hand and personal washing. Soap could be made accessible throughout the project duration, financed either by the NGO, or more sustainably, the school management committee (SMC). Mirrors could be built into tapstands to aid washing, and potentially develop student’s sense of self respect.

The active participation of teachers is essential. Teachers and the SMC should be sensitised to perceive the importance and benefits of the project, and feel a sense of control, ownership, and pride over it. The school could be promoted as a ‘model of best practice’ within the community, and the programme could reaffirm the teachers sense of job satisfaction by feeling they are driving change in the area. A sustainable approach would be to train the teachers in HP for students, rather than NGO staff undertaking HP sessions in the schools. Teachers and caretakers should be encouraged to have patience with students using and dirtying the latrines, recognising the fact that they may be using them for the first time. HP activities should be made practical wherever possible, with teachers taking charge of activities such as showing how to wash the body and hands effectively, as students may not learn this at home. Students should play an active role in managing the environmental sanitation of the school, and competitions could be undertaken for ‘the cleanest’ schools in the area. Teachers could be encouraged to take an active role in monitoring the hygiene status of the children, acknowledging good practices, and condemn bad ones, such as open defecation whilst at schools. Some schools in the area hold annual award ceremonies for students, with a prize for the cleanest child, which they found to be successful, as it can install healthy competition and peer pressure for cleanliness amongst students.

Students should be encouraged to teach other children not present in the school about their improved practices, particularly younger siblings and friends/family that do not attend school.

Out-of-School Child Education

An approach working in schools may not address all children, particularly lower caste (Dalit) children and females over around 10 years, for whom school attendance is limited. Whilst child-child education can be encouraged to the students, out of school hygiene promotion sessions through children’s groups could also be useful. This would be particularly relevant where the local school is experiencing regular closures and staffing issues. These could include sessions with girls who supervise younger siblings on care practices and child washing, and ‘action groups’ could be promoted to undertake household visits, village clean-ups, and monitor against open defecation. Experience of other NGOs in the country has found that children can become highly active in HP and environmental sanitation improvement within the communities (UNICEF 2006, Plan 2007 pers comms ), proud to be involved in driving forward development. Whether in or out of school, child HP should be made as practical, participatory, and fun as possible, incorporating mediums such as song, drama, puppetry and competitions.

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6 Conclusions & Recommendations

The Importance of Hygiene and Sanitation in the Area

Mugu and Humla are among the least developed of the 75 districts of Nepal; which itself is one of the poorest countries in the world (Ockelford 2007). The districts are remote and drought prone, and the prolonged conflict in the area has impaired local governance, social organisation and cohesion, and community based services.

Sanitation coverage in the area is among the lowest in Nepal (CBS & ICIMOD 2003), and was calculated at less than 10% in the area of this study (ACF 2007). Hygiene practices are poor, with key risks identified as; open defecation, indiscriminate stool disposal, and low incidence of handwashing, particularly with soap. Solid waste, greywater and livestock excreta management practices create poor environmental sanitation conditions, particularly in the dense, nucleated communities. Personal and clothes washing is infrequent, and child hygiene is an area of particular concern.

Diarrhoea is the biggest cause of mortality in the area, and there is a widespread prevalence of intestinal worms and skin infections (DHO Mugu & Humla 2007 pers comms ), in addition to a high incidence of child malnutrition (ACF 2007e). Whilst this research cannot quantify the impacts of the hygiene and environmental sanitation conditions on disease and malnutrition incidence, it seems clear that they bear a strong influence.

Although hygiene and sanitation may be the priority in the eyes of the outsider, they are lower priorities to the communities, particularly in light of uncertainties of food and water supplies.

Whilst progress has been made in the area, opportunities certainly exist to develop approaches to hygiene and sanitation, particularly relating to relevance, effectiveness, impact, replicability and sustainability.

Overall community approach

Given the improving security and field access in the area, approaches could shift towards a more community orientated ‘software’ approach, focussing on sensitisation, mobilisation and demand building for the WASH services and infrastructure that will follow. Pro-active project selection and planning, limited community participation, high levels of subsidy, and a focus on hardware activities may limit the sustainability and impact of projects, and reinforce the community’s feelings of dependency on external assistance.

Many of the post-conflict communities visited were experiencing weaknesses in social cohesion, leadership and initiative. Interventions could take the opportunity to build up ‘social capital’, and empower the communities, particularly the CBOs to be able to manage and drive change. Any attempts at mobilisation should be complemented with frequent, and sustained follow-up support, as a community trying to mobilise and failing, may install a sense of fatalism, inhibiting future self-help initiatives. Beliefs and practices are deep rooted, and change needs time, support and encouragement.

For ongoing sustainability, projects should be linked wherever possible with more permanent structures, such as local schools, health posts, VDCs and district authorities, and procurement of materials should endeavour to reinforce local supply chains.

The local skills base should be developed, and left within the area after the project finishes. These skills include community based masons and hygiene promoters, and district level social mobilisers and facilitators.

Sanitation Approaches

Although much research and piloting of sanitation approaches has been undertaken in other areas of Nepal, little research has been done in the Karnali zone. Previous sanitation initiatives, such as the Maoist latrine

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construction programme and other NGO projects in the area show that whilst latrines may be constructed, usage may not be sustained. These past experiences should be capitalised on when developing future approaches in the area.

The approach suggested should have a strong ‘software’ focus, where the community is mobilised with participatory techniques such as iPRA tools, and demand is built for sanitation at the community level. Sanitation should be promoted with messages in line with user’s perceptions of issues, in combination with health based messages.

A total sanitation approach is suggested to maximise public health benefits. Also, by making sanitation a community initiative, barriers faced by individual households such as land access may be worked through, and CBOs could be encouraged to act as community pressure groups to strive for 100% coverage and usage .

Due to the remoteness of the area, and material costs, ‘conventional’ designs for latrines incur high per- capita costs, and pose challenges for replicability, and the user’s ability to sustain them. Given the low presence of other sanitation ‘actors’ in the districts, particularly in the remote VDCs, national financing resource gaps for sanitation, and optimistic national coverage targets; there is a clear need for more low-cost, replicable approaches.

Past experiences of ‘temporary’ latrines, previous promises, high community expectations, limited household resources and ulterior household priorities are all local factors that make purely ‘software’ approaches such as CLTS or revolving funds potentially limited in terms of effectiveness or impact in the area.

It is argued that, in the case of the study area, communities need to be provided with some form of material subsidy, if the majority of the households are to build latrines.

A minimal ‘basic’ subsidy is suggested, to provide households with sufficient materials to build ‘permanent’ latrines and satisfy them that they are receiving material support from the intervention, however minimising per capita material procurement and transport costs, and encouraging innovative design.

The basic subsidy suggested provides flexibility in design, to accommodate user’s preferences and constraints, and could be augmented with a Sanimart system for those aspiring for higher standards of latrines.

To maximise impact and local replicability outside the NGO’s intervention communities, and to harness local demand ignited for sanitation, communities should be able to access support from their VDCs or DDC in the form of community mobilisers, training and financing for basic subsidies. VDCs and DDCs could also provide rewards and incentives for achievements in sanitation at the community, and VDC level.

Poor coordination and overlapping projects, with varying policies of community incentives and subsidies in the area is leading to high community expectations for assistance, and bargaining for ‘the best deal’. This inhibits self help initiatives and the community acceptance of projects offering limited or no subsidies for latrines.

District level coordination of activities is essential to mitigate conflicting approaches, and a standardised approach at the VDC (or multi-VDC) would also build on economies of scale, making decentralised Sanimart outlets more viable. Standardised material procurement practices would strengthen the district level supply chains and reduce costs through bulk purchase.

A tight partnership is necessary between the implementing NGO and local government, to coordinate activities, build up the local skills base, and to advocate for their active involvement in supporting community- driven sanitation projects.

Central government could facilitate the process by channelling funds mandated for sanitation, providing training, and advocating the importance of sanitation to the DDCs, and incentivising and rewarding district- level achievements.

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Hygiene and Environmental Sanitation

This research identified that community priorities or perceptions of issues do not necessarily correspond to that of the environmental health issues. With such a range of environmental health issues, there is a danger of trying to address too many problems, potentially cramming HP sessions, to an audience with strong constraints on time availability. Interventions and messages should be prioritised to; address the key high-risk practices; practices with the most community interest; and those with potential for knock-on effects on other issues.

As with sanitation, HP should be initially undertaken through community-level participatory mobilisation, providing a platform for issues to be highlighted by all castes, ages and genders, and addressed by the community. The ‘total sanitation’ concept could be further extended to ‘community clean-up’ initiatives, coordinated by supported CBOs such as mother’s groups or the WSUCs, and VDCs/DDCs could reward achievements. Initial community mobilisation should be followed by more targeted HP sessions.

HP sessions should be as participatory, relevant, and enjoyable as possible, and incentives for attendance could be through attendees keeping the end product of practical sessions. The local skills base should be developed for HP capacity, including those of FCHVs, health post staff and teachers, for post project sustainability.

Low-cost technical solutions exist for environmental sanitation issues in the communities, and some have a strong potential for integration with food security activities. CBOs could be linked with other organisations potentially supporting improved stoves or village path paving, to facilitate holistic improvements in community and household cleanliness. Other barriers identified by interviewees to improved hygiene practices, such as privacy whilst washing, soap access should be addressed.

Child hygiene is a serious and complex issue in the area. Children are often left autonomous for their hygiene at an early age, and parental teaching on hygiene and sanitation issues appears to be limited in many households.

A multiple approach is suggested to address the issue; including improving the environmental sanitation conditions of the communities, addressing barriers mentioned, such as water and soap access, and the time availability of mothers, along with targeted hygiene promotion.

Child-care practices could be developed in group sessions; an activity that potentially overlaps with preventative malnutrition activities. However, given that not all households would be interested, or able to significantly improve practices, direct child hygiene promotion is recommended. The local schools could be equipped with facilities, and developed as centres of best practices, where students learn defecation, washing and environmental sanitation practices, and encouraged to teach others. The active involvement of teachers is critical in this approach, and the DEO could support inter-school competitions and reward achievements.

However, given the issues of functionality faced by local schools, and trends of attendance, out-of school child clubs would also be useful to communicate the messages to all.

Operational Recommendations

Regarding the NGOs current and future operations in the area, the following points are highlighted:

• Working in a limited number of VDCs across two district’s boundaries does not seem to be efficient. • From the author’s perspective, from the villages visited in this research, Mugu has higher needs in terms of WASH interventions. • If child hygiene is to be taken on as a key component for future activities, a multiple approach is needed, to include direct child hygiene education, improving the environmental sanitation conditions,

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addressing enabling factors, and developing child-care practices. This latter intervention has clear overlap with preventative malnutrition initiatives. • An integrated approach between nutrition, food security and WASH programmes would maximise the impact of the interventions, and the interest from the side of the community. • The NGO should develop a win-win partnership with local partnership, moving away from somewhat contractual relationships. Local (district-regional-level) NGOs could be used for partners, and reputable NGOs such as NEWAH could be contracted to provide their training. • The NGO should move towards a longer-term (multi-year) developmental approach, with corresponding donor support.

Regarding the conclusions from the KAP Survey (ACF June 2007); in light of this research, the following points are highlighted:

• The topics to be covered in HP are important, but there is a danger of trying to cram too many messages. Key risks, such as safe excreta disposal (including child hygiene) and handwashing should be prioritised, as should treatment of diarrhoea. This prioritising should be based, to a maximum extent, on objective, scientific datasets. • HP messages should be in line with the users perceptions of their realities, not solely health based. • ‘Advocating’ for changes in community practices through HP need to be achievable for the audience, therefore enabling factors should be addressed.

Summary

Implementing sanitation and hygiene projects in the area is likely to remain challenging, particularly as individuals and households give relatively low priority to change, incomes are low, local government and community leadership remains weak, and supply chains are long and costly. However, change can occur, albeit with time, and should be driven by the communities themselves. In light of national targets and financial constraints, approaches to hygiene and sanitation in the area need to be coordinated, low-cost, replicable, and sustainable.

A holistic and integrated approach should be taken to work towards the common goal of reducing mortality and morbidity through malnutrition and sanitary related diseases.

Recommendations for Further Research

The following areas of further research are suggested in the area; • The appropriateness and modality of implementing graduated subsidies in the context of post- conflict, potentially egalitarian communities. • The potential application of CLTS iPRA tools in communities where social cohesion and leadership structures are weak, and expectations on external assistance are high. • The potential, viability and needs of Sanitation Marketing at the VDC level in remote mountainous areas. • Objective methodologies and criteria for identifying key environmental health risks, and prioritising interventions in communities.

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7 References

ACF (2006a) A food security diagnostic in conflict-affected communities of Mugu and Humla, Karnali, Mid-Western Region. ACF Nepal, Kathmandu ACF (2006b) Manual for the integration of child care practices and mental health within nutrition programmes. ACF Paris. ACF (2007a) Water, Sanitation and Hygiene Policy ACF-IN. Action Contre La Faim, Paris. ACF (2007b) Knowledge, attitudes and Practices (KAP) Survey on WASH. July 2007. ACF Nepal. Kathmandu ACF (2007c) Field Visit Nepal. Jean Lapegue (WASH) ACF. Prepaired May 2007. ACF Paris. ACF (2007d) ECHO/NPL/BUD/2007/01005 Interim narrative report. Reporting period: 1 st April 2007 to 30 th September 2007. ACF Nepal, Kathmandu. ACF (2007e). Anthropogenic Nutritional and Retrospective Mortality Surveys: General population and Dalit population, Mugu and Humla Districts, Karnali Zone, Nepal. Final report March-April 2007. ACF Nepal, Kathmandu. ACF (2007f) Post CFW-FFW Distribution Monitoring: Irrigation canal rehabilitation Mugu Humla Preliminary Results: June 2007(Food Security Nepal Team), ACF Nepal, Kathmandu. ADB (2007) Water and the Millennium Development Goals. Accessed at ADB http://www.adb.org/Water/Topics/MDGs/target-ten-south-southwest.asp#6 on 21/12/2007. Cairncross, S. Handwashing with soap- a new way to prevent ARIs? Tropical Medicine and International Health. Volume 8, No.8. PP 677-679 Central Bureau of Statistics & ICIMOD (2003) Districts of Nepal: Indicators of Development. Hillside Press, Kathmandu. CETS (2007) An Assessment of CLTS Projects and Formulation of the Strategy on Sanitation Promotion Final Report for NEWAH. CETS, Kathmandu. Clasen, T. & Cairncross, S. (2004) Editorial: Household water management: refining the dominant Paradigm Tropical Medicine and International Health. volume 9 no 2 pp 187–191

Curtis, V. et al (2000) Domestic Hygiene and Diarrhoea-Pinpointing the Problem. Tropical Medicine and International Health. Volume 5, 1. pp22-32.

Curtis, V. (2003a) Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Infectious Diseases, Vol 3, Issue 5. Pages 275-281. Curtis, V. (2003b) Water, Sanitation and Hygiene at Kyoto: Handwashing and sanitation need to be marketed as if they were consumer products. British Medical Journal 232-4-5. DWSS (2007) Environmental Sanitation Section. Accessed at: www.dwss.gov.np/sanitation/default.php on 20/12/2007. DWSS & UNICEF (2006a) Participatory Assessment of the School Sanitation and Hygiene Education Programme in Nepal. Ministry of Planning & Physical Works, GoN. Kathmandu. DWSS & UNICEF (2006b) Guidelines on School Led Total Sanitation. Document Produced for the Steering Committee for National Sanitation Action. Ministry of Planning & Physical Works. GoN, Kathmandu. Esrey, S.A. (1996). ‘No half measures - sustaining health from water and sanitation systems’, Waterlines, Vol.14 No.3, 24-27,

Will Tillett, 01-2008 86

Franceys, R. et al (1992) A Guide to the Development of on-site sanitation. World Health organisation, Geneva. Government of Nepal (GoN) (2004) Rural Water Supply and Sanitation National Policy & Strategy 2004 (Unofficial Translation). GoN, Kathmandu. GoN & Helvetas (2000). Transport Infrastructure Map: Humla, Jumla, Mugu, Bajura and Kalikot. 1:250 000 base map. Mapple, Kathmandu.

Harvey, P. Eds (2004) Excreta Disposal in Emergencies: A Field Manual. An inter-agency initiative by IFRC, Oxfam GB, UNHCR and UNICEF. IRC (2005) Low-Cost Handwashing Technology. Accessed at www.irc.nl/page/1315 on 22/12/2007. International Rescue Committee (IRC) (2005). Environmental Health Field Guide. Price & Sons. New York. Joint Monitoring Programme (JMP) (2006) Homepage for Water Supply and Sanitation. Accessed at www.wssinfo.org/en/welcome.html on 19/12/2007 Kosek, M., Bern, C., Guerrant, R.L. (2003). The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Bull. WHO 81(3): 197-204.

Kar, K. & Pasteur, K. (2005) Subsidy or self-respect? Community led total sanitation. An update on recent developments. IDS Working Paper 257 Institute of Development Studies, Brighton. Ministry of Health & Population (MoH&P) (2006) Nepal: Demographic & Health Survey 2006. Kathmandu. Nepal Development Information Institute (NIDI) (2006) Nepal District Profile 2006.Upahar Press, Kathmandu. NEWAH (2007) Policy and Working Guideline of Community Led Basic Sanitation for All (CLBSA). Kathmandu. Ocklefold, J. (2007). Food Security and Water and Sanitation Programme- Bajhang. End of Project Evaluation. Jeremy Ockelford & Associates Limited, London. Ockelford, J.& Shrestha, V. (2003) Institutional Assessment of the Rural Water Supply and Sanitation Sector in Nepal. ITAD. London.

Plan (2006) (Unpublished) Community Led Total Sanitation (CLTS): An Approach; Empowering Healthy Living Habits: Documentation of CLTS Program in Rautahat/Bara. Rautahat/Bara Program Unit, Plan Nepal, Kathmandu

RVWRMP (2006) Rural Village Water Resources Management Plan, Homepage. Accessed at: www.rvwrmp.org.np on 12/12/07.

RWSSFB (2006) Rural Water Supply and Sanitation Fund Board: Annual Report 2006. Kathmandu Sakthivel, R. (Undated). Inventive Villagers: Innovative Approaches to Total Sanitation in Maharashtra (from, WES-Net India, c/o Plan International, New Delhi) Accessed at: http://www.solutionexchange-un.net.in/environment/cr/res05070601.pdf on 21/12/07

Shrestha, G, R. et al . (2005) Assessing Nepal’s national sanitation policy 31st WEDC International Conference, Kampala, Uganda, 2005 Sphere Project (2004) Humanitarian Charter and Minimum Standards in Emergency Rsponse. 2004 (Revised) Edition. Oxfam Publishing, Oxford. Tabiri, J. (2005) The Impact of Action Against Hunger’s Flood Disaster Risk Reduction Interventions in Kampong Cham province, Cambodia. Unprinted MSc Thesis, University of Southampton, UK

Will Tillett, 01-2008 87

UN (2005) The Millennium Development Goals Report. Accessed at www.undp.org on 20/12/07 UNDP (2006) Millennium Development Goals: Needs Assessment for Nepal. Government of Nepal, Kathmandu. UNDP (2007) Human Development Reports: Reports 2007/08: Nepal. Accessed at http://hdrstats.undp.org/countries/data_sheets/cty_ds_NPL.html on 12/01/2008 WaterAid (2006a) WaterAid Nepal: Position Paper on Sanitation (2005-2010). Position Paper. WaterAid Nepal, Kathmandu. WaterAid (2006b) Community led total sanitation in Nepal getting us back on track. WaterAid Nepal, Kathmandu WaterAid (2007b) Community level models for financing sanitation in rural Nepal. A sector review. (Draft version, December 2007). WaterAid Nepal, Kathmandu.

WEDC (2005) WELL FACTSHEET: Some global statistics for water and sanitation related disease. Accessed at http://www.lboro.ac.uk/well/resources/fact-sheets/fact-sheets-htm/sgswsrd.htm on 19/12/2007

WEDC (2005) Implementing National Sanitation Policy in Nepal: Challenges and Opportunities. Accessed at http://www.lboro.ac.uk/well/resources on 21/12/07

WHO (2004). World Health Report 2004 – Changing History. WHO, Geneva.

WHO & UNICEF (2004) Meeting the MDG Drinking Water and Sanitation Target: The Urban and Rural Challenge of the Decade. WHO Geneva. WHO (2005) Sanitation and Hygiene Promotion: Programming Guidance. WHO Geneva.

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8 Appendix

1. Interviewee and Contacts List 2. Questions for Communities (Field Research Question List) 3. Sphere Standards for Excreta Disposal 4. Map Showing Geographical Distribution of Sanitation ‘Actors’ in Nepal 5. Comparison of RWSS Policy and Strategy and ACF-IN WASH Policy (from ACF 2007) 6. Annual Cropping and Social Calendar for Communities in the Study Area 7. List of Schools and Health posts Visited During Field research

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Appendix 1. Interviewee and Contacts List Organisation Type

Organisation Name Location Phone Email NGO INGO Nat. Govt Nat. Local Govt. Local Donor/Fund Donor/Fund organisation Local/National Local/National Agricultural Development Office (Humla) 1 ? SMK 680011 Agricultural Development Office (Mugu) 1 Durga Rajal G GD 87460086 Appropriate Technology Asia 1 KTM 15549774 [email protected] ATA 1 Chris Evans KTM 15549774 [email protected] Care Nepal 1 Nirmala Sharma KTM 15522800 [email protected] CBWSSP 1 Kishora Sskya KTM 14430948 [email protected] CCDC 1 ? GGD CESI 1 Hari Har Sapkota Surkhet 4414430/4419412 [email protected] Concern 1 Pradeep Shrestra NPG 81520704 [email protected] DDC (Humla) 1 Tilak Paudel SMK 680016 DDC (Humla) DACAW Project 1 ? SMK Deepros 1 ? SMK District Education Office (Humla) 1 Namsum Bhistra SMK District Education Office (Mugu) 1 Kul Bhadur Pardera GGD District Health Office (Humla) 1 Dr. Sarbesh Sharma SM K District Health Office (Mugu) 1 Chakra Bar Mulla GGD 87 460161 District Land Office 1 Topbhadur Rawl GGD 87460083 District Livestock Office 1 Binde Shaaray SMK 680010 District Technical Office (Humla) 1 Rajesh Kumar Yada b SMK District Technical Office (Mugu) 1 Shoviyat Khadka GGD 87460137 District WatSan Sub Office 1 Shiva Kumar Shrestra GGD 8 7460130 District WatSan Sub Office 1 Dhurba Deb Khumar SMK 8768 0057 DOLIDAR 1 J. Sherma KTM 15521021 [email protected] DomesticDOLIDAR & Small Industries Department 1 Hirlal Shres 1 Kamal Jaishitra KTM SMK 15546355 DWSS 1 Kamal Ashikari KTM 9841435467 DWSS 1 Mr. Nawal Mishtra KTM 9841628139 DWSS 1 Khum Subdedi KTM 14413670/[email protected] DWSS 1 Khamal Adigari KTM 9841435467 Helvetas 1 Adhir Sharma KTM 15524925 po.helvetasnepal.org.np INF 1 ? GGD (Jamaldara) Jay Nepal Youth Club 1 ? GGD KIRDAC 1 Madoc Neoparney NPG 81524013 Malica 1 ? GGD NEWAH 1 Umesh Pandey KTM 14377107 NEWAH 1 Laxmi Paudel KTM 14377107 [email protected] OXFAM 1 Narbikram Thapa KTM 1536075 [email protected] Plan Nepal 1 Nabin Pradhan KTM 15535580 [email protected] RRN 1 Mr. Ratna KTM 14422153 RVWRMP (FINIDA) 1 1 Ram Bahadur Thapa SMK 87680144 [email protected] RWSS FB 1 Chandra Bista KTM 14410761 [email protected] Saapros 1 ? GGD SNV 1 Hendrik Visser KTM [email protected] UMN 1 Kari Mitchell GGD 460043 UNICEF 1 Larry Robertson KTM 15524991 UNICEF 1 Radhika Thumbahangphey NPG 81550008 UNICEF 1 Pursotum Achari KTM 15523000 UNICEF 1 Surindra Rana/ Mr Amir NPG 81550008 WaterAid 1 Oliver Jones KTM 15552765 [email protected]

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Appendix 2 Questions for Communities (Field Research Question List)

Village ………………………..… VDC ….………………….. District …………… Date …….……...

Stats: Age………. Sex……………. Caste………………….. Vulnerable Group? ……….… Location of house …………………………… Size/Structure of Family: Total..… , <5… , 5- teen…… , Teen….., Adult…….

Environmental Hygiene/Sanitation Situation (Open ended/broad to gauge perceptions and priorities) • Major perceived issues in the village relating to hygiene and sanitation? Order of importance/priority? • What can be done about them? Defecation Practices • Where do you/your child defecate (variability seasonally/time availability/sickness/night) • What do you use for anal cleansing? If water – where collect, where are water sources in village? How transport etc. • What are the problems with your/child defecation practices/locations? • What do they do with child faeces? Where/do children learn where to defecate, anal cleansing -0- 18,18-24, >24months Latrines Have you ever built a latrine? If yes; • Did they use it? Design? How long? Why? Why stop (if applicable)? • Any problems with it? • Where was it located? Why? Issues with location? Shared? Plan to build another latrine (replacement of temporary, one of ACF planned intervention areas)

• Plan/aspire to (demand)? Barriers? • Where locate it? How acquire land? Financial methods/practicalities/timescales/barriers? Perceptions of location within the house/balcony/cowshed- women/animals space? Realistically enough space – for 1/2 pits? Put pits under paths? • How close need to be to be used at night and by the children/elderly/dispose child/sickness faeces? Achievable? • Perceptions of sharing latrine/latrine block for cost reductions? Who possible to share with? • What to do when it is full? Nightsoil collection/disposal methods/realities-whose responsibility? Space available to switch pits? Perceptions of Ecosan? – Demand for high grade/additional compost, willingness for upkeep/bulking agents available through year/moisture control? • Cultural/spiritual beliefs about faeces? • What kind of design? External materials – how feel they could sustain ? Where can they access them – logistics/costs.. • How can they finance all this? – Land acquisition and materials/labour/construction/porterage? • Contributions and subsidies – realities of graduated subsidy? • When would they construct it? Barriers to construction? • Are there the skills within the community to construct it? • Who would be responsible for cleaning it? How ensure it remains clean? What use to clean it? • What do for anal cleansing in the latrine? What if water not available/bucket lost/broken – use of solid wiping material? • How ensure latrines were being used ? Usage by the adults instead of going to the jungle? Individual or community? • What would they do when away from latrines/seasonal migration – replicability? • What can be done about child/sick/elderly/night defecation? Potties?

Village Cleanliness • What do/could they do with their domestic/ food processing refuse? What type of refuse/volume variability /year?

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• What is done with rooftop drainage/greywater? – Issues? Roof – space to drain away from street? Space for soakaways? • Where are the animals kept through the year? Why? Length of time in village – length of time shit in street? • What is done with their faeces? Clean up or left there? Composting? • Any issues regarding animal waste/composting practices (erosion/health/cleanliness)? • What could be done about this? How could the village be cleaner? • Perceptions of keeping animals/processing compost outside village/communal area? • Perceptions of bunding/isolating compost – design ideas to address issues mentioned? – space/resources available?

Personal Hygiene Personal washing • Are there any issues with your/family personal hygiene in the village? Health problems associated to these? Causes? • How frequently do they/family wash themselves? Seasonal variation? Why? • Issues of washing where/the way they do? Are they/family as clean as they want to be? • What use? Use/see benefits of soap? Access/costs? Handwashing • (When) do they/family wash their hands? Restrictions? Why do they wash them? – Perceived benefits? • What do they use to wash them – Different materials at key times? – Perceptions of using ash? • Where do they wash them (facilities) – using what? Clothes washing • How often do they wash their/families clothes? – Why? Annual variability? Who is responsible for clothes washing? • What do they use for washing?

Schools/Child Hygiene • How do they/their children learn about hygiene/sanitation practices? Gender? How to wash themselves/clothes? • How/do they teach the child to use the latrine? • Rites/coming of age and significance of stopping looking after child? Different for boys/girls? • Who washes the children’s hands/teaches? When do they wash/with what? Where? • Who is responsible for the children’s hygiene/sanitation/bathing upkeep/supervision – seasonal variation? • Who looks after the kids when the parents are absent? • Do they/their children go to school? – What prevents them? • What facilities exist at school for hygiene/sanitation? – Do they use them? • Do they learn about hygiene/sanitation in lessons? Interested? Fun? Memorable? Recommendations?

Village or community approach/CBOs • What do they think would be/is the most powerful medium of change in the village? Who respected? • Any CBOs/ever created in village? • Would people listen more to an NGO/external (e.g. KIRDAC) representative or member of own community? • Would an approach based on community monitoring, vigilance and shame be effective? • What do people learn best/enjoy most/participate most in; visual aids, community exercises, lessons, drama, songs?

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Appendix 3. Sphere Standards for Excreta Disposal. Source: Sphere (2004, Revised Ed.)

Excreta disposal standard 1: access to, and numbers of, toilets People have adequate numbers of toilets, sufficiently close to their dwellings, to allow them rapid, safe and acceptable access at all times of the day and night. Key Indicators: •A maximum of 20 people use each toilet •Use of toilets is arranged by household(s) and/or segregated by sex. •Separate toilets for women and men are available in public places (markets, distribution centres, health centres, etc.). •Toilets are no more than 50 metres from dwellings. •Toilets are used in the most hygienic way and children's faeces are disposed of immediately and hygienically.

Excreta disposal standard 2: design, construction and use of toilets Toilets are sited, designed, constructed and maintained in such a way as to be comfortable, hygienic and safe to use. Key Indicators relevant to the research situation include; •Users (especially women) have been consulted and approve of the siting and design of the toilet. •Toilets are designed, built and located to have the following features: - they can be used by all sections of the population, including children, older people, pregnant women and physically and mentally disabled people; - they are sited to minimise threats to users, especially women and girls, throughout the day and night; - they are sufficiently easy to keep clean to invite use and do not present a health hazard; - they provide a degree of privacy in line with the norms of the users; - they minimise fly and mosquito breeding. •All toilets constructed that use water for flushing and/or a hygienic seal have an adequate and regular supply of water. •Pit latrines and soakaways (for most soils) are at least 30 metres from any groundwater source and the bottom of any latrine is at least 1.5 metres above the water table. Drainage or spillage from defecation systems must not run towards any surface water source or shallow groundwater source. •People are provided with tools and materials for constructing, maintaining and cleaning their own toilets if appropriate.

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Appendix 4.

Source: WaterAid 2007

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Appendix 5 . Adequacy between the RWSS Policy (2004) and the ACF-IN policy. Source: ACF (2007c)

Criteria ACF-IN policy Nepal policy Bajhang Evaluation Principles of intervention MDGs MDG 1, 3, 4, 5, 6, 7, 8 MDG 1, 3, 7 X Integrated management of Compromise between environment, Measures will be taken to reduce X the resource resource & social environmental impacts & water resource development Criteria of intervention General criteria Survival threatened, deficiency local 100% population will get water supply Conflict-affected population, IDPs, stress structures, recurrent crises, general state of facility & sanitation services by 2017 on coping mechanisms, increased under-development vulnerability of the poorest parts of the population (Dalits) Specific criteria (WS) Sanitation = health hazard, insufficient Reduce water borne diseases & its Not really defined either in the first quantities of water, distance from WP is a victims in the nation. assessment and concept paper in 01/05 socio-economic limiting factor Utilise in productive works the time & labour of women, men & children saved from carrying water Target beneficiaries IDPs or refugees, lost of livelihoods due to On priority basis, backward people and conflict-affected population, ethnic crisis, ethnic minorities victims of ethnic groups minorities victims of discriminatory discriminatory behaviour, remote behaviour, remote communities, pop at communities, communities unable to risk of acute malnutrition maintain min. standards, risk of acute malnutrition Definition of intervention Vulnerable people, better to cover the entire Long list of activities with target indicators, priorities (WS) targeted pop., average quantity of average assumption that short assessment (2 quality, breaking faecal-contamination, key weeks) found all the problems and places (health centres, schools) solutions, partner’s knowledge & experience of working was not used

Intervention modalities ACF-IN policy Nepal policy Impact KAP surveys 1 & 2 Public awareness & health education = integral part. Basic - Greatest measurable Nut, FS, WS, health, advocacy sanitation package of UNICEF/DWSS through the Hygiene impact Monitoring & evaluation tools Improvement Framework - Integrated approaches Maximum impact of project if the needs of the pop are - HH focused approach covered in priority at the HH level Appropriateness & relevance Context, population, environment Participatory approach (leadership of the local community) Multidisciplinary team

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- Needs analysis driven Optimum utilisation of locally available know-how, skill & response Good targeting (participation of the pop., fit prog. with resources. The type and level of service will be according to - Multidisciplinary analysis existing social dynamics, monitor prog. impact, handling the capacity as well as the willingness to pay by the - Direct approach to over activities, work with local institutional capacity) consumers, for which they will have to contribute to capital populations Beliefs, knowledge & management = respect investment for such facility - Understanding, respecting & integrating Technical decisions with social & cultural aspects Human resource development programme will be developed & local factors (willingness, management capacity, respect beliefs & taboos extended from central level to the community level. VDCs will - Response adapted to the & hierarchy, resources available) play the lead role in involving WUCs in the construction and to capacities & willingness mobilise their contributions in cash and kind. of the communities Participatory approach, community involvement, grass-roots - Involvement & approach, local staff promotion Given their stability and infrequent mobility in community life, participation of affected preference will be given to married women while selecting communities & local Hydrological validation & hydro-chemical suitability Village Maintenance Workers for each schemes actors Low cost technologies, maintenance mechanisms, - Feasibility study replicability Appropriate technology that is affordable to and manageable - Appropriate, tested, by the user’s committees. A consumer-oriented catalogue replicable & sustainable include affordable, appropriate and environmental friendly techniques technologies and estimation of construction, O&M costs Coherence Project consistent with the mission strategy, guidelines of National Water Supply and Sanitation Coordination Committee - Coordinating activities ministry of WS, donor strategy. All stakeholders to coordinate the activities. Overlapping or inconsistent (communities, authorities, NGOs, UN, private sector) policies and regulations will be made more efficient, effective and consistent. DDC/VDC will coordinate and monitor the international NGOs… Necessary standards will be set and implemented for the International & national standards mainly WHO guidelines material & equipment, system design & construction to - Standards & guidelines and Sphere standards maintain the quality of work. The standard service level will be defined according the water QARQ* Coverage Need to reach major population groups facing life- Participation of gender, caste & disadvantaged ethnic groups. threatening suffering wherever they are and focusing on Poor communities will be targeted. Proper methodology and most vulnerable ones norms will be developed in identifying the poorest households within the community and such households will be provided with specified target grants Efficiency Quantitative & qualitative outputs of the project, cost- Proper budget allocation will be ensured to meet the effectiveness shall be demonstrated through proper budget scheduled target for the construction of new water supply follow-up, procurement rules projects as well as O&M of the completed projects. O&M fund and rehabilitation fund will be created at DDC and VDC level to support rehabilitation financing Effectiveness Extent to which an activity achieves its purpose (respect of X the timeframe, monitoring, PCM, LFA indicators reached) Sustainability Reinforce social organisation and cohesion through a NGOs will train the community level female health workers on - Community, civil society communal approach to water management the promotion of sanitation issues. Appropriate guidelines for

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& institutions WUSC management will be developed (O&M, water tariffs, strengthening Gradual withdrawal of aid with total at the end, official social sanctions for illegal connections, O&M fund) - Transfer of knowledge & handover, technical training & maintenance groups, The consumers themselves will own, operate and have handover community ownership, availability of and access to spare responsibility to maintain water supply projects. DWSS will - Capitalising on parts and transparency in the management hand over ownership and responsibility for O&M of all experience & analysis schemes to local bodies (DDCs, VDCs, Municipalities or Sharing of essential information is invariably an objective of WUCs). Technical assistants of the VDCs will be trained in any programme O&M as a back-up support to enhance internal capacity of WUCs - Operational research, link Operational research projects and short term studies A Water Users and Sanitation Federation may be established with Universities for independent monitoring and social auditing Research & development included in the policy Gender Ensure that the programmes implemented could benefit Plans of the VDCs and the DDCs will be formulated by equally men & women according to their specific needs and ensuring proper representation of disadvantaged people on with equal collaboration and participation of both sexes the basis of gender, caste and ethnicity. Such groups should include at least 30% representation of women People living with HIV/AIDS Access to safe water and sanitation is indispensable for X people living with HIV/AIDS Elderly people Restricted mobility so special consideration should be given X to ensuring that they receive an equitable service Disabled people Routinely excluded by WS but should always be considered X in infrastructure projects Children Particularly measures must be taken to ensure their X equitable access to basic services Protection WS facilities should be made as safe and accessible as X possible taking into account security situation Respect for the environment Assess the environmental risks and minimise impact (over- Environmental impact should be included in the indicators. An exploitation environmental screening appraisal will be included in all projects to identify environmental concerns. Public/private sector Can provide essential products and practical solutions faster Service delivery mechanism of water supply & sanitation by participation or more cost-effectively than relief agencies user’s committees, CBOs, NGOs & private sector in partnership with each other will be established

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Appendix 6 Annual Cropping and Social Calendar for Communities in the Study Area. Accessed from Food Security Team, ACF Nepal.

January February March April May June July August September October November December Activities 123412341234123412341234123412341234123412341234 Agriculture Upper Village Ploughing Lower Village Wheat / Upper Village Sowing Barley Lower Village Upper Village Harvest Lower Village Upper Village Ploughing Lower Village Upper Village Mustard Sowing Lower Village Upper Village Harvest Lower Village Upper Village Ploughing Lower Village Paddy Sowing / Upper Village (Irrigated) Planting Lower Village Upper Village Harvest Lower Village Upper Village Ploughing Lower Village Paddy (Rain Upper Village Sowing fed) Lower Village Upper Village Harvest Lower Village Upper Village Ploughing Lower Village Upper Village Vegetables Sowing Lower Village Upper Village Harvest Lower Village Upper Village Ploughing Lower Village Millet / Upper Village Sowing Kaguno Lower Village Upper Village Harvest Lower Village Festivals Dashain Diwali Maghi Common Anante Purni Bich-chhati Saune Sankranti Chaite Astami Dashahara (Jaira VDC) Specific Taga (Darma VDC) Migration Leaving village India Return back to village

Wedding Season

Wood / NTFP Collection AVAILABILITY

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Appendix 7

List of Schools and Health posts Visited During Field research

Mahadev Primary School (Nerah) Kalika Primary School (Libru) Health Post (Dhupi) Dhupi Primary/Secondary School Jamaldara Alternative School Nachara School Pumeru Secondary School Jima Primary School Melcham Health Post Melcham Secondary School Mahadev Secondary School (Dharma)

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