OPM Report Template Version 5

Water and Sanitation Sector Equity Analysis for Ghana

Final Report

Peter Burr, John Pinfold, Christopher Sackeyfio, Lucrezia Tincani, Gertrude Asokwah Amissah and Mawuena Dotse

In association with: Final report – Equity Framework for WASH Sector, Ghana

Table of contents

List of tables and figures v Abbreviations vii Executive summary I Key findings: sector coordination, monitoring and planning II Priority recommendations: sector coordination, monitoring and planning III Key findings – equity in sanitation V Priority recommendations – equity in sanitation V Key findings - equity in water VII Priority recommendations – equity in water VII 1 Introduction 1 1.1 Background to the project 1 2 Methodology 2 2.1 Introduction 2 2.2 Analysing existing inequities in WASH service delivery 2 2.3 Analysis of equity in WASH services delivery 3 2.3.1 Background analysis 3 2.3.2 Fieldwork 3 2.3.3 Limitations 4 3 Mapping access to WASH services in Ghana 5 3.1 Situational analysis (2015) 5 3.2 Where do the unserved live (spatial equity)? 7 3.2.1 Water supply 7 3.2.2 National MIS and other data on spatial equity (water) 9 3.2.3 Sanitation 10 3.3 Who are the unserved (wealth equity, group based indicators)? 12 3.3.1 Wealth equity 12 3.3.2 Other group related inequities 14 4 Assessing how the WASH sector is addressing equity concerns 17 4.1 National polices, strategies and plans 17 4.1.1 National development plan 17 4.1.2 Equity focus of Donors and NGOs 20 4.2 Sector Financing - mapping of WASH resources 22 4.2.1 Introduction 22 4.2.2 The ‘TrackFin’ Initiative 22 4.2.3 Expanding the Track Fin analysis 24 4.2.4 Development Partners / Donors and NGOs 24 4.3 Sector Coordination and sub-national planning 27 4.3.1 Sector Coordination 27 4.3.2 Decentralised planning and budgeting for WASH activities 28 4.4 Realities of programme implementation 30 4.4.1 Equity in Urban water supply 30 4.4.2 Equity in Rural Water Supply (point source) 31 4.4.3 Equity in Urban Sanitation 32 4.4.4 Equity in Rural Sanitation 34 4.5 WASH sector monitoring systems 35

4.5.1 Overview 35 4.5.2 GWCL – performance monitoring system 36 4.5.3 CWSA - DIMES 37 4.5.4 Rural sanitation - BASIS 38 4.5.5 WASH equity in household surveys 40 5 Recommendations 41 5.1 Introduction 41 5.2 Prioritising recommendations 48 5.2.1 Sector coordination, financing, sub-national planning and monitoring 48 5.2.2 Equity in Sanitation 50 5.2.3 Equity in water 51 6 References 53 Annex A Methodology – secondary data analysis 55 A.1 Objectives 55 A.2 Overview of data 55 A.2.2 Overview of analysis 57 Annex B Methodology – fieldwork 60 B.1 Objectives and data collection tools 60 B.2 Selection of fieldwork sites and respondents 62 6.1.5 Fieldwork site selection 62 6.1.6 Selection of KII informants 66 6.1.7 Selection of FGD participants 67 B.3 Fieldwork logistics 67 6.1.8 Piloting and training 67 6.1.9 Fieldwork team 68 6.1.10 Logistics of data collection 68 B.4 Data analysis and limitations 69 6.1.11 Quality control, data management, and analysis for the FGDs 69 6.1.12 Quality control, data management, and analysis for the KIIs 70 6.1.13 Ethical considerations 70 B.5 List of Donor and NGO projects included in the financial analysis 72 Annex C Fieldwork findings 74 C.1 Summary of Government Policies and strategies on WASH 74 C.2 Summary of Equity focus of donors 78 C.3 Fieldwork findings 82 C.3.1 Planning, funding and monitoring 82 C.3.2 Planning of WASH initiatives 82 C.3.3 Funding allocation 89 C.3.4 Approaches to sector monitoring 92 C.4 Implementation of urban and rural water initiatives 93 C.4.1 Demand for improved water in urban and rural areas 93 C.4.2 Capacity to meet demand for water services 94 C.4.3 Community management of boreholes and small piped schemes 95 C.4.4 Demand fo sachet water 97 C.4.5 Accountability – knowing who to contact to gain service access 99 C.5 Implementation of urban & rural sanitation and hygiene initiatives 99 C.5.1 Demand for improved sanitation 99 C.5.2 Capacity to meet demand for sanitation services 100 C.5.3 Attitude to public latrines 100 C.5.4 Affordability and practicalities of private household latrine construction 103 C.5.5 CLTS or subsidised latrines? 108

C.5.6 Attitude to sharing 111 C.5.7 Disability-friendly toilets 113 Annex D List of people interviewed 114 D.1 KIIs at national level 114 D.2 KIIs with MMDA 115 D.3 KIIs with Regional offices of GWCL 116 D.4 KIIs with Regional offices of CWSA 116 D.5 KIIs with Regional offices of EHSD 117 Annex E Equity focus of policies and strategies 118 E.1 Comparison of government policies (water) 118 E.2 Comparison of government policies (sanitation) 120 E.3 Comparison of donor policies and strategies 122

List of tables and figures

Table 1. Overview of the Component B ...... 3 Table 2 Fieldwork sites and fieldwork map ...... 4 Table 3 Unpacking the equity focus of WASH strategies in the GSGDA II ...... 17 Table 4 Key equity provision within sector polices and plan ...... 18 Table 5 Summary of donor programme and equity focus ...... 21 Table 6 Latrine costs as a percentage of household income ...... 32 Table 8 Potential equity indicators to be incorporated into existing MIS ...... 38 Table 9 Available quantitative data ...... 55 Table 10. Number of communities sampled per site ...... 63 Table 11. Rationale for fieldwork site selection ...... 64 Table 12. Final sample of FGD participants ...... 67 Table 13. Summary of fieldwork schedule ...... 68 Table 14. Comparison of equity focus on water-related government policies and strategies ...... 74 Table 15. Comparison of equity focus on sanitation-related government policies and strategies ... 76 Table 16. Comparison of WASH activities by key donors and NGOs ...... 78 Table 17. Example of district-level ‘situation analysis’ of existing facilities ...... 83 Table 18. Funding sources of WASH at MMDA ...... 89 Table 19. Average prices paid at different water point types ...... 93 Table 20. Average volumetric prices paid at standpipe versus a metered connection ...... 94 Table 21. Summary of performance of WSMTs (Source: IRC) ...... 97 Table 22. Latrine costs as a percentage of household income...... 104 Table 23. Descriptions of common ‘improved’ latrine types in Ghana ...... 106 Table 24. Rural construction cost estimates (in GHC) for pit latrines (one-seater) ...... 108

Figure 1 Sanitation sharing practices in Ghana (DHS 2014) ...... 7 Figure 2 Ghana water coverage, by region ...... 8 Figure 3 Proportion of non-functional handpumps by region (IRC, 2015) ...... 9 Figure 4 Water-point functionality map – northern region 2015 (IRC, 2015) ...... 9 Figure 5 Estimated demand for urban water services which is being met by Ghana Water Company Ltd. by region (2015) ...... 10 Figure 6 Ghana ‘basic’ sanitation coverage, by region ...... 10 Figure 7 Regional disaggregation of water access and across quintiles ...... 12 Figure 8 Distribution of Sanitation Facilities by Wealth Quintile (National) 2014...... 13 Figure 9 Distribution of water sources by gender of household head, by area ...... 15 Figure 10 Distribution of sanitation facilities by gender of household head, by area ...... 15 Figure 11 Estimated number of visually and physically disabled people practicing OD in Ghana 16 Figure 12 Overall WASH expenditure 2014 ...... 23 Figure 13 Estimated annual expenditure on WASH services, USD $ million (exclusive of household and NGO expenditure) ...... 23 Figure 15 Estimated donor commitments and expenditure by WASH sector ...... 24 Figure 16 Estimated grant commitments by region / US $ Millions ...... 25 Figure 17 Donor investments compared with those unserved by WASH, by region ...... 25 Figure 19 Proportion of DACF spent on Water and Waste Management ...... 27 Figure 22. Map of sites...... 63 Figure 23. Information saturation curve ...... 66 Figure 24. Process leading up to data collection ...... 68 Figure 13. Comparison of water point functionality, population density and drilling success rates – for the Northern Region ...... 87 Figure 14. GWCL standpipe in Kumasi town ...... 93 Figure 15. Rural handpump in the Upper West Region ...... 96 Figure 16. Trends in usage of improved water sources, piped on premises, and bottle and sachet (DHS 2014) ...... 97 Figure 17. Public toilet in Kumasi town ...... 101

Figure 18. Average improved latrine construction costs (Source: TREND, 2016) ...... 103 Figure 19. Breakdown of latrine construction costs (Source: TREND, 2016) ...... 105 Figure 20. Sharing of compound latrines and public latrines (DHS data) ...... 113

Abbreviations

ABFA Annual Budget Funding Amount

AFD Agence Francaise de Development

CBS Container Based Sanitation

CLTS Community-Led Total Sanitation

CLUES Community-Led urban Environmental Sanitation (UNICEF project)

CONIWAS Coalition of WASH NGOs

CWSA Community Water and Sanitation Agency

DA District Assemblies (rural only)

DACF District Assembly Common Fund

DDF District Development Fund

DESSAP District Environmental Sanitation Strategy and Action Plan

DHS Demographic Health Survey

DIMES District Monitoring and Evaluation System

DMTDP District Medium Term Development Plan

DWSMT District Water and Sanitation Management Team

DWSP District Water and Sanitation Plan

EHSD Environmental Health & Sanitation Directorate

EKN Embassy of the Kingdom of the Netherlands

FGD Focus Group Discussion

FOAT Functional and Organisational Assessment Tool

GAC Global Affairs Canada

GWCL Ghana Water Company Limited

GWF Ghana Water Forum

HH Household

HPBH Handpump-fitted borehole

IGF Internally Generate Funds

JMP Joint Monitoring Programme

JSR Joint Sector Review

KII Key Informant Interview

LICSU Low Income Customer Support Unit

MBH Mechanised borehole

MICS Multiple Indicator Cluster Survey

MIS Monitoring Information System

MLGRD Ministry of Local Government and Rural Development

MMDA Metropolitan, Municipal and District Assemblies

MOF Ministry of Finance

MSWR Ministry of Sanitation and Water Resources

MWRWH Ministry of Water Resources, Works and Housing

NCWSS National Community Water and Sanitation Strategy

NDAP National Decentralisation Action Plan

NDPC National Development Planning Commission

NDPF National Decentralisation Policy Framework

NESSAP National Environmental Sanitation Strategy and Action Plan

ODF Open Defecation Free

OHLGS Office of Head of Local Government Service (formerly known as Local Government Services Secretariat)

OPM Oxford Policy Management

PURC Public Utilities Regulatory Commission

RCC Regional Coordination Council

RPCU Regional Planning Coordination Unit

SIP Sector Investment Plan

SIS Sector Information System

SWA Sanitation and Water for All

WASH Water, sanitation and hygiene

WATSAN Water and sanitation

WSMT Water and sanitation management team (at community level)

WSSDP Water Sector Strategic Development Plan

Executive summary

Background to the project The global Sustainable Development Goal targets for drinking water, sanitation and hygiene call for the equitable access to safe and adequate services for all. Through national and international commitments the Government of Ghana has aligned itself with the SDG goal of universal access with the goal ‘sustainable water and basic sanitation for all by 2025’.

For Ghana to meet these stated goals an improved understanding of equity issues is imperative. To date, there has not been sufficient analysis of the existing and persisting WASH equity constraints in Ghana, limiting the development of informed, equity-focussed programming. In this context, Oxford Policy Management (OPM) and MAPLE Consult have been contracted by UNICEF Ghana to work closely with the Government of Ghana to research the drivers of inequity in rural and urban water and sanitation services and to develop an equity action-plan with practical recommendations for how these issues can be addressed overtime.

To achieve the study objectives, the study combined quantitative analysis of existing household surveys and sector MIS data, with qualitative data collected from interviews and focus group discussions conducted in 5 regions of Ghana. The quantitative analysis reported the current status of WASH inequities across different socio-economic and demographic groups within Ghana; whereas the qualitative fieldwork sought to ground-truth these findings and explore additional dimensions of inequity not captured in existing datasets.

The key findings and recommendations of the study are presented in a series of tables and graphs examining equity issues related to three thematic areas: a) sector coordination, monitoring, and planning; b) sanitation (rural and urban); and c) water (urban and rural). During the final equity workshop these recommendations were then prioritised according to their likely effectiveness (-in addressing equity issues) and feasibility (-in terms of the likelihood that these recommendations will be implemented). Guidance is also provided to help inform how these may be implemented.

Key findings: sector coordination, monitoring and planning

Secondary data analysis  Trends (water) - in the last decade progress in water access has been concentrated in middle quintile (or richer) households Over the same period progress was slowest among the ‘poorest’ quintile households (17% rise in coverage for middle quintile household compared to a 5% rise for the poorest households)  Trends (sanitation)- coverage at household level show little improvement over the past decade with rates of open defecation stagnating at around 31% in rural areas  Rural/urban disparities (water) – most Ghanaians have access to basic ‘improved’ water service, however access to on-plot piped services is nearly always restricted to urban areas  Inter-regional disparities (sanitation)– the vast majority (88%) of all those practicing open defecation in Ghana are clustered in the three Northern regions (Upper East, Upper West and Northern)  Intra-regional disparities (water)- there are stark differences in water coverage within regions which is linked to difficult hydrological conditions and low levels of wealth Policy and financial analysis  Sector reliant on donor funded projects but then support tends to be fragmented as project location is not based on any systematic allocation according to WASH demand or need – leading to spatial inequities  In the last five years, overall donor financing have been more focussed on improving service levels in urban areas of higher coverage regions, rather than providing first time services in poorly covered and hard to reach regions.  Local government financing WASH activities is limited with little/no funds available for household sanitation promotion without donor/NGO support – leading to highly localised spatial inequities in promotion activities. Equity in Monitoring  In the absence of a functioning Sector Information System there is little data on inequities below region level  There is equally little secondary data on group-related on inequities as neither national surveys nor sub-sector monitoring systems report on how WASH activities are being targeted to reach sub-groups such as women and the disabled, nor do they report and track WASH progress for these sub-groups.  Currently there is no MIS system for urban sanitation, and the system for rural sanitation (BaSIS) has had limited roll out nationally, and is reportedly not well institutionalised  The rural water monitoring systems (DiMES) is well established nationally - however few districts dedicate funds to keep this system up to date, and fewer still are able to complete range of indicators the DIMES seeks to collect Key informant interview and focus group discussions  Attempts to introduce a more coordinated approach to WASH financing has stalled. The Water Sector Working Group does not meet regularly and Joint Sector Reviews are irregular with the last being held in 2013.  Donors and NGOs appear less willing to invest in hard to reach areas due to higher costs  At the local level, WASH investment plans are reportedly subject to political interference with funding reallocated to communities who supported the party in power.  Basic household sanitation promotion not prioritised or mainstreamed at local levels and there is a tendency to rely on donor/NGO funding for water and sanitation activities.  Coordination of NGO activities tends to be weak leading to ad-hoc and poorly targeted implementation  Existing MIS (such as DIMES in rural water supply) are not utilised in the local planning process

Effectiveness/feasibility of possible long list recommendations

Priority recommendations: sector coordination, monitoring and planning Although the Government of Ghana has a vision of water and sanitation for all, the above findings highlight a number of areas limiting progress towards this goal. In addressing these inequities there is a clear need for more effective mechanisms for measuring and analysing progress towards equity which will in turn help guide more effective investment planning and strategy development towards meeting this goal. 1) Strengthen Sector Coordination and Planning for achieving goal of sustainable water and basic sanitation for all a) Define sector level indicators for measuring and tracking sector performance in an equity focussed performance measurement framework. The indicators would define sector performance in meeting annual targets and the goal of sustainable water and sanitation access for all, and must therefore incorporate indicators tracking progress among disadvantaged groups. Typically 8 – 10 headline indicators would provide the structure for an annual Sector Performance Reports (SPR) and we recommend that at least half of these would report on equity issues1. Specific indicators to be considered include: i. Rural water supply coverage to people living in hydro-geologically challenged areas ii. Proportion of urban water supplied by GWCL through public standposts iii. Proportion of MMDA funds spent on sanitation promotion iv. Public toilets providing a standard level of service (access) and usage b) Revitalize an annual Sector Performance Report with strong equity focus. The SPR should provide an analysis of annual progress against sector targets. As well as the headline indicators outlined above, the SPR should routinely incorporate data from periodic survey or studies to highlight specific issues regarding the poor or disadvantaged groups. c) Revive the annual Joint Sector Review (JSR) framed around the SPR findings and recommendations. The JSR provides a forum for sector stakeholders to review progress and discuss adjustments to be made to sector strategies and plans, implementation approaches and resource allocation. The main output from JSR deliberations would ideally take the form no more than 5 realistic key sector undertakings chosen from the long list provided in the SPR. The idea is that the undertaking are achievable within one year and their status rigorously scrutinized by the sector working group and next JSR. d) Develop a realistic Sector Investment Plan (SIP) including rigorous costing to reach vulnerable groups (e.g. peri-urban poor) and difficult to reach locations (e.g. hydrologically challenged/sparsely populated areas). This provide annual estimates of required water and sanitation investments disaggregated by district based on the size of unserved population and the estimated per capita cost of water and sanitation access - differentiated by service level, type of group and location. e) Develop an ODF Ghana Strategy with simple framework but high level launch. This is aimed at harnessing political and public commitment to prioritise sanitation at all levels. The launch should include a strong publicity component including an ODF Ghana logo, IEC support materials, mass media and profiling of sanitation champions from public and private domains.

1 An alternative option would be to create a performance management framework solely focussed on equity indicators. As it stands the recommendation purposely embeds equity issues alongside other performance indicators as part of a push to mainstreamed sector performance report. The authors feel that this will help insure equity are not marginalised in further reporting cycles.

2) Strengthen equity in monitoring by improving information flow for more functional SIS and quality of equity information for selected indicators

a) Rationalise MIS indicators to better align with the realistic capacity and resources which MMDAs have to collect this data. Improved reporting across a limited set of indicators would contribute to more functional and useful SIS.

b) Leverage MICS and DHS national surveys to collect intra-household differences in WASH access – such as by age, sex or disability. This is major gap in current understanding of WASH inequities – especially in urban areas.

c) Increase regional capacity on MIS to support data visualisation and use at MMDA level. Given the challenges faced it is felt that intensive capacitating of regional MIS officers would be a more cost-effective way to support (i) local level data reporting, and (ii) the production more useful data visualisation, and (iii) the use of this data in MMDA level planning and budgeting for WASH

Next steps to establishing these recommendations:

i) Link MIS equity indicators with the Sector Information System. The equity indicators proposed by this study should inform the development of finalised indicator list. The selection of these indicators must be accompanied by guidance on data collections and reporting requirements at sub-national level. ii) Establish clear responsibilities for the Sector Performance Review. The structure of the SPR should be defined by the headline indicator selected, however roles and responsibilities for production needs to be established. Ideally this would be a government –led process and would includes focal point persons from M&E, Planning, each WASH sub- sectors representatives from partner NGOs and donors. Consultants may be required to help define the roles of the team members and build capacity so that less external support is required for each subsequent SPR.

i) Develop an approach and associated guideline for updating the decentralized sector investment plan at district level. This should incorporate local coverage targets, different technology options, and cost estimates of service provision for difficult to reach groups and would be used to engage with NDPC and MoF on more equitable resource allocation at the district level

Key findings – equity in sanitation

Secondary data analysis  Since 1990, the proportion of rural population practicing open defecation has risen from 19% to 34%  Those living in rural areas are five times more likely to practice than those in urban areas and third of all Ghanaians practicing open defecation live in the Northern Region  Eighty-eight per cent of those practicing OD are from the poorest two wealth quintiles (-the bottom 40%), moreover access to a basic sanitation service is the preserve of the rich (35% of richest quintile vs 7% of middle quintile)  In the absence of household facilities, public toilets are the primary sanitation facility used over a third of urban households. However, access to these facilities is unaffordable for the poorest households who must resort to other more high risk behaviours such as: Open Defecation, or defecation in a plastic bag (‘shot-put’; ‘takeaways’)

KIIs and FGDs Households toilets Urban areas lack appropriate and affordable toilet options for poor and middle income households. Nationally there is no coherent policy or strategy addressing urban sanitation for the poor and local government opinions on the effective approaches vary. Sanitation policy discourages subsidies for household toiles, yet most municipal assembly respondents believe some form of subsidies (whether cash or with materials) are necessary to bridge the affordability gap. Furthermore, informants are also sceptical of the effectiveness of CLTS initiatives in urban areas due to issues of large-community sizes (limiting community cohesion) combined with low owner-occupier rates and the limited financial incentives for landlords to invest in sanitation – even if partial subsidies are available. Public toilets The only safe sanitation option available to many urban poor is a public toilet and in general respondents see these as a necessary interim solution in the absence of affordable household toilets. However issues of accessibility and cost means the urban poor or vulnerable often revert to other unhygienic practices at different times. Reasons for occasional use include: inconvenience; not suitable for children; poor accessibility especially for elderly/disabled. Girls/women also cited risk of infections, safety and general conditions (smell, lighting) - so often preferred to defecate in a plastic bag and dispose in gutters/solid waste sites. Patterns of toilet use appears to vary by population sub-groups with male youths most likely to practice OD. Policies and strategies do not reflect the reality of public toilet use, nor their appropriateness and accessibility to vulnerable sub-groups. In some areas (such as Kwabre East in Ashanti), public latrine operators shunned poor or sparsely populated areas due to their lower commercial viability.

Effectiveness/feasibility of possible recommendations

Priority recommendations – equity in sanitation 1) National policy on sanitation and associated strategies should be developed to include guidance on public toilets in urban areas

a) Ensure Urban Sanitation Strategy recognises that public toilets are an important, if interim, sanitation service for the urban poor to complement the promotion of household sanitation. Implementation strategies should place emphasis on expanding the provision of these facilities in unserved and poor areas and explore options for reducing the cost of access for the poor (including free access for children), and vulnerable.

b) Empower local authority in a regulatory role to oversee the quality of service provided by public toilets and perform this function. Local Environmental Health Staff are well placed to monitor the operations of public toilets

c) Develop normative criteria for public latrine assessments are agreed and mainstreamed into sub-sector strategies and MMDA monitoring. This guidance can also be harmonised with that for other institutions: schools and health facilities.

d) Clarify policy regarding Assembly owned and managed toilets to resolve any potential conflict of interest in their service provider/regulator role – which may undermine the credibility of service monitoring.

2) Rigorously review available low cost household toilet options in terms of affordability and suitability in meeting requirements of the urban poor and, for rural areas, addressing sustainability of traditional latrines where pits are prone to collapse. Affordability is a fundamental barrier to scaling access to basic sanitation, but current designs of improved latrines are not addressing these challenges. Review should also consider Container Based Systems (CBS).

Next steps to establishing these recommendations

I. Undertake policy review and revision of the National Environmental Sanitation Policy and related strategies to incorporate issues on management and regulation of public toilets, and ensure these are mainstreamed into the urban sanitation policy

II. Conduct further research and consultation on best practice including management and regulatory arrangement for public toilets operating in urban areas

Key findings - equity in water

Secondary data analysis  Northern and Eastern regions contain the highest number of people unserved (around 1.1 million people representing 36% of the overall total unserved).  There are large swaths of the rural Ghana, and the Northern region in particular - which are not covered by formal water services and this appears to be linked to challenging hydro-geological conditions. ‘Pockets’ or underserved communities were also identified – such as among the poorest fifth of households in western region.  The lowest level of rural water-point sustainability are found in Northern and Western regions – and the highest were in Upper East and Upper West regions.  Provision of piped water services is also very patchy between regions. At present the Ghana Water Company Limited (GWCL) estimates it’s able to meet 80% of water demand in Accra – however outside the capital this figure falls dramatically and GWCL is estimated to meet between a quarter and a third of demand.  The rapid rise in sachet water in Ghana doesn’t appear to be an equity risk, as consumption within poorer quintiles is minimal and overall it is drunk more as a refreshment than as the sole source of drinking water. KIIs and FGDs In community managed rural systems, access to and paying for water does not appear to lead to equity risks, as communities have come up with a variety of ways to ensure poor and vulnerable are able to access basic water services – should they exist. Nevertheless, the overall functionality of rural water and sanitation teams remains especially weak in a number of dimensions (such as tariff collection, and gender balance) which risk sustainability. In terms of resource allocation – respondents in Northern and Upper-West regions indicate that due to cost-effectiveness considerations donors have been unwilling to invest in certain hard to reach communities which risks perpetuating geographical inequities in WASH access driven by unequal funding allocations.

In urban areas, GWCL strategies to target poor communities remain weak – despite recent progress. The life-line tariff is poorly targeted and access to the poor is not tracked as part of GWCL monitoring nor by the sector regulator. Most urban poor rely on standpipes (where available) as household connections often prove too expensive. However, GWCL staff perceive that there is less money to be made from investing in standpipes and GWCL’s which translates to a greater emphasis on in-house connections – at the cost of services in low income areas. For the urban poor, fewer standpipes mean increased time in water collection (distance and queuing) and greater reliance on alternative unsafe water sources as was found in Tamale in the Northern Region.

Effectiveness/feasibility of possible recommendations (water)

Priority recommendations – equity in water Establish a dedicated budget line reporting on investments in hard to reach areas in rural areas – this will be informed by the costing analysis undertaken as part of the decentralised sector investment plan (-see recommendation 1d) 1) Improve the equity focus of Ghana Water Company Limited (GWCL) to ensure continuous expansion of services to the urban poor, through the following actions:

a) Introduce a pro-poor indicator Key Performance Indicator for GWCL reporting (the pro-poor indicator should be top of the list so as not to be overlooked), and also included in the annual SPR. This will need to go hand in hand with increased focus from PURC on expanding service to the poor in line with their social policy. b) Increase advocacy and capacity development with GWCL and PURC focussed on serving the poor – in particular this should focus on i) increasing standpipe provision in poor areas where the connection fee/monthly bill are considered too expensive; ii) reassessing decision making around network expansion to ensure that poor and marginalised areas are not excluded; and iii) expanding the role of the Low Income Consumer Support Unit (LICSU) to the regions c) Reduce price of water at standpipes by reducing tariff charged to operators

Next steps to establishing these recommendation:

d) Overlay hydro-geological maps on DiMES data for local water coverage and link to SIP (recommendation 1 d) e) Additional consultation with sector stakeholder on options to include pro-poor indicators within GWLC routine monitoring and as part of the regulatory oversight of the Public Services Regulatory commission.

1 Introduction

1.1 Background to the project

The global Sustainable Development Goal targets for drinking water, sanitation and hygiene call for the equitable access to safe and adequate services for all. As such these targets can only be considered achieved if they have met for all sub-groups within a population, including those who are most marginalised and/or hardest to reach.

Through national and international commitments the Government of Ghana has aligned itself with the SDG goal of universal access. The Water Sector Strategic Development Plan (WSSDP) (2012-2025), defines the government’s vision for the sector as the delivery of ‘sustainable water and basic sanitation for all by 2025’. This vision has re-iterated through Government of Ghana’s formal commitment to Sanitation and Water for All (SWA) by 2025, at the 2014 SWA high level meeting in Washington D.C.

For the Ghana to meet these goals it’s imperative that key sector stakeholders have a clear understanding of the various ways in which water and sanitation inequities play out amongst different vulnerable sub-groups across the country, and are actively using this information to develop appropriate policies, strategies, and programmes to tackle priority issues for these groups. To date, there has not been sufficient analysis of the existing and persisting WASH equity constraints in Ghana, limiting the development of informed, equity-focussed programming.

In this context, this study have been contracted on behalf of the Government of Ghana to research the drivers of inequity in rural and urban water and sanitation services. This study looks at several different ‘dimensions of equity’ relating to both individual and group based characteristics encompassing wealth, geographical location, sex, age, race, ethnicity and disability. The main output of the research is a priortised series of recommendations to help facilitate and accelerate equity-focused water and sanitation programming. To inform the overall recommendations framework the research seeks to:

i. assess the extent to which existing sector information systems contribute to planning to eliminate inequities;

ii. provide a basis for planning and the allocation of financial resources at the national and local government levels to address the imbalances identified. In particular, there is a keen interest in understanding options for incorporating critical equity indicators into existing national and programme monitoring systems in a way that is feasible and sustainable;

iii. provide insights and recommendations to inform the revision of policies, plans and strategies to enhance equity in water and sanitation service delivery;

iv. provide insights and recommendations to inform programmatic design to address identified inequities in service delivery, and

v. highlight WASH service delivery as a key thematic area in the formulation of the rolling 4 year medium term national development plan with a view to ensuring universal access by 2025 as envisioned in the water sector strategic development plan.

2 Methodology

2.1 Introduction

To achieve the objectives the study combined a quantitative analysis of existing household surveys and sector MIS data, with qualitative data collected from interviews and focus group discussions conducted in 5 regions of Ghana. These approach undertaken is summarised in sections 2.2 and 2.3 below, with full details provided in Annex A and Annex B. The full analysis of the fieldwork is provided in Annex C, and list of informants are presented in Annex D.

2.2 Analysing existing inequities in WASH service delivery

The component of the study assessed the status WASH inequities in Ghana through the detailed analysis of national household surveys, supplemented with additional data drawn from available sector monitoring information systems (MIS), and other published sector literature.

The quantitative analysis consisted of a detailed Level 2 (‘deep dive’) analysis using the raw data files of DHS 2008 and DHS 2014, and summary Level 1 analysis of national survey data from MICS 2006; MICS 2011; GLSS 2006; GLSS 2013; and the Census 2010.

For the level 2 analysis raw data files obtained from the DHS website and analysed using STATA. Various combinations of population stratification were used: 1) area (urban/rural), 2) region, 3) wealth quintiles 4) gender of the household head and 5) education level of the household head investigation of the distribution of households that share latrine facilities for all types of such facilities. To compare wealth quintiles within rural and urban geographies a principal component analysis was undertaken which created separate wealth indices for urban and rural households. Statistical ‘t-tests’ were used to evaluate the significance of differences in access to improved water and sanitation facilities across regions and wealth quintiles. The surveys in the level 1 analysis were used to as comparators for the DHS data, and enabled the analysis of coverage trends over time.

Additional secondary data was drawn from (i) sector information systems namely, Ghana Water Company’s Performance management tool and the district monitoring and evaluation system (DiMES), and (ii) other related programme outputs or published literature related to the status of WASH services in Ghana – most prominently IRC’s Ghana work on rural water point mapping.

Limitations of the secondary data analysis:

 Group-based indicators (such as race, colour, ethnicity, and religion), and individual-level indicators (such as: age or disability) are not captured within the main household survey tools of the DHS and therefore cannot be systematically compared with access to WASH services.

 Definitions of key water and sanitation indicators are not consistent the between survey tools. Specifically, the definitions used by the GLSS and the national census are not fully consistent with the JMP – inhibiting comparability.

2.3 Analysis of equity in WASH services delivery

This component of the study sub-divided into two separate elements: (i) background analysis of government, donor and NGO policies and resource allocation, and (ii) field-based primary data collection (fieldwork) in rural and urban areas in 5 regions of Ghana.

Table 1. Overview of the Component B

Background analysis Field-based primary data collection (fieldwork) 1. Identifying and collating sector policies and strategies 1. Design of interview and focus group 2. Analysis of government, donor and NGO discussion guides policies 2. Targeted KIIs with national level 3. Analysis of government institutional stakeholders capacity, sector coordination, and 3. Fieldwork in 5 regions, covering 8 MMDAs, monitoring systems and 16 communities/ urban sites 4. Mapping of WASH resources at national and regional level

2.3.1 Background analysis

Analysis of policies, strategies and monitoring systems: based on existing literature / data sources and were guided by stakeholder key informant interviews at national level.

The mapping of WASH financial flows was built upon the findings of the recent ‘TrackFin’ analysis to include additional details on: (i) donor funding and INGO in the last five years based on data collected from national informants and (ii) decentralised WASH spending based on district records collected during the fieldwork and published data from the Ministry of Finance. This mapping exercise only looks at financial input and is therefore unable to make comment on the value or cost- effectiveness of how resources are being deployed. Moreover the analysis is limited by the fact that (i) comparing the level of regional investment over a single five year period can give a distorted picture of sector priorities – for example in cases when a large-scale investment narrowly falls outside this range - such cases are noted when the authors are aware of then; (ii) the input-based nature of mapping means that financial data only reflects that which was shared with the team during data collection and is not exhaustive.

2.3.2 Fieldwork

Field activities were designed to act as both a ‘reality check’ on the background analysis, and to provide new insights into equity issues not currently captured in the literature or emerging from the data The research was primarily qualitative in nature and drew on key informant interviews, focus group discussions and individual case studies (full details on each of these tools, including the pretesting process and sampling approach is provided in Annex B):

The fieldwork took place in five regions, covering both urban (Municipal Assembly) and rural (District Assembly) areas. In total eight districts were covered, with selection made to deliberately explore both outliers and interesting case studies on WASH access. In these districts, visits were made to 5 urban, 4 peri-urban and 6 rural communities (total of 15), which were chosen with the help of the MMDA – see Table 2. District officials organised and accompanied the community visits.

Table 2 Fieldwork sites and fieldwork map

# Region District Area Community

1 Asokore Asokore Mampong Mampong Urban 2 MA Aboabo Number 2 Ashanti 3 Kwabre Peri- Adanwomase 4 East DA urban Asomomaso

5 Greater Ashaiman Old Tulaku Urban 6 Acccra MA Moni Obaanye

7 Upper Nadowali Yiziiri Rural 8 West DA Gboboyiri 9 DarSalam Mion DA Rural 10 Warvi-yepala Northern 11 Urban / Dungu Tamale MA Peri- 12 urban Kabonayiri Sekondi Urban / 13 Takoradi Peri- Ngyiresia MA urban Western 14 Juaboso Antobia Rural 15 DA Juaboso Nkwanta

2.3.3 Limitations

The following challenges were encountered during the fieldwork:

 Organisation of FGDs and KIIs - while invitation letters organising the timing and content were sent out several weeks in advance, some letters were misplaced or were not passed on to the intended recipient. These letters were followed up with repeated phone calls in order to confirm meetings. Despite these efforts, a small number of intended KII respondents could not be interviewed, but in each of these cases these respondents were replaced with a different respondent from the same department.

 There was an imbalance of gender participation in FGDs (31% of women across all FGDs). There was unfortunately not enough time and budget to hold separate FGDs with men and women, gender-sensitive issues which particularly concerned women and girls were explored with the remaining female participants separately, through a separate follow-on discussion after the FGD.

 FGDs were accompanied by personnel from MMDA and local MMDA committee members. In the Upper West & Northern Regions, the presence of the local government representative was necessary to assist in community translation as there weren’t sufficient resources for a translator to be present. To mitigate the potential heuristics associated with the presence of these individuals, the consultancy team took the following steps: We briefed the MMDA member on the role, purpose of FGDs and how they would be conducted; and emphasised the need for an open and honest discussion and for the consultancy team to run the conversation.

3 Mapping access to WASH services in Ghana

3.1 Situational analysis (2015)

The Joint Monitoring Programme (JMP) estimates show that in 2015 around nine out of ten (88%) of Ghanaians had access to an improved drinking water source, with around 68% having access to a basic water services2. However only around one in seven (14%) had access to a basic sanitation service3 (JMP, 2017).

In general access to improved WASH facilities is skewed in favour of urban areas. More than ninety per cent (93%) of the urban population have access to an improved water source and around a third (32%) have access to a piped water system on premises. This compares with only three per cent of the population who access piped water on premises in rural areas – where the majority (81%) access other types of improved sources. Whereas access to basic sanitation is very low in all areas of Ghana (- estimated at 15%), those living in urban are twice as likely to access improved sanitation as compared to those in rural areas (Urban - 20%; Rural – 9%). Significant urban/rural disparities also exist for those not accessing any form of sanitation facility – i.e. practicing open defecation – to the extent that someone living in rural areas is five times more likely to practice defecation compared to those in urban areas (Urban – 34%, Rural – 7%)4.

Overall trends show that access to improved water and sanitation is improving in Ghana, but the rate of progress is uneven and slow, particularly for sanitation. Over the last 35 years (1990-2015), access to improved water has risen by thirty-three percent (56-89%), whereas access to basic sanitation has risen by just eight per cent (7-15%) and these increases have been concentrated predominantly in urban areas.

The most dramatic changes in sanitation practices has been the shift away from the use of unimproved facilities towards the use of improved ‘shared’ sanitation facilities (including public latrines). These facilities are now used by nearly two-thirds of the population rising from 29% in 1990. Similarly dramatic has been the regression in rural sanitation over this period with the proportion of people practicing open defecation rising from 28% to over a third of the population (34%) in rural areas; compared to 19% nationally.

Households in Ghana rely on shared latrines more than any other country in the world - totalling 68% of the urban population, and 59% across the whole country (DHS 2014). The political and social acceptability of shared sanitation as an improved sanitation solution is a contentious topic in sector (see box 2 below). This issue is particularly salient in Ghana as the definition of shared sanitation as a ‘limited service’ is the primary reason why headline coverage figures fall so far behind counterparts in the region.

2 An basic water service is defined as drinking from an improved source (-i.e. piped water into dwelling, yard or plot, public taps or standpipes, boreholes or tubewells, protected dug wells, protected springs and rainwater); provided collection time is not more than 30 minutes for a round trip, including queuing. 3 A basic sanitation services is defined as using an improved facility (-flush or pour flush toilets to sewer systems, septic tanks or pit latrines, ventilated improved pit latrines, pit latrines with a slab, and composting toilets) that are not shared with other households. 4 The authors note that the self-reporting of open defecation in urban Ghana can be problematic, and findings from internal studies by UNICEF suggest that these numbers are systematically under-reported.

Box 2: Global monitoring of sanitation in the SDGs

The post-2015 monitoring framework for sanitation (JMP, 2015) defines different sanitation service levels on a five point ladder ranging from a bottom rung of ‘no service’ (open defecation) to a top rung ‘sustainable’ service. Access and use of an improved but shared sanitation facility is reported as its own rung termed ‘limited’ indicating that this type of service is considered better than using an unimproved facility, but is not yet considered a ‘basic’ level of service.

Despite this, there is currently no clear international consensus on whether certain categories of shared sanitation should be considered “improved” (Giné Garriga et al., 2011; Heijnen et al., 2014).

The Special Rapporteur’s 2015 report on drinking water and sanitation service levels notes that while sharing of sanitation facilities is widespread in some regions and countries there are concerns from a human rights perspective about a lack of privacy and an increased risk of violence or assault for people (particularly women) leaving the house, particularly at night. These concerns are at least partially mitigated through access and use of a household latrine.

Nevertheless the classification of shared facilities as unimproved can also be questioned. Public toilets or toilets shared between households, although not optimum, can be an interim solution where they are well-managed, culturally acceptable, kept in a hygienic condition and where access is affordable or free (Exley et al., 2015). We recognise that public facilities could satisfy all these criterion (-although often they do not) and it’s therefore sensible and prudent that the assessment of the sanitation service level in any community is informed by the context, as well as the needs of particular groups which may have different sanitation needs.

Within the SDG monitoring framework national level stakeholders have a certain amount of freedom to tailor definitions of acceptable service to align these with country context and national priorities. The Government of Ghana could formally incorporate service provision through well managed public toilets as part its medium-term planning and accordingly look to develop appropriate policies, strategies, and investment plans. Currently there is little sector information, or widespread understanding of the dynamics of shared sanitation use, and the quality of service which they are able to provide to users with different needs, and in different locations. Additional contextual information on status and various dimensions of shared sanitation in Ghana is presented in Box 3 below.

Box 3: Characteristics of shared sanitation in Ghana

Shared sanitation also takes many forms across Ghana. Figure 1 illustrates that the patterns of sanitation facility sharing are broadly similar across both rural and areas. Use of public/communal toilets5’ are the most common form of shared facility used – which is slightly more common in urban areas. Sharing with only one other household (i.e. a neighbour) is relatively rare – covering around 5% of households in urban and rural areas. Use of toilet facilities shared between 3-9 household are more common in urban areas (28%) than rural areas (16%) and likely represents the use of ‘compound6’ facilities (-a single facility situated with a multi-household compound) – found in many poor urban areas across Ghana7. In terms

Figure 1 Sanitation sharing practices in Ghana (DHS 2014)

100%

80% 68%

60% 48% 34% 40% 29% 20% 17% 20% 11% 9% 5% 4% 8% 8% 0% Urban Rural Not sharing Sharing with one other HH Sharing with 2-4 HH's Sharing with 5-9 HH's

Sharing with more than 10 HH's (public/ communal toilet) Sharing (all forms)

3.2 Where do the unserved live (spatial equity)?

This section explores how access to improved water and sanitation services varies according to where people live: specifically focussing on inequities in inter-regional coverage. This mapping enables more nuanced understanding of spatial equity beyond the standard rural-urban dichotomy provided in most sector surveys.

The dimensions of spatial equity are illustrated with maps and other visuals showing the number, proportion and regional distribution of the entire population: (i) without access to an improved water sources; (ii) who do not access and use a sanitation facility (open defection); and (iii) who do not access and use an improved sanitation facility (basic sanitation service level).

3.2.1 Water supply

Across Ghana there is a disparity of around 20% between the region with the highest water coverage (Greater Accra – 97%), and the region with the lowest coverage (Northern – 76%), Figure 2. Four out of the ten regions have achieved over 90% coverage, this includes the most

5 This analysis assumes a latrine shared by more than 10 households is a public/ communal toilet. In Ghana a ‘public toilet’ is understood as a pay-per use, most commonly privately operated, facility typically found in urban areas. A communal toilet is a facility may have been constructed by local authorities, communities or with external assistance and is free at the point of use. These types of facility are more common in rural areas. 6 A ‘compound house is a dwelling lived in by 2 or more households, but often well over a dozen households crowded into existing rooms. The dwelling is typically constructed around a central courtyard. Compound houses remain the major form of housing in Greater Accra, representing 55% of the housing stock in the 2010 census (GSS, 2012)

© Oxford Policy Management, August 2017 7 WASH Sector Equity Analyses for Ghana –Final report populous region, Ashanti, and the two least populous and remote regions (Upper East and Upper West). The lowest coverage regions, other than Northern, are Volta (80%) and Eastern (81%) – but there doesn’t appear to be any geographical clustering of low or high coverage regions.

Figure 2 Ghana water coverage, by region

94% 97% 95% 100% 88% 90% 90% 85% 81% 84% 76% 80% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ashanti Brong Central Eastern Greater Northern Upper East Upper Volta Western Region Ahafo Region Region Accra Region Region West Region Region Region Region Region

Arguably a more effective way to conceptualise the distribution of water and sanitation facilities is to focus on the absolute number of people without access to an improved water source within each region (illustrated in Maps 1-3 in the sections below)8.

Map 1 illustrates Northern and Eastern regions Map 1: Number of people without access contain the largest number of people without to an improve water source, by region access to improved water services. Together they contain 36% (around 1.1 million people) of all those unserved in Ghana. In addition, considerable service gaps are also found in Volta, Brong Ahafo, and Western regions - with between 350-430k unserved in each region.

The two most populous, and urbanised, regions (Ashanti and Greater Accra) have a relatively low number of people unserved by improved water sources. The region with the fewest people without access is Upper West – at 38,000. This is driven by a combination of low population and relatively high water coverage.

Although informative for high level decision making regional maps such as this do not provide more nuanced understanding of sub-regional coverage gaps, or deprived pockets of unserved. The nature of national sample surveys (-such as MICS, DHS, etc.) means that further disaggregation along spatial dimensions (e.g. by district) would not present a representative picture. This more detailed analysis of sub-national data sources must therefore be provided by national MIS and other project sources. This data is explored in more detail below.

8 These data are calculated by multiplying regional water coverage (percentage of population as derived from DHS 2014) regional population reported in the 2010 census.

3.2.2 National MIS and other data on spatial equity (water)

Data from the district monitoring and evaluation system (DiMES) is used by the CWSA to report on water coverage across all rural areas of Ghana and can be disaggregated at various levels (region, district, area council). This data does not tend to be collected or updated routinely so figures may be inaccurate or outdated, but it can be a potentially powerful tool to better understand spatial equity, as explored below and in the later dedicated section on monitoring systems.

IRC Ghana through the ‘sustainable services at scale’ and ‘Smarter WASH’ projects have provided long term support to rural water point monitoring. In 2015 IRC produced a series of factsheets providing an inventory and mapping of rural water facility functionality in six regions. This data shows that rural water point functionality is considerably worse in Western Region (35%) and Northern Region (31%), particularly in comparison to Upper East and Upper West (Figure 3). Moreover, the mapping data highlights large areas not served by improved water sources such as in the Northern Region (Figure 4), where issues of low-population density, and poor hydrogeological conditions effectively drive up the per person costs of services delivery, and reportedly disincentivise external investment in these areas.

Figure 3 Proportion of non-functional handpumps by region (IRC, 2015)

40% 35% 35% 31% 30% 28% 25% 20% 18% 17% 15% 13% 10% 5% 0% Western Central Brong Ahafo Northern Upper West Upper East

Figure 4 Water-point functionality map – northern region 2015 (IRC, 2015)

Urban water Figure 5 reports data from GWCL’s performance monitoring system on the estimated proportion of consumer demand which is being met by GWCL managed services9. The regions with urban areas least well served by the GWCL services are Easter, Volta, Brong Ahafo and Upper East. There only between. 25% - 33% of urban demand through GWCL managed systems. The most comprehensively covered region is Greater Accra with 82% of urban demand met by GWLC – the coverage of remaining regions range between 55% and 65%.

Figure 5 Estimated demand for urban water services which is being met by Ghana Water Company Ltd. by region (2015)

100% 90% 82% 80% 70% 65% 58% 61% 60% 55% 56% 50% 40% 35% 33% 30% 25% 24% 20% 10% 0% Greater Ashanti Western Central Eastern Northern Volta Brong Upper Upper Accra Ahafo East West

3.2.3 Sanitation

Despite starting from a lower base - regional disparities in ‘basic’ sanitation coverage in Ghana follows a similar pattern to water. There is around a 20% difference between the region with the highest sanitation coverage (Greater Accra – 23%), and the region with the lowest coverage (Northern – 3%) - Figure 6. Sanitation coverage disparities are clustered with the three lowest coverage regions found in the Northern part of the country (Northern, Upper East, and Upper West), and all with coverage of between 3-5%. Elsewhere coverage ranges from 10-15%.

Figure 6 Ghana ‘basic’ sanitation coverage, by region

25% 23%

20% 14% 15% 15% 13% 14% 12% 10% 10% 8% 4% 5% 5% 3%

0% Ashanti Brong Central Eastern Greater Northern Upper Upper Volta Western National Ahafo Accra East West (average)

9 To generate this coverage data GWCL calculate daily water demand in m3 as a function of the number of people living in the service areas in small towns and urban areas they serve multiplied by assumed per capita daily water consumption. This is compared water ‘supply’ in m3 based on the reported production data from GWCL systems in each region.

Open defection remains prevalent and is practiced by nearly 1 in 5 Ghanaians (Map 2), around a third Map 2: Number of people practicing (32%) of these people live in the Northern Region, and open defecation, by region all three northern regions together contain 55% of all those practicing OD, despite making up only around 18% of the population.

In general, use of sanitation facilities is much more common in the southern regions. Western Region containing the lowest proportion and fewest number of people practicing open defecation, followed by Easter Region.

National level data on the spatial distribution of sanitation facilities and services are not consistently available - this will be explored in the dedicated section on monitoring systems further below. On an annual basis data derived from the BASIS system is used to rank districts sanitation coverage – however this data is not comprehensive or regularly updated.

Map 3 (below) quantifies the number of people without access to ‘basic’ sanitation and it presents a very different picture of sanitation coverage:

Map 3: Number of people without  Ashanti region contains over four million people access to an improved sanitation without access to ‘basic sanitation’ – this is nearly 20% facility, by region of all those without access nationwide and nearly twice as many as any other region in Ghana. Given that Ashanti is one of the more wealthy regions in the country, could also mean that would be a good candidate for increased sanitation marketing opportunities.

 Upper East and Upper West regions contain comparatively few people unserved by an improved private facility.

Given the low coverage of ‘basic’ sanitation services across Ghana, this distribution of the unserved in Map 3, is more reflective of the difference in regional populations that differences in coverage. Nevertheless, the comparisons of maps 2 and 3 does illustrate the fact that government and donor priorities really matter when making investment and policy decision making. If, for example, the priority sub-sector goal is to reduce open defecation then resource targeting should be informed by Map 2; whereas if ‘basic’ sanitation is the goal, then Map 3 is more effective at illustrating these needs. These maps are also useful entry point for the private sector to assess market opportunities for sanitation products.

3.3 Who are the unserved (wealth equity, group based indicators)?

This section explores how access to improved water and sanitation services varies according to group based indicators: such as wealth, gender, ethnicity and disability. The purpose of this analysis is to identify the extent to which each of these characteristics impact access to water and sanitation services.

3.3.1 Wealth equity

In all cases examined a households wealth (-measured by wealth quintile) was found to be a major determining factor on the level of water and sanitation services attained. Wealth equity was examined separately across urban and rural areas, and across regions – in each case there was a clear trend whereby progressively richer households achieved progressively better service than poorer households. This holds true for access to both water and sanitation services.

Figure 7 presents the proportion of households within each wealth quintile accessing an improved water source, disaggregated by region. It shows clear significant differences across all wealth quintiles in each region, specifically it shows that:

 In all regions of Ghana, the poorest households have the lowest levels of access to, and use of, improved water points.

 There is a profound disparity in access for the poorest households in the western region. A clustering of low coverage households in the certain parts of the western region. This disparity was also identified in our analysis of the DiMES dataset.

 The disparities between the poorest and middle class and rich are stark. In 5 out of the 10 regions of Ghana the proportion of the ‘poorest’ households accessing an improved water point stands at less than 60%, compared to the access for the middle, rich and richest quintiles of nearly 100%.

Figure 7 Regional disaggregation of water access and across quintiles

Figure 8 illustrates wealth inequities identified in access to sanitation services at the national level – note trends described here are very similar to those found in both rural and urban areas (graphs not included). Figure 8, shows that at national level:

 Eighty-eight per cent of all open defecation is practiced by the bottom 40% of the income distribution (-represented by the poor and poorest quintiles).

 The proportion of households openly defecating falls rapidly with wealth – for example in moving up one quintile from ‘poorest’ to ‘poor’ the proportion of households practicing OD falls to 24% (a drop of 40%).

 Almost no households from the richest quintile practice open defecation.

 Access and use of basic (private) sanitation service is largely the preserve of the richest households only. Although a small percentage (<10%) of households across all other quintiles do access and use these services.

 Shared sanitation facilities are rarely accessed by the poorest fifth of households - likely reflecting the fact that ‘public facilities are unaffordable for some’.

Figure 8 Distribution of Sanitation Facilities by Wealth Quintile (National) 2014

100% 4% 5%0% 13% 7% 90% 24% 80% 9%

70% 64% 15% 59% 60% 50% 80% 40% 71% 55% 30% 10% 20% 21% 35% 10% 7% 10% 0% 5% 6% Poorest Poor Middle Rich Richest

Basic service / private Limited service / shared Unimproved No service / open defecation

3.3.1.1 Trends (wealth equity)

Over the eight year period (2006-2014), ‘middle quintile’ households have benefitted the most from water supply investments. Whereas water progress can be seen across all quintiles – the biggest gains have been made in middle quintile households who have seen coverage rise by 17%, and now 94% access 97% 100% an improved source. Considerable gains of 100% 98% between 9-14% were found for ‘rich’ and 95% ‘poor’ quintile households. Over this period 94% the richest households have now achieved 90% 89% full (100%) service coverage. 85%

In contrast, progress amongst the poorest 80% households has been marginal - a five per 77% 77% cent increase in eight years. This provides 75% clear evidence that, to date, investments in 70% 69% the water sector have not been effective in 64% targeting the poorest households. On the 65% contrary, water supply programmes appear to 60% have been effective at providing services to MICS 2006 DHS 2014 those households towards the middle of the Poorest Poor Middle income/wealth distribution. Rich Richest

If these trends persist it’s highly likely that it will be the poorest households, in rural areas, who will be the last to achieve access to improved water services.

3.3.2 Other group related inequities

3.3.2.1 Gender equity dimensions

Analysing DHS data, we find no significant differences in the distribution of water sources with respect to the gender of the household head. In both rural and urban areas female-headed households are more likely to use an improved source of water – but the difference between male and female headed households is marginal (Figure 9 and Figure 10). National WASH monitoring systems do not track any dimensions of gender equity, and these are not issues of WASH and gender issues are not mainstreamed in national surveys. Despite the paucity of institutionalised evidence of gender and equity issues in Ghana – the issues faced are well documented across the global WASH sector. JMP monitoring has demonstrated very powerfully that women and girls shoulder the burden of collecting household water, restricting their time for other activities, including education and work. An analysis of data from 25 countries in sub-Saharan Africa showed that in 71% of households without access, responsibilities for water collection fell to women and girls (JMP 2012). These global findings mirror similar trends identified in a UNICEF baseline report in the Northern Region10, which showed that the burden for latrine cleaning, and water collection fell to women and girls. Similarly, gender- sensitive services for effective menstrual hygiene management and safe and private sanitation are globally recognised as important factors determining access and use of WASH services. In Ghana, the widespread use of shared sanitation facilities across all regions, and the potential impact this may have access amongst women, suggests that this should be a key aspect of future sector monitoring.

10 Akumatey et al., (unpublished 2016), Accelerated Sanitation in Northern Ghana Project – baseline survey for 13 districts and small towns

Figure 9 Distribution of water sources by gender of household head, by area

80% 73% 67% 70% 56% 60% 47% 50% 50% 41% 40% 30% 21% 20% 13% 14% 12% 10% 3% 3% 0% Female Male Female Male Rural Urban

Bottled and Sachet Water Improved Source, excluding bottled and sachet water Unimproved Source

Figure 10 Distribution of sanitation facilities by gender of household head, by area

72% 80% 67% 59% 60% 47% 40% 32% 22% 19% 12% 15% 20% 7% 11% 9% 7% 7% 7% 7% 0% Female Male Female Male Rural Urban

Basic service Limited (shared) Unimproved No service / open defecation

3.3.2.2 Disability

There remains a risk of the needs of persons with disability being excluded – even from apparent inclusive approaches such as CLTS. Wilber and Jones11 note that persons with disability tend not to be present at triggering and their needs are going unrepresented. All CLTS approaches aim to be fully inclusive and the use of participatory and community-based approaches are central to achieving this aim, and form a core component of CLTS practitioner training. Nevertheless inclusivity is difficult to achieve especially when those within the community lack voice in the community, and may even be hidden by their family – as can be the case with the disabled (ibid).

In Ghana, wider awareness of the needs of persons with disability was evident as institutional toilets (schools, office buildings) are generally constructed in a disability friendly manner with toilet seats, rails, ramp access and doors wide enough for wheel-chairs. The same held for public toilets recently constructed by district assemblies. Existing public toilets were also sometimes upgraded to address disabilities - if the district had funds available – but no examples of this were encountered.

At community level we did not find any cases or indications of social exclusion of persons with disability, on the contrary, FGD participants reported that the community ‘safety net’ ensured a level of inclusion (-such as help in collecting water). Nevertheless the fieldwork found

11 Wilbur, J, and Jones, H, (2014), Disability: Making CLTS Fully inclusive’ CLTS knowledge Hub, Institutie of development studies

© Oxford Policy Management, August 2017 15 WASH Sector Equity Analyses for Ghana –Final report that rural ‘communal’ toilets were rarely disability friendly (-despite the occasional ad hoc upgrade by the district assembly). Moreover the prevalence of open defecation practices across large swaths of Ghana means that tens of thousands of visually and physically disabled persons will currently be facing substantial health and physical risk to access areas for OD (Figure 11), or face the prospect of long journeys to a non-adapted communal latrine.

Figure 11 Estimated12 number of visually and physically disabled people practicing OD in Ghana

Region Type of disability 18,000 16,000 Visual/Sight Physical 14,000 Ashanti 11,022 7,102 12,000 Brong Ahafo 3,920 3,297 10,000 Central 5,859 3,914 8,000 6,000 Eastern 10,008 6,948 OD practicing Greater Accra 5,260 2,906 4,000 Northern 12,146 7,803 2,000 Upper East 12,778 6,980 persons disabled of number Estimated 0 Upper West 5,696 3,196 Volta 15,860 9,514

Western 3,298 1,998 Visual disability Physical disabiltiy National 56,187 35,629

In Ghana, there are multiple donor and NGO actors implementing variations on the CLTS approach and it is key that disability issues are given a high profile pre and post implementation. The continued scale-up of CLTS in rural and some urban areas aims to address the fundamental gaps in sanitation coverage outlined above. However persons with disability are those most at risk of being left out of general improvements in sanitation coverage. More research needs to assess whether their needs are given sufficiently high profile during practitioner training, triggering events and as part of ODF monitoring frameworks.

3.3.2.3 Religion/ Ethnicity

In some countries, there are significant disparities in access to public services amongst ethnic, religious, and language minorities. While such minority groups exist in virtually all countries, discrimination manifests itself differently between countries. Group-based indicators (such as race, colour, ethnicity, and religion) are not captured by the main household survey tools of the DHS and therefore cannot be systematically compared with access to WASH services.

In Ghana, a persons’ religion or ethnicity is not observed as a major cause of the disparities in WASH access. Through discussions with key informants and qualalitative discussion conducted during the fieldwork, there were no indications that specific ethnic or religious sub-groups were systematically excluded from access to water services. Rather, the disparities in access which may exist between these groups are driven instead by geographical and socio-economic factors – such as the region and area (-rural and urban), wealth, or on occasion party political affiliation.

12 Estimates made using regional data on open defecation from the DHS, and disability data drawn from the 2010population census

4 Assessing how the WASH sector is addressing equity concerns13

4.1 National polices, strategies and plans

4.1.1 National development plan

Ghana’s overall national development plan for the 2014-2017 period is laid out in the Ghana Shared Growth and Development Agenda (GSGDA II). This document defines key medium-term policy interventions and strategies such as reduction of poverty and inequality; access to potable water, environmental sustainability and hygiene and the provision of basic social services that are available and accessible to all citizens. The GSGDA II lays out a range of different goals and strategies in relation to delivery of WASH services, including those with either an explicit or implicit equity focus - these are summarized and critiqued in Table 3 below. Table 3 Unpacking the equity focus of WASH strategies in the GSGDA II

Equity-related WASH strategies outlined in the # Unpacking actual or potential equity dimensions GSGDA II

The WSSDP has been developed with the stated goal to deliver Developing and implementing a Water Sector 1 'sanitation and water for all' by 2025. This universality of the Strategic Development Plan commitments will require all equity bottlenecks to be addressed

Improving sector M&E. especially improving the understanding and Developing and implementing a comprehensive 2 tracking of key equity dimensions. It is important decision makers to M&E for the water and sanitation sector target resources and design programmes that meet these needs.

Reviewing charges for low-income consumers, specifically strategies to reduce the inequity of the life-line block, the establishment of the 3 Instituting appropriate water charges/tariffs water fund, and exploring options for cross-subsidy between richer and poorer consumers

As shown in the previous section private latrines are almost exclusively used by the richest two quintiles in Ghana. Efforts to expand the access to improved private latrines, especially in urban Promoting the construction and use of improved areas, on a large scale is likely to be unrealistic in the short-term, 4 sanitation facilities by households and institutions and unlikely to be effective for the poor. In the interim more equitable service outcomes should focus on improving the performance and accessibility of other options – such low-cost latrines / and improving the accessibility and affordability of public toilets.

This has a clear equity focus, and is most relevant to MMDAs as they 5 Expanding disability-friendly sanitation facilities construct and rehabilitate shared public latrines.

CLTS promotion is, by design, inclusive of all members of a community and therefore equitable. Further scale up would also Scaling up CLTS and RSMS for the promotion of 6 necessitate a scale up in local resource allocation – particularly household sanitation in urban and rural communities through MMDA allocations to basic sanitation and associated software activities.

This has been developed, and includes an commitment to provide an Developing a Strategic Environmental Sanitation 7 annual contribution of approximately US $6 million (25m GHCs) to a Investment Plan sanitation revolving fund

Relevant by-laws refer to the building code provision to construct household latrines – there may be scope to improve enforcement for Reviewing, gazetting and enforcing MMDAs by-laws new households, and especially in less densely populated parts of 8 on sanitation Ghana. However the unplanned and informal nature of large parts of major city centres (-and especially Accra) makes it next to impossible to enforce these given current low levels of commitment to regulation.

13 Chapter 4 is based on the detailed fieldwork

Overall the GSGDA II, does outline a number of strategies which, if implemented effectively, would directly or indirectly address some of the identified WASH inequities (i.e. improving affordability of water tariffs for the urban poor; improving sector M&E (-to improve report on equity dimensions); and scaling up CLTS and RSMS across rural communities). The promotion of construction of improved household facilities and the enforcement of related by-laws in places like Accra face serious structure constraints related to affordability and available space for household latrines, as well as limited commitment to enforcing by-laws (further explored in the section 4.4.3 on sanitation implementation). The GSGDA does not include any targets around improving services amongst women and children, although disability issues are mentioned.

Themes of equity, and ‘universality’ of service coverage feature prominently national WASH sector policies, strategies, and plans. These are summarised in Table 4 below.

Table 4 Key equity provision within sector polices and plan14

Key sector policies, plans and strategies Key equity provisions reviewed

Water

The focus of overarching water policy is on achieving equity in access to water supply for peri-urban and urban poor to meet their basic needs at affordable cost National Water Policy (NWP) and achieving sustainable provision of and access to potable water to rural communities and small towns, mindful of the need to ensure affordability, equity and fairness for the poor and vulnerable

Sets out the government’s long-term vision for the WASH sector as “sustainable water and basic sanitation for all by 2025” – and call for differentiated service Water Sector Strategic Development Plan delivery options to be implemented in urban, peri-urban, small town, rural and low- (WSSDP) income areas. It also calls for intensive efforts to ‘mainstreaming gender issues’ in WASH services delivery.

Urban focussed, the newly formed Low Income Consumer Support Unit (LICSU) should help target services on the poor and marginalised through tailored and CWCL Corporate Plan appropriate strategies. No specific consideration is given for access for the women or people with a disability.

Rural focussed, and promotes the targeting of poor communities through the construction of point sources and small town piped systems. No specific CWSA Corporate Plan provisions or strategies for targeting service delivery approaches for PWDs, or poor persons within a community. The role of women is emphasised as part of the community ownership and management approach.

Rural focussed strategy, which emphasis the challenges of services provision in poor communities (such as low demand and affordability concerns) leading to National Community Water and Sanitation service breakdown and reversion to unprotected sources. Promotes improved Strategy (NCWSS) mapping of the underserved and development of realistic cost estimates to serve these communities/ sub-groups.

Sanitation

Defines a strict set approved latrine technologies15 to achieve community National Environmental Sanitation Policy sanitation provision, and states that the promotion, regulation and funding of (NESP) community sanitation is left at the discretion of the District Assemblies

Strategy focussed on ending open defecation based on CLTS and sanitation marketing approaches – differentiated according to the ability to pay and needs of Rural Sanitation Model and Strategy the extremely poor and to areas with higher and lower open defecation. It places (RSMS) 2011 the responsibility on the District Assemblies to create demand for household latrines and monitor ODF status. It also discourages the construction of communal latrines in rural areas.

14 Note a local government sector operating manual, and other guidance were also reviewed. These inform the analysis but are not discussed in detail 15 Water closet and septic tank system; pour flush latrines, ventilated improved pit latrine, and aqua privy.

Key sector policies, plans and strategies Key equity provisions reviewed

Accompanying strategy to implement the NESP, but it more aligned with the CLTS National Environmental Sanitation Strategy approaches outlined in the RSMS, rather than focussing on approved types of and Action Plan (NESSAP) sanitation facility, as per the NESP. It is also explicit in its recognition that women and children are particularly vulnerable to service failure.

This contains a small section on sanitation. Specifically it proposes the National Community Water and Sanitation development of lower costs latrines in a manner broadly consistent with CLTS, Strategy (NCWSS) but there is little exploration of appropriate latrine types. Calls for MMDA to enforce bye-laws to trigger the construction of toilets

In general, water and sanitation water and sanitation policies place strong emphasis on serving the poor through differentiated service approaches – however a similar emphasis is not given to the specific needs of sub-groups such as women, children and PWDs.

Moreover, despite the generalised focus on the poor and marginalised running throughout the policy framework, the plans and strategies to serve these areas are often partially implemented or contradictory, for example:

 Practical steps to map the location and the estimated cost of serving hydro- geologically challenged areas and hard to reach communities have not been implemented. The engineering and fiscal challenges of providing water services in such areas are mentioned in National Water Policy, the NCWSS, and the CWSA Corporate Plan. The NCWSS provides the most detailed guidance on these challenges and calls for improved mapping of the unserved, the development of specific cost estimates to serve the hard to reach, and for providing better information on groundwater availability to be shared with MMDAs, but steps have not been taken.

 Despite some progress in recent years, in general GWCL strategies to target poor communities are weak, not mainstreamed across the organisation, not subject to regulatory oversight or measured as part of performance. The recently established Low Income Consumer Support Unit (LICSU) within GWCL spearheads efforts to deliver affordable services to the urban poor. Currently this unit is small, limited to Greater Accra, and interviews suggest that currently it remains marginal to most GWCL operations and strategies.

In respect of sanitation, there are some contradictions and gaps in policy which affects how equity issues are being addresses in the sector:

 Minimum latrine standards are defined differently between government institutions and this undermines efforts to promote household latrines for many of the poor where standards are too high (CWSA/REHSU). The National Environmental Sanitation Policy (NESP) issued by the Ministry of Local Government and Rural Development promotes improved latrine designs, whereas the Rural Sanitation Model and Strategy (RSMS) issued by the same Ministry promotes traditional pit latrines. This generates mixed messages for the MMDAs implementing the policies with some still promoting more costly latrines (e.g. KVIP) which the poor households cannot afford.

 Unclear guidance on latrine subsidies. The RSMS clearly promotes a ‘no subsidy’ approach, whereas the NESP makes no mention for or against subsidies. The uncertainty on this issue has also fed through to differing donor and NGO sanitation implementation approaches and this has tended undermine a consistent approach to promotion of household toilets in all areas.

 The Rural Sanitation Model and Strategy is based on the principle of equity and provides a range of recommendations for the implementation of CLTS, such as tailored approaches in those districts with high / low levels of open defecation. It also promotes a needs-based approach to CLTS to take into account extremely poor, those with HIV, disabilities and elderly. However, Even though extensive consultations were held in developing the RSMS, it has not been widely disseminated to the MMDAs nor has MLGRD provided much support for its implementation. Some Development Partners (DPs) and government staff find the no subsidy approach too prescriptive and would opt for more flexibility in its operationalization.

Some CWSA colleagues are defending the new rural sanitation model launched by REHSU, but most of us are against it. We are promoting latrine subsidies. We need to promote KVIP which allow proper containment”. (CWSA Northern Region)

 The absence of an urban sanitation policy is a major gap. As a consequence policies and strategies do not address key financial and structural barriers which can prevent poor households from accessing household sanitation in urban areas, nor does they reflect the reality of public latrine use, nor their appropriateness, accessibility and use by vulnerable sub-groups. For example:

o As Van der Geest and Obirih-Opareh (2008) report, some district assemblies maintain the ‘public toilets are meant for visitors to the city and not for residents’. Such sentiments, and the overall policy framework, doesn’t face up to the fact that these facilities have become permanent features for many across Ghana – and therefore need to be specifically addressed in policy.

o There is weak guidance on location and management of public toilets - including the absence of guidance on service standards or equity provisions. The NESP restricts public toilets in ‘central business districts, major commercial and light industrial areas, local markets and public transport terminals’ – even though the reality is that the construction and use of public and communal toilets is much more widespread. There is some guidance on public toilet operation in the NESP but limited guidance on issues of public toilet service standards, equity provisions or regulation.

4.1.2 Equity focus of Donors and NGOs

The key donors and NGOs operating in the WASH sector in Ghana are funding a range of different water and sanitation approaches. Almost all have some sort of equity focus, but these vary depending on institutional preference of the donor or NGO:

 The majority of funders in the sector have a pro-poor focus, with four out of ten with project or programmes targeting the urban poor specifically

 Few organisations are explicitly targeting the most hard to reach and underserved communities – perhaps as a result of cost-effectiveness considerations. Those which are doing so tend to be NGOs with limited reach in comparison to the major sector donors.

 UNICEF is the only donor with a strong focus on targeting services at women and children – but these themes are mainstreamed with many of the NGOs

 Targeting services at PWDs is not a priority areas mentioned within any of the major donor strategies or programmes. However large NGO’s including SNV and World Vision do have strategies focussed on adapting services for the disabled.

The majority of initiatives make reference to national WASH policies which they are aligned to. However, some funders continue to implement latrine subsidy programmes which are at odds with the RSMS.

Table 5 Summary of donor programme and equity focus

Name Sub-sector/ programme focus Equity focus (dimensions)

poor poor

finance

CLTS

Subsidy

Children

Women / / Women

Pro (general)

Disability

Sanitation Sanitation Sanitation

Target low Target

Urban poor Urban

Water supply supply Water

Micro

coverage areas coverage

Promotion / IEC IEC / Promotion

Key donor

Agence Française de Développement    ≈ (AFD)

Embassy of the Kingdom of the    ≈ Netherlands (EKN)

Global Affairs     ≈ Canada (GAC)

World Bank    

UNICEF      

USAID  ≈  ≈

NGOs

Global Communities     

Plan Ghana    

SNV      

Water Aid      ≈ ≈

World Vision     

Key  clear focus; ≈ partial focus

There is a general consensus amongst donors and NGOs that there has been marginal improvements in the profile of equity issues within the sector in recent years. Improvement in equity is attributed to a number of factors including the higher profile of equity and inclusion in efforts to address the sanitation challenge (i.e. through the RSMS and CLTS implementation).

Nevertheless, at present NGOs strategies are much more explicit in how they are or plan to mainstream equity issues within their programming. WaterAid, for example, has developed an Equity and Inclusion Framework to guide their programme design. World Vision also has a policy that ensures that every WASH facility provided is gender sensitive and disability friendly, as well as a dedicated unit that deals with advocacy and gender mainstreaming as well as child protection.

4.2 Sector Financing - mapping of WASH resources

4.2.1 Introduction

This section provides a high-level spatial analysis of WASH sector investment flows in Ghana over the last five years, using available data collected at national level. This mapping will be used to better understand the extent to which expenditure in each of the four sub-sectors (rural/urban; and water/sanitation) is both sufficient to meet agreed sector strategic objectives and well targeted to those areas or population sub-groups without access to improved services. This analysis builds upon the findings of the recent ‘TrackFin’ analysis, and provides additional details in the following areas:

1. Donor funding– provide details of the regional focus and scale of donor grant spending in the different WASH sub-sectors in the last five years – based on information shared at national level; and

2. Decentralised WASH spending – provide further analysis of MMDA expenditure on WASH; based on district records and published data from the Ministry of Finance.

4.2.2 The ‘TrackFin’ Initiative

The second round of UN-Water GLASS ‘TrackFin’ Initiative in Ghana was conducted in late 2016. This initiative sought to quantify total annual expenditure in 2014 on WASH from all sources (taxes, tariffs and transfers), disaggregated by sub-sector, expenditure type, and expenditure source.

Overall WASH expenditure in 201416  In 2014, approximately US $1,252 million was spent on water and sanitation services – with water services accounting for around 55% of expenditures and sanitation around 45%.

 The vast majority of this spending (69%) came from household ‘self-provision’, largely consisting of purchasing bottle and sachet water for drinking and paying for use of public toilets – meaning that in many cases access to more aspirational or convenient services is contingent on ability to pay.

 Donor grants to the sector was the next largest component of spending at 14%, with a further 8% of spending coming from loans both to GWCL and central government.

 Direct allocation from the government (primarily through the DACF and DDF) are marginal at just 2% of overall spending.

 NGO and CBO spending is a relatively small component of overall sector allocations at approximately US $6.8 million.

16 Note Trackfin report refers to data captured for the period 2013/14

Figure 12 Overall WASH expenditure 2014

Government agencies Donor (loans / 2% repayable fianance) 8% Donor (grants) 14%

NGOs and CBOs 1% Household (tariffs) 6%

Households (self- provision) Total expenditure (2014) 69% USD $ 1,252 million

Source: Adapted from WHO (2016)

4.2.2.1 Trends in WASH sector spending

Due to improvements in reporting of household and NGO expenditures in 2014, comparisons with WASH sector spending in earlier years can only be made if these costs are excluded (Figure 13)

i) Over the period 2010-2014 sector expenditure ranged between $326 and $443 million. This expenditure peaked in 2012 and has reduced in the two subsequent years.

ii) The 2012 Country Status Overview (AMCOW, 2012) estimated that Ghana requires an annual capital investment of $643 million to reach agreed SDG targets for both water and sanitation. The data below, combined with the knowledge that households are not tending to invest in capital infrastructure and the expectation that Donor funds will leave the sector in the coming years, strongly suggests that existing levels of investments, particularly from government, are insufficient to meet universal coverage goals – especially given the higher per capita costs of reaching the hard to serve.

Figure 13 Estimated annual expenditure on WASH services, USD $ million (exclusive of household and NGO expenditure)

500 443 450 388 385 400 373 350 328 300 250

200 million $ million USD 150 100

Annual expenditure WASH on Annual / expenditure 50 0 2010 2011 2012 2013 2014

Source: Adapted from WHO (2016)

4.2.3 Expanding the Track Fin analysis

4.2.4 Development Partners / Donors and NGOs

The main donors to WASH sector in Ghana are the World Bank, Global Affairs Canada (GAC), The Netherlands, USAID, UNICEF (who are currently the lead partner for the sector and are the recipient of sizable allocations from GAC, the Netherlands, and JICA), African Development Bank (AfDB) and Agence France de Développment (AFD). The EU and DANIDA are currently not funding WASH projects in Ghana.

Over the period 2011 to 201617, the total committed funds from donor grants stands at US$ 485 million – although some data gaps remain meaning that this figure will be an underestimate18 (see Error! Reference source not found.). Over half of donor grant funding (52%) is contributed by the World Bank, followed by GAC (18%) and the Netherlands Embassy (16%).

The sub-sector focus of donor contributions are summarised in Figure 14. These indicate that a little over 50% WASH allocations over this period is focussed on water (either rural or urban), with around 2% specifically focussed on the provision of water in peri-urban areas. Sanitation allocations constitute around 27% of sector spending and are also fairly evenly split between activities in rural and urban areas. The remaining allocations were targeted on various forms of institutional strengthening (13%) and other expenditure of consolidated WASH activities. Figure 14 Estimated donor commitments and expenditure by WASH sector

WASH: Institutional Water: Peri-urban Strenghthening 3% Other 13% WASH: Rural 0% 2% WASH: Urban 6% Water: Urban 29%

Sanitation: Rural 12%

Sanitation: Urban Water: Rural 15% 20%

4.2.4.1 Regional focus

Over the last five years, approximately one third (33%) of donor investments in WASH focussed on Greater Accra largely through the GAMA and Ghana/ Netherlands WASH programme (Figure 15). The next most targeted regions are Brong Ahafo, Central and the three regions on northern Ghana (-between 8-11% of investments each), followed by Upper East and Upper West

17 Note this is not an exact date range. Some AFD funding was committed in 2008, some World Bank programmes are set to conclude in 2019 while some Government of Netherlands projects conclude in 2019. This chosen ranges covers the vast majority of finances. 18 The figure for UNICEF is for 2013/2014 only and these come from its own sources, Hilton Foundation and UNILEVER. Contributions to UNICEF from GAC, The Netherlands Government, JICA (totalling over USD $7 million) have been reallocated to these development partners.

© Oxford Policy Management, August 2017 24 WASH Sector Equity Analyses for Ghana –Final report regions (6% each). The regions attracting the least investment during this period are Eastern and Ashanti regions19.

Figure 15 Estimated grant commitments by region / US $ Millions

180.0 159.9 160.0 140.0 120.0 100.0 85.1 80.0 53.8 60.0 40.8 47.1 28.8 28.8 40.0 21.8 16.9 US$ US$ Millions 20.0 1.1 4.8

0.0 Absolute commitments /

At the per capita level (Figure 16), WASH commitments and expenditure targeting the Greater Accra total approximately US $55 per capita over this period – more than any other region and despite it being the second most populous region of the country behind Ashanti. The inter-regional disparities in donor investments may, in part, explain why regional disparities in coverage persist however the other factors mean that this data shouldn’t be over interpreted20. Figure 16 Donor investments compared with those unserved by WASH, by region

180 1,400,000 160 1,200,000 140 120 1,000,000 100 800,000 80 600,000 60 400,000 millions 40

20 200,000 Numberpeople of 0 0 Ashanti Brong Central Eastern Greater Northern Upper Upper Volta Western Donor commitments Donor commitments US / $ Region Ahafo Region Region Accra Region East West Region Region Region Region Region Region

Donor investment People accessing an unimproved water source People practicing open defecation

Comparison of per capita investment with WASH (-particularly sanitation) coverage gaps shows that in areas such as the Northern Region the exisitng patterns of investment are unlikely to be sufficient to meet national targets. Moreover, we also recognise that the future of sector financing and the gradual withdrawal of donor support, will necessitate a much greater reliance on domestic resource mobilisation to meet these needs. In order for this financing to be well

19 The authors note that the German Development Organisation (KfW) was very active in the Ashanti region in the years in earlier years, and prior to that Ashanti region benefitted from the World Banks’ first and second Community Water & Sanitation project. 20 For example comparing the level of regional investment over a single five year period can give a distorted picture of sector priorities – for example in cases when a large-scale investment narrowly falls outside this range as is the case for investment in Ashanti region prior to 2012.

© Oxford Policy Management, August 2017 25 WASH Sector Equity Analyses for Ghana –Final report targeted, domestic systems and processes of inter-governmental transfers of sector funds will need to incorporate more explicit measures for these needs to be met.

4.2.4.2 Local government financing of WASH

Over the last decades the GoG has gradually developed an increasingly clear and consistent policy framework for reform of the public sector along the principles of decentralisation by devolution to the Metropolitan, Municipal and District Assemblies (MMDAs). The current National Decentralisation Policy Framework (NDPF) and the associated updated National Decentralisation Action Plan (NDAP 2015-19) outlines that five thematic action areas that guide Ghana’s decentralisation reforms; this include fiscal, political and administrative decentralisation.

MMDAs are responsible for the provision of water and sanitation services in their territorial areas. The main sources of income for the MMDAs are the District Assemblies Common Fund (DACF), which is a percentage of national revenue distributed across the MMDAs in the country based on a formula21 approved by parliament. They also receive the District Development Facility (DDF). This consists of funds given as performance grants to the MMDAs which depend on meeting certain specified requirements as prescribed in the Functional and Organisational Assessment Tool (FOAT)22. The DDF is discretionary and each MMDA chooses which percentage to spend on WASH. Another source of revenue for the MMDAs are Internally Generated Funds (IGF) from taxes and rates collected. The allocation of these funds are also discretionary.

In theory decentralisation should mean better allocation of resources to meet the (locally defined) needs of the population - but funds are still limited so there is never enough to go round. Moreover, a report by CONIWAS found that only about half of the DACF provided to MMDAs was through ‘direct transfer (i.e. on an unconditional basis), the rest were tied to national priorities (CONIWAS, 2014).

4.2.4.3 District Assembly Common Fund

Current national level reporting on the DACF – in DACF Annual Report - does not distinguish between expenditure on ‘basic’ sanitation, ‘solid waste management’, and other expenditures associated with environmental protection.

Expenditure on WASH can only be reported against two lines activities for water and sanitation, ‘Water’ and ‘Waste Management’ respectively (Figure 17). This data shows that allocations for ‘waste management’ ranges from around 1-3% in more remote and rural regions (Northern, Upper East/West, Central and Volta), to between 7-13% in the more urban dominated regions (Ashanti, Greater Accra, and Western). Allocations to water are consistently lower at around 1-2% with the exceptions of Upper East (6%) and Upper West (4%). Overall MMDA’s are found to be allocating around 7% of the DACF - well below the 35% assumed by TrackFin23.

Expenditure under ‘waste management’ includes payments to ZoomLion, a central contracted private company undertaking solid waste management in the districts. Payments are deducted from

21 The formula for the allocation of the DACF includes equity as a factor; the other factors being (a) responsiveness (b) need and (c) service pressure 22 However, the decentralisation SWAp report (2016) does recommend incorporation of performance based grant allocations within DACF (use of a revised FOAT) and general management of the DACF in view of devolution (partially in progress). 23 The TrackFin initiative made an assumption that 35% of DACF resources were spent on environmental sanitation, made up of basic sanitation such as provision of public latrines (15%) and management of solid waste (20%). Expenditures from DDF and IGF were not accounted under TrackFin.

© Oxford Policy Management, August 2017 26 WASH Sector Equity Analyses for Ghana –Final report the Common Fund at national level, before the funds are disbursed to the districts, and reportedly accounts for most sanitation related expenditures at local level. District informants stated that this was not an effective arrangement, as ZoomLion was paid regardless of its performance, thereby taking away the Districts’ ability to control and manage performance.

In terms of the overall budget, donor commitments constitute 50% of the district budget, followed by 40% from the DACF and 9% from internally generated funds. The composition of WASH-related spending is even more donor dependent (80%), with the rest made up of DACF allocations (19%), and very little coming from internally generated revenues (1%).

Figure 17 Proportion of DACF spent on Water and Waste Management

20% 18% 16% 14% 13% 12% 10% 7% 8% 7% 5% 6% 5% 6% 5% 4% 4% 3% 3% 2% 2% 2% 1% 2% 1% 2%2% 1% 2% 2% 1% 1% 0%

Water Waste Management (-including environmental protection)

Source: District Assembly Common Fund Annual Report – 2015

4.3 Sector Coordination and sub-national planning

4.3.1 Sector Coordination

The WASH sector has made some advances in improving sector coordination but progress seems to have stalled in recent years. Historically, most interventions in the WASH sector in Ghana have been project driven with little or no government involvement or influence. This resulted in fragmented processes for planning and prioritising investments and increased transaction costs. Attempts to systematically address this situation began in 2006/7 a WASH Sector Working Group (SWG) was established, comprising Government, Development Partners and Civil Society, and was set-up to meet monthly and review critical issues and overall progress of the sector. SWG meetings have become increasingly infrequent and has only met a few times in the last 3 years.

The Water and Sanitation Sector roadmap and code of conduct developed sought to mirror the level of donor alignment and harmonisation which had been achieved in the health sector signed in 2010. In order to harmonise regular sector policy review for effective service delivery, the MWRWH and MLGRD introduced the Ghana Water Forum (GWF) in 2009 for the Joint Sector Review (JSR) process together with Sector Performance Reports (SPRs) that provided an overview of sector progress and highlighting key sector challenges. Only 2 SPRs were produced (2009 & 2010). Annual JSRs were held from 2009 – 2011 but the last was held in 2013. A World Bank report on report on effectiveness of Joint Sector Reviews globally categorises Ghana as basic discontinued (World Bank, 2016)

The development of a Water Sector Strategic Development Plan (WSSDP 2012 - 2025) was also a key step in sector coordination. The WSSDP is a consolidation of the separate sub sector investment plans and strategies into a single harmonized sector plan and included the Strategic Investment Plans (SIP) of the CWSA and GWCL as well as the NESSAP of the MLGRD. The WSSDP aimed to provide a common sector-wide coordination framework and a country assessment study was expected to be carried out to establish the financing mechanism. Although the WSSDP set goals of 100% water supply and sanitation coverage by 2025 there has been no systematic review process to assess progress in achieving these goals and revise strategies accordingly. The WSSDP is therefore more of a plan on paper rather than reality.

These underling constraints reduce the capacity to coordinate funding across is a key constraint to addressing geographical inequities in access. As a result a sizable proportions of sectoral investments are actually made in accordance with donor plans and priority areas which may not be aligned with priority needs – this tendency seems to be borne out in the prior Figure 16 mapping donor investments by region.

The increasingly fragmented WASH sector has significant implications for equity – in particular it means there is no systematic process in place to: i) review and jointly develop an strategy to address those left behind in terms of water supply and sanitation coverage or ii) to effectively review progress against the goal of 100% coverage by 2025.

4.3.2 Decentralised planning and budgeting for WASH activities

MMDA planning and budgeting for WASH services encompasses a variety of sector plans and stakeholders. As a condition of the ‘Environmental Sanitation Management’ performance indicator under the FOAT MMDA’s are encouraged to develop DESSAPs/ MESSAPs which are derived from the NESSAP while the District Water Supply and Sanitation Plans (DWSP) are derived from the WSSDP. The respective district departments are represented in the District Planning and Coordinating Unit (DPCU) and this is where the M/DESSAPs/DWSP are used to support the development of the District Medium Term Development Plan (DMTDP).

However decentralisation has limited impact in addressing WASH equity issues for the following reasons:

 DMTDP plans, however, are generally not effective at incorporating the WASH priorities due to the limited influence of sector departments. Although the central level has ensured WASH equity issues are part of the GSGDA and these have generally been well captured in the M/DESSAPs and DWSP, the translation of these into the DMTDPs has been the weakest link. The water supply section and EHSU are both sub departmental level and under different departments (Works and Health respectively) and the KIIs at that level suggest that their voice in the development of the DMTDPs is weak. Moreover, influence of EHSU at the Health Departmental level is general less than that of Water supply in Works.

 KIIs with MMDAs suggest that government decision makers often prefer infrastructure over software activities because infrastructure lead to tangible outputs that are easier to account for while the outputs from software activities are not so easy to account for. Therefore there is a higher risk that funds for software activities may be wasted in comparison to infrastructure.

 Water supply interventions are largely prioritised based on level of interest and demand from the community rather than attempting to mobilise demand among the unserved. There was little evidence that district staff attempt to identify pockets of unserved

and undertake community outreach to assist them in developing WASH proposals – meaning they are not considered in the investment prioritisation process. As a consequence the more vocal, less remote and politically connected communities will likely receive services first. Relative poverty was not found to be a factor in investment prioritisation. District and regional staff interviewed were not aware of secondary data on poverty, nor did they possess a methodology to measure poverty or the means to carry it out.

 The final decision-making on the local government WASH priorities and funding plans are vulnerable to politicization. Local informants from the field visits mentioned multiple occasions when new water supply investments were added to the DMTDP during discussion at the executive committee – which were unrelated to demand-led considerations. This raises the potential that communities without access to political power, or remote communities largely disconnected from the district capital will be overlooked in district funding:

“Politicians are very powerful – when we budget for 10 boreholes they put them in communities who supported the political party in power. Even a school gets planned, it end up getting built in another community who voted the party”. (DA Nadowli)

“Yes we see a lot of political interference especially in Government of Ghana funded projects. Donors are currently seeing through the political interference and verifying communities before projects are implemented”. (DA Juaboso)

 All MMDAs visited complained about lack of funds and that WASH services have to compete with other basic services. Furthermore, funding for solid waste management contracted at central level (Zoomlion) make sanitation funding look relatively large in comparison to other services so arguments for investing more on sanitation become less convincing. Attempts have been made through the RSMS to mobilise funds for sanitation promotion that “the MLGRD will seek cabinet’s approval to allocate 2% of the District Assemblies Common Fund for sanitation promotion”, but this has not yet been approved.

 Monitoring systems not effectively used for local situation analysis on inequities in WASH coverage. KIIs at the local level suggest that the inventory of existing water and sanitation facilities is not drawn up in a systematic manner but informants tends to rely on District staff ‘walking around’ communities to count facilities.

Decentralisation has not had such an impact on delivery of service for urban water supply as this is generally covered by Ghana Water Company Limited (GWCL) where the planning and budgeting is centrally controlled and there was little evidence of interface with MMDAs or RCCs.

MMDAs reported not carrying out any assessment of urban water demand or coverage gaps. Most capital investments for infrastructure extension are decided on a commercial basis rather than any pro-poor considerations.

CWSA mandate covers small towns but there is some overlap of responsibility with GWCL (see under realities of implementation section). CWSA has offices at the regional level but no representation in the MMDA level planning process and are generally reliant on DP funds for project implementation. They provide technical support to MMDAs if they do manage to get funding support from NGOs or DPs.

4.4 Realities of programme implementation

4.4.1 Equity in Urban water supply

Given that richer people consume more water, they capture far more of the subsidy from the government to GWCL. GWCL falls well short of cost recovery with income from water charges barely meeting the O&M costs (Sector Performance Report 2010). The capital investment costs are mainly for water source development and piped networks and subsidised by the government or donors. With this improved level of service there comes an increase in water usage per capita so even with a progressive tariff, the richest households with their in-house connections consume considerably more water than the poorest 20%, and so capture far more of this subsidy.

Commercial concerns are a higher priority than equity for GWCL, and this has implications of how services are targeted at the poor. GWCL staff interviewed at the regional offices did feel responsible for providing services to all, for example the production manager in Kumasi seemed to know exactly where the unserved poor lived and was proud of the fact that they were piloting an initiative with WSUP and Coca-Cola to improve their coverage to low income householders. However, their main constraint was limited funds for capital investment and business plans submitted to headquarters for funding are reviewed on their commercial viability – and not the pro-poor credentials.

Unwillingness to focus on standpipes as a targeted solution for the poor. Although there have been attempts by GWCL to construct more standpipes in densely populated poorer areas, the commercial culture and influence from richer and more powerful communities means there is still a preference to provide household connections – as illustrated by the quote below:

“If you want to supply water for the poor, stand pipe is the best – because even if household connections are free, the poor cannot pay the bills at the end of the month. There have been instances where NGOs have subsidised household connections, but households are unable to pay bills at the end of the month. In the end they get disconnected. It is mainly NGOs who assist poor communities with standpipes. On rare occasions, GWCL also takes the initiative to provide standpipes for such communities”. (GWCL Greater Accra Region)

With the rapid urbanisation GWCL cannot keep up with demand for water supply services. Expansion of urban water provision beyond the current service areas (i.e. to low income areas) are constrained by the significant infrastructure investments required. GWCL estimates that is requires roughly $2 billion USD annually for infrastructure expansion and feels that the greatest challenge is being able to provide enough volume of water to meet demand, rather than network expansion to the poor or other areas.

“The greatest challenge for reaching the poor is the high cost of laying pipes and making clean water easily available everywhere. Once availability has increased, even the poor can afford to pay for their daily bucket”. (GWCL Northern Region)

“Piped schemes is based on boreholes (not surface water) but boreholes are low-yielding. GWCL only meeting only 25% of estimated demand – so very many private operators have sprung up”. (GWCL Upper West Region)

The regulatory framework for urban water does not include binding provision to serve the poor and the subsidised tariff tends to discourage private investment. There are few incentives for GWCL to focus on the poor and while urban MMDAs may have closer ties with the people could be more responsive to equity needs, funds at this level are limited. There was evidence of the MMDAs trying to encourage private sector investment for small water kiosks in Kumasi (borehole with motor pump to tank and taps for kiosk). However, they indicated that interest from the private

© Oxford Policy Management, August 2017 30 WASH Sector Equity Analyses for Ghana –Final report sector were limited as the returns on investment were not deemed very attractive (especially when compared to public toilets – see below). This is not surprising given that people are used to a tariff that is heavily subsidised so difficult to set a selling price much higher than this.

The establishment of the Low Income Consumer Support Unit (LICSU) by GWCL in Accra signifies a move towards a greater focus on the poor – but its reach and resources are very limited. Initiatives include ensuring more poor household have their own connections by subsidising connection fees; removing the high mark-ups that water vendors charge consumers through public sensitisation on prices, and reviewing the current tariff design which penalizes consumers living in compound housing. LICSU are receiving technical support from WSUP, Water for Life and other NGOs as well as funding from the WB GAMA project but LICSU is in its early stages and still marginal to GWCL operations, an institutional culture change may be required to make it a major part of GWCL’s operations.

Many residents in urban areas, especially the poor, still depend on alternative water service providers. There are a variety of service providers such as tanker providers, private water vendors, sachet water and private water producers (Adank et al., 2011). Rates charged by these alternative water providers tend to be higher than the GWCL tariff. There has generally been an increase in demand for sachet water but is appears to be more as a convenient refreshment than as the sole source of drinking water. Sachet water was widely perceived as better quality than tap but when probed, preference was largely driven by it being cold and convenient. According to GWCL, most producers use piped water as the source and some sachet water is of poorer quality than tap water due to contamination during packaging. As such there does not appear to be significant equity issues regarding the water quality of GWCL services.

Unclear service mandates between CWSA and GWCL undermines systematic planning for small towns, the peri-urban fringes and hydrologically challenges areas. Water supply services for small towns tend to be the domain of CWSA but there is no clear mechanism for CWSA and GWCL to coordinate the planning of water provision in the boundary of cities or for small towns. Discussions at the regional level revealed that GWCL may provide water for towns in areas with difficult hydrogeological conditions (where groundwater not readily accessible) or if a GWCL feeder pipeline runs near rural communities requiring water. On the other hand, CWSA may contribute to urban water provision supplied with production boreholes as found in Wa town where GWCL water supply lines had low yields. However, such collaborations seemed to come about from ad-hoc discussions rather than any formal joint planning process.

4.4.2 Equity in Rural Water Supply (point source)

Women appear to be excluded from roles of responsibility and leadership within community Water and Sanitation Management Team – especially in the Northern regions. In some cases it is reported that the lack of gender mainstreaming at local levels is negatively affecting the sustainability of WASH services in rural Ghana. A review from Care in the Northern region showed a significant link between empowerment activities and the sustainability of WASH behaviours and infrastructure observed over time (Qutbuddin, 2016). These findings resonate with a UNICEF commissioned study on gender mainstreaming “WASH sustainability depends on gender equity since it is unlikely that repair or renewal (of a broken facility) will take place… as it does not affect the daily responsibilities of men” (Ivens 2008).

Few equity risks were reported under the community based management model for rural water supply, as access for PWDs or the poor are covered under a community ‘safety-net’. The communities visited during the fieldwork for the Equity study generally did charge either a ‘pay

© Oxford Policy Management, August 2017 31 WASH Sector Equity Analyses for Ghana –Final report as you go’ tariff of flat rate monthly fee. Neither option appears to lead to significant affordability risks, as:  Under ‘pay as you fetch’ models, the very poorest are usually exempt from paying fees at handpumps, (though not at mechanised boreholes where the running costs of the pump need to be covered).  Under ‘monthly contribution’ models, only “working, able-bodied adults” were expected to pay, with both the poor and elderly exempt from contributing. Furthermore, most of the FGDs with rural communities revealed that it was common practice to bring water to the elderly/disabled who are unable to walk to the water point.

It is also evident from the fieldwork that many Ghanaians invest in their own water supply facilities such as hand-dug wells, boreholes, mechanized wells and rain harvesting systems. Although self- supply tends to be the domain of wealthier households, building the capacity of the private sector to support self-supply can help take some of the pressure away from public service providers so that they are better able to focus on serving poorer unserved households. This might be the only option for households in hydrologically challenged areas irrespective of wealth.

4.4.3 Equity in Urban Sanitation

Trends in urban sanitation suggest a gradual increase in improved household facilities but in the main this only applies to richer households.

A basic sanitation service (private, improved household latrine) is unaffordable for many households – especially the poor covering both rural and urban areas. Communities and district assembly informants indicate that the average cost of urban latrine is estimated at US $706 (max: $1,017, min: $405).

Table 6 Latrine costs as a percentage of household income24

Area Latrine cost as % of annual income Per capita Per household Urban (LSMS data) 25% 8% Urban poor (our data) 39% 13% Rural (LSMS data) 53% 15% Rural poor (our data) 117% 38% All Ghana (LSMS data) 33% 11% In addition to these affordability challenges, the urban WASH challenge in Ghana has been exacerbated by rapid urbanisation with over half (51%) the population living in cities and this trend is set to continue.

Such rapid urbanisation presents considerable challenges for the provision of WASH services – especially sanitation in low income areas. Only 32% of households in Accra are owner occupied and high cost of housing has led to overcrowding of compound houses with the conversion of bathrooms/washrooms into additional rooms to be rented out. Almost all FGDs revealed that the poor (and not so poor) usually lived in rented accommodation and suitable affordable toilets options were just not available.

24 The table below displays both annual income estimates based on our and LSMS data extrapolated from the 2014 survey. The LSMS data indicates that household incomes are on average 3.12x per capita incomes so we used the same assumption for this income data.

While building codes require every house of residence to have a toilet, district assemblies do not have resources or political will to enforce these. District assemblies reported that they do not have the staff to inspect every house – but this also reportedly a function of insufficient political will at local levels to enforce these.

“Sanitation is not a big priority for the government. MMDAs need more political will to be able to do their enforcement work [to persecute landlords without toilets]. We should tie sanitation performance indicators to political performance – so that the government gives more attention to sanitation”. (Tamale MA)

We need CLTS plus enforcement – so that we prosecute landlords who rent rooms but have no toilets. Next we should prosecute the new houses that are being built that have no toilets (Northern Region, ESHD)

The absence of household latrines means people in low income areas are forced to depend on public latrines for a formal place to use a toilet, or are forced to use alternative unhygienic options (chamber pots in the home, ‘takeaway’ bags or open defecation).

However, understanding of the dynamics of individual’s access and use of public latrines remains very low given how important these facilities are in urban areas. Information is not well captured by national surveys or MIS data. However, one study (Peprah et al., 2015) found that the majority of the users of public latrines were adults and only 12% of users were children aged between 5 and 18 despite the fact that this age-group constitutes around up 38% of population of households surveyed. Reasons provided in not using public toilets vary: they not suited for them (children); poor accessibility in terms of distance and toilet characteristics (elderly and disabled), and cost and cleanliness (a cross cutting issue across all groups). Girls in particular indicated that they preferred not using public toilets due to the health risk of infections, safety and general conditions (smell, lighting etc), so often preferred to defecate in a plastic bag.

From the FGDs it was found that young men were more comfortable defecating in the open than women due to reasons of privacy and vulnerability (for young women) but in the more congested urban/peri-urban areas there is less privacy available to practice Open Defecation (OD). Apart from public toilets the other option commonly cited option was to defecate in a plastic bag within the home (termed “shot put or takeaway”) and dispose of it in the rubbish pit or solid waste collection skip or drain.

Urban residents reported that public toilets were an important sanitation option for them – but not used on all occasions, in part because access to services is unaffordable for the poorest. All five FGDs conducted in urban areas, were of this opinion – as it was more manageable to pay a regular small amount rather than a large outlay to construct a private household toilet. However, people who used a public toilet did not access every day, and according to global report card monitoring by the NGO “Global Communities” found that such facilities were deemed an unaffordable option for poor households, and particularly those with many children.

Access to public toilets will also likely depend on issues of wealth and location. Typically public toilets are found in densely-populated urban areas where there is sufficient demand to make it profitable for the private operators, and incentives for the private sector to serve poorer or less populated areas is an issue.

“The Assembly man asked a public latrine operator to come [to our village to set up a public latrine] but he was not interested because there is not enough population here. In town the operator can earn 250cedis per month but here he would not even get half of that”. (FGD in Kwabre East DA, Ashanti Region)

The type of public toilets available include MMDA constructed but privately managed, some renovated and run by private operators and others built and managed through private

© Oxford Policy Management, August 2017 33 WASH Sector Equity Analyses for Ghana –Final report investment. The condition of those visited varied widely with some very clean and well maintained to some in a pretty awful state (dirty, smelly and faeces present). The older MMDA toilets managed by individuals tended to be the worst while the best tended to be those constructed by private investors. In Kumasi the MMDA had attempted to improve the management of public toilets by using a franchise mode but in many cases people still reported that those public toilets built by private individuals were cleaner and better managed. It also seems that they were happy to pay a bit more to use these public toilets.

There was no evidence of any regulation or oversight of public toilets in places visited, or within the wider literature – these activities could be undertaken by MMDA staff as part of the remit of Environmental Health Officer duties. Box 4 below proposed some potential criteria for assessment.

Box 4: Proposed normative performance/ equity indicators for public toilets

All the below would be based on facility assessments conducted by MMDA EHO staff.

 Accessibility: % of public facilities with: adaptation for: child friendly use (appropriately sized) / adaptations for the physical challenged / elderly (adapted toilets and access) / effective menstrual hygiene management (privacy, place for safe disposal of menstrual materials)25

 Appropriateness: % of public latrines which are appropriate to local conditions.

o If piped water available (and good) then water flushed toilets should be minimum standard with specifications covering septic tank(s), emptying options, water tank specifications in case of supply outage (it would quickly become a public health hazard if water shortage occurred), hand washing and bathing facilities

o Where piped water not available: Pit latrine toilets VIP or similar (if VIP must have separate compartments in pit for each vent pipe), easy access for emptying, facilities such as seat etc for disable/pregnant women/elderly, hand washing facilities with some sort of water supply (borehole) and tank for storing water

 Affordability: % complying with national pricing guidelines; (this may include free access for children or PWDs – although this may be difficult to enforce).

 Quality / safety: % which are hygienically safe to use (clean, no insects, limited odour)

Inspected as part of public health visits – to check type of facility; handwashing facilities

Another option that is being tried in Kumasi that shows promise is a Container Based Systems (CBS). This involves providing a toilet that has a regular collection system so can be put anywhere within the house and incurs small regular payment rather than one off large payments. WSUP have been piloting the CBS option in Kumasi with the Clean Team. However, in order to reach economies of scale the price has to be attractive there underlies the constraints to business viability.

4.4.4 Equity in Rural Sanitation

Household toilet options have traditionally focussed more on providing higher level latrines options (e.g. KVIP) without considering the market requirements, particularly regarding affordability. One of the reasons for the low numbers of toilets is the cost - particularly as the KVIP

25 Note similar menstrual hygiene indicators are appropriate for WASH in schools

© Oxford Policy Management, August 2017 34 WASH Sector Equity Analyses for Ghana –Final report was for a long time promoted as the minimum standard with costs of between 3 - 5,000 Ghana Cedis while a traditional latrine can cost as little as 3 - 500 Ghana Cedis. Costs vary and very much depend on the local situation particularly in areas with difficult soil conditions and labour charges. Under CLTS people are beginning to be more innovation around affordable and appropriately designed toilets. However, there is a clear trade-off between using cheaper local materials and the life-span of the toilet as communities interviewed often reported that the walls of pits collapsed after heavy rains and the floor of the latrine collapsed due to rotting wooden poles or poles infested by termites.

When CLTS is successful, evidence of the inclusiveness of the approach was apparent. For example all four CLTS communities interviewed unanimously reported that if an elderly or disabled member of the community was not able to build a toilet, neighbours or relatives would help them build it.

Although the NESSAP / RSMS highlights CLTS as the primary method for promoting household sanitation it is not being uniformly implemented across all districts. The districts visited had widely differing views on whether such promotion could be best achieved through CLTS triggering, or through the provision of toilet subsidies.

CLTS doesn’t work – the community spirit is gone. Also aiming for 80% ODF still actually carries a 20% cholera risk! This is like faecal man slaughter! The poor need latrine subsidies: we have latrines built with subsidies from 10 years ago and they are still used! (CWSA Northern Region).

Yes CLTS works! We still have community spirit here! (DA UpperWest)

The overlapping mandates of REHSU and CWSA on rural sanitation is leading to implementation of slightly different and conflicting sanitation approaches.

In the past, many donor programmes implemented a subsidy approach which has clearly made it more challenging to implement CLTS. Some NGOs still promote a subsidy approach while others have introduced a micro-credit scheme or village savings & loan schemes where households can pay construction cost back in instalments. Communities visited that had experienced subsidises reported that subsidised materials often ended up not being used for toilet construction.

The overlapping mandates of REHSU and CWSA on rural sanitation is leading to implementation of slightly different and conflicting sanitation approaches in part due to the history of two institutions. CWSA tend to advocate for a higher minimum standard for toilets and felt that combining demand-creation with ‘support’ is key for moving up the ladder, and encouraging households to upgrade their basic pit latrines. However, the experience has been that approach does not address equity as most poor households cannot afford the type of toilet options promoted. Hence, it was more common for REHSU to promote pit latrines under a CLTS approach, but for CWSA to promote VIP/KVIPs, usually through a subsidy approach. Some donor CLTS initiatives were coordinated by the REHSU while others were coordinated by CWSA – with no apparent lesson sharing between them. The sanitation coverage data compiled by REHSU using data from the DESSAP does not appear to be shared with CWSA.

4.5 WASH sector monitoring systems

4.5.1 Overview

Summary of sector existing WASH sector monitoring systems

National level - Sector Information System (SIS) is a monitoring system developed by the Water Directorate of the Ministry of Water Resources, Works and Housing – but it has not yet been rolled out. The aim of the SIS is to collate data key sector level indicators from the various WASH sub- sector monitoring systems and it doing so establish a common means of measuring, analysing and communicating results in the sector.

The SIS platform aims to give an overview of coverage of WASH interventions within the various regions as well as districts and communities within the country, such that funding will be tailored to regions where coverage levels are low and also in special cases such as the outbreak of water related and communicable diseases.

To populate the SIS, sub sector agencies and departments within the WASH Sector will collect the primary data on the agreed indicators for their own sub-sector MIS, which will be inter-operable with the SIS Platform. The WASH SIS will then analyse and collate the data for reporting which will then inform the planning and policy development with the Sector.

The value and accuracy of SIS data will therefore be wholly reliant on the quality and type of data inputted in the sub-sector monitoring systems described below.

 Urban water supply – GWCL performance monitoring system provides data on actual supply and projected demand for all GWCL systems. The ratio between supply and demand is reported as percentage covered.

 Rural water supply – District monitoring and evaluation system (DiMES) DiMES is a Microsoft Access based database is set up to capture data on a wide range of details primarily on water infrastructure, including: the specifications, performance and maintenance of existing and newly constructed facilities; the communities where they are located; and the projects that financed them. The DiMES tool is hosted and managed by district assembly staff and has been rolled out across the country. In theory, the system would be updated as part of periodic monitoring at the district level. Information from each district assembly is collated at regional CWSA level and then once again at by CWSA head office for a national overview.

 Rural sanitation - BaSIS is a district-based tool for monitoring sanitation interventions with in-built provision for processing household and community data. BaSIS also possesses capacity for generating regional and national reports on sanitation, rolling up data from the community level. The system allows the district to input and share progress on basic sanitation activities such as Community Led Total Sanitation (CLTS) and Sanitation Marketing.

 Currently there is no information system in place to monitor and collate the provision of, or access to, urban sanitation facilities.

4.5.2 GWCL – performance monitoring system

Urban water supply monitoring is designed to report on operational and commercial performance only of the utility and is an ineffective tool to track progress towards service delivery for urban or peri-urban poor or other subgroups. The GWCL performance monitoring system (PMS) focuses on operational and commercial efficiency with indicators on production, distribution, non-revenue water, and end-line quality of service being delivered. The system does not report on overall coverage in terms of the number and type of people served. This means that

© Oxford Policy Management, August 2017 36 WASH Sector Equity Analyses for Ghana –Final report there is no routine or established means for civil society, regulators or central government to track whether GWCL is effectively targeting the poor or priority sub-groups.

GWCL data collection is driven by the requirements of urban water regulatory framework, which do not include binding provisions on equity. Urban water regulation is the responsibility of the Public Utility Regulatory Commission (PURC) and consists of key performance targets covering operational and commercial aspects, which in turn informs how PURC determines sector tariffs that are reviewed on a bi-annual basis. In theory the PURC has a pro-poor focus, its social policy states that urban water investments should be targeted to serve the poor, but such equity considerations are not part of the current regulatory framework.

4.5.3 CWSA - DIMES

The District monitoring and evaluation system (DiMES) is a potentially powerful national monitoring system to help pinpoint issues of spatial equity in rural areas. It is a Microsoft Access based database hosted and managed by MMDA staff and is used to report on rural water coverage, amongst a range of other performance indicators. DiMES can report water coverage levels26 down to the area-council administrative level and can potentially provide decision makers with a high resolution understanding of the inequities in access which exist - presuming the database is kept up to date.

However districts report inadequate financial resources at local levels for continuous monitoring if external financing is not available27. As outlined previously, the reduction in allocations to operational budgets at district level means expenditure on monitoring becomes increasingly hard to justify. Other than resources, monitoring also requires considerable staff time, and motivation to collect this data. A study by IRC in 2014 found that actual operational cost of the detailed monitoring of rural water services is estimated at between US$ $5,000 and $9,000 per district per year28 - this excludes costs of staff salaries of 6 assembly staff at 25 person (150 days in total), plus allocated time of CWSA regional staff and some project staff.

Incentives for improved data collection are weak – especially if this data is not used for local planning purposes. Data collection (dis)incentives are broken down into three dimensions: (i) the low incentives for districts to invest time and operational resources into periodic WASH functionality monitoring ahead of other possible activities such as infrastructure maintenance and development which brings tangible short benefits for district resident; (ii) the perception that at district level data collection is the ‘end in itself’, as the data is only being used for sector reporting at higher governance levels and iii) the weak individual incentives of district staff to collect this data, in a context when there is little accountability and oversight of their activities – especially in the field. It is hoped that the integration of DiMES with the AkvoFlow water point mapping tool, and mobile reporting via ‘SKY FOX’ SMS will mean that ‘continuous’ data collection under DIMES will become more functional and sustained – but this is still to be seen.

26 DiMES calculates coverage as the function of the administrative area population divided the design capacity of available infrastructure in that areas – for example – a borehole is meant to serve 300 people; a hand dug well 150 people. Note the population figures used by DiMES are extrapolations from 2000 census data and as such, their accurany can be questioned 27 Dutch Government SMARTerWASH project is currently funding the WASH services monitoring exercise in six regions in the country. 28 Kumasi et al., 2014; Monitoring water services in Ghana: the why, the what, the how and the cost – note this is reported in 2012 dollar values

4.5.4 Rural sanitation - BASIS

In theory the BASIS system could be an effective tool for tracking both aspects of spatial equity, as well as inclusivity and effectiveness of rural sanitation CLTS programmes – however institutionalising data collection has proved difficult. BASIS was originally developed by EHSD to systematically capture an array of sanitation data at household level which can then be reported at community, district, regional and national levels. However, it seems that District Assemblies are not making use of the system29 even though computers were purchased and District officials trained. A second iteration of the BASIS MIS has been developed which enables district staff to use smart phones to capture data directly on the field, with rounds of data collection aligned to CLTS protocol (i.e. intensive data collection for the first 6 months and then tapering down over time). This is in its early stages but overall, the roll out and use of the BASIS system remains limited.

In addition MMDA’s collect patchy data on provision of sanitation facilities as part of the development of the DESSAP. Typically a DESSAP may contain information on the public sanitation facilities available in the district and some measure of the number of households with private latrines. In the MMDA’s visited during the fieldwork this data was very patchy, and it was clear that DESSAP data were not representative of all facilities in the district (-either public or private). Whatever data are reported in the DESSAP is collated at regional level by the REHSU – but is not interlinked with any of the sector monitoring systems (DiMES or BASIS) which may feed into the SIS.

Table 7 Potential equity indicators to be incorporated into existing MIS

1) Equity indicator for urban water supply

Currently GWCL performance indicators are largely bases on efficiency of providing water services through household connections. Now they are trying to achieve better services to the poor through LISCU and the interest in whether this will lead to a broader institutional culture change, with an expanded role for the LISCU nationwide. In addition it would be beneficial if they were to develop and track a performance indicator would help to measure progress towards serving the poor,

One simple but powerful performance indicator which may be relatively simple to collected is the: % of water provided through standpipes over total amount of domestic water provided.

This would have annual targets each year to reflect their improved coverage household that cannot afford house connections. The calibration this targets requires further discussion and research.

2) Equity indicators for rural water supply The aim is to ensure this indicator is as simple as possible – leveraging existing data sources (DIMES, SmarterWASH)

29 As part of a UNICEF funded programme, Maple consult undertook a range of assessments across MMDA to assess their capacity for the delivery and management of WASH services. This analysis found that in many cases the BASIS system was not in use, with department staff unware of its function or purpose.

 % of population covered by water services by area council overlaid with hydrogeological conditions. This will require the integration of existing DIMES / SmarterWASH coverage data, with available hydro-geological mapping data

3) Equity indicators for sanitation promotion activities

Monitoring ODF – including a focus on PWDs

 % of districts, disaggregated by region, monitoring ODF communities on an annual basis (based on district annual reviews);

During ODF monitoring, ensure significant emphasis on access for the disabled to ensure they are not invisible to the process – this could be done through routine through more disaggregated programme of district monitoring, such as:

 # of people living in verified ODF environments – disaggregated by age-group, PWDs – as part of 6 month monitoring

Or insights could be derived from periodic outcome surveys which capture:

 % of women and girls, elderly, and people with disabilities living in ODF environments indicating satisfaction with their sanitation and hygiene facilities

 Total number of people (in # and %) segregated by gender, age, and disabilities living in 100% Open Defecation Free communities

4) Equity indicator on financial mobilisation / project targeting

Two types of equity indicator are proposed to track the extent which sector investments are being focussed on the poor and vulnerable, these are:

 Domestic resource mobilisation: Proportion of government expenditure on sanitation promotion. This would require an amended budget line coding for sanitation promotion activities which also includes staff time – this is planned within the next round of NDPC guidelines

 Investment targeting: The current sector information system indicator list suggests the following equity indicator:

o # or percentage of WASH Interventions undertaken in pro-poor and peri-urban areas and the number or percentage of people served by those interventions

Note: the WASH MIS systems do not have a working definition of the poor, and even and national poverty mapping exercises have stalled. Without progress in these two areas it’s hard to envisage how these indicators could be measured and reported. Proxies of this data may include, some type assessment of the ‘pro-poor’ nature of the implementation approach or specific pro-poor adaptations made. However these assessments would be potentially highly subjective (-as opinions on pro-poor approach differ) and potentially limited value.

4.5.5 WASH equity in household surveys

National household surveys do not collect information on intra-household differences in WASH access – such as by age, sex or disability. This seems like a crucial gap, especially in Ghana, given the considerable WASH equity risks posed by shared sanitation specifically for the women, children and the disabled – and the current paucity of representative data in this area.

The most recent DHS (2014) did undertake a specific women’s and men questionnaire – but WASH questions were not included. The women’s questionnaire from all eligible women aged 15-49 covered questions on maternal and child health; plus other questions on knowledge practices and behaviour – which were applied in both surveys. Individual access to, and experience of WASH services was not covered.

Going forward it would extremely valuable both in terms of sector learning and advocacy, to monitor how gender, age, and disability related inequities manifest themselves in public sanitation facilities, as well as attitudes to household facilities. Suggested questions are presented in Box 5 below.

Box 5: Proposed equity indicators for national surveys (DHS, MICS, GLSS)

Access to public sanitation among priority sub-groups – individual questions

 Use of public sanitation facility30: Do you use a public sanitation facility at any time?

 Frequency of use: Times per week accessing a public latrines (disaggregated by men / women / PWD and children (if possible/appropriate)

 Alternative sanitation: Do you have other sanitation options which you use? (disaggregated by men / women / PWD and children (if possible/appropriate). Include options (including plastic bags)

 Reasons for non – use: either at all, or at certain times of day - (disaggregated by men / women / PWD and children (if possible/appropriate)

Household level question

Accessibility of public latrine: return trip to primary sanitation facility disaggregated by wealth quintile

30 Using WSUP definition

5.1 Introduction

The key findings and recommendations of the study are presented in a series of tables (overleaf) examining water and sanitation equity issues related to: sector coordination, financing and sub-national planning; sanitation (rural and urban); water (urban and rural); and sector monitoring. These recommendations are then priortised according to their effectiveness to address equity issues and feasibility in terms of the likelihood that these will be implemented, and guidance is provided as to how these may be implemented.

WASH equity issues related to sector coordination, financing, sub-national planning and monitoring

Underlying problems Possible explanations for why they exist Long-list of possible solutions

Weak coordination mechanize with the sporadic SWG and JSRs 1. Develop a Performance Measurement Framework (PMF) for sector with equity indicators. leave little room for dialogue and actions on the equity agenda.  The SIS is developing a list of “golden” sector level indicators and the recommendations from this study could be used to inform the developing of equity indicators in the SIS. The WSSDP not adequately translated into medium term 2. Annual Sector Performance Report (SPR) with equity focus. The SPR will provide an overview of the 1) Overall, there is a poor development plan or expenditure framework whole sector using the indicators developed under the PMF. targeting of donor and government funds on the hard  The SPR needs to be closely linked to the development of the SIS as these will provide the sector to reach / areas of greatest Sector monitoring systems and national household surveys don’t level indicators and influence the overall design of the SPR. need leading to inequities in report on WASH equity. 3. Revival of the annual Joint Sector Review (JSR) (Water Forum) by key sector stakeholders with the SPR water and sanitation access providing the basis for review sector progress (including equity) and inform sector and national

No clear framework in the sector for reviewing progress in budgeting. A disproportionate share of meeting access goals and making key sector adjustments to sector investments are focussed improve performance 4. Sector Investment Plan (SIP) revised to provide decentralized annual estimates of the water and on a higher level of water supply sanitation investments to meet more realistic targets at district and national levels. This will then be used service for people living in urban to engage with NDPC and MoF in the annual budgeting process. areas or high WASH coverage For cost effectiveness reasons donors/GoG are less willing to regions. invest in hard to reach sparsely populated regions  To be useful, this needs to be fully aligned to the NDPC procedure and tested to ensure that it provides practical and realistic guidance to MMDAs.

Strategy recognises hydro-geologically - challenged areas but no 5. Implement National Community Water and Sanitation Strategy for hydro-geologically challenged areas clear process for prioritising service delivery when provision is (i.e. map the location and the estimate cost of serving hydro geologically-challenged areas and hard to more costly than elsewhere. reach communities)

Even well established and recently updated sector MIS (such as DIMES) are not utilised in the local planning process. 2) Prioritization of investments at local level is based on Measures of poverty are not used in MTDP process in partial data and is subject to contravention of NDPC guidelines. This is partly because there is 1. Strengthen WASH evidence in planning process by district using smarter visual maps political interference which no practical guidance of how measures of poverty should be may counteract equity determined at local levels 2. NDPC should define a criteria for carrying out poverty profiling by MMDAs. considerations in planning. Individual power / party political considerations, can override the establish planning mechanism

1. Sector Investment Plan (SIP) revised to provide decentralized annual estimates of the water and Traditionally the provision of basic water and sanitation, and the sanitation investments to meet more realistic targets at district and national levels. This will then be used monitoring of those services had been financed by donors to engage with NDPC and MoF in the annual budgeting process. 3) Government allocations for  Captured above. WASH are persistently well Lack of transparency over local government financing for basic below required levels so not sanitation (promotion of household sanitation and environmental 2. Evidence based advocacy to demonstrate sanitation promotion is cost-effective in improving household enough resource to address sanitation bundled together). access to basic sanitation inequities in WASH access 3. Greater transparency on sanitation expenditure at local level in order to clearly see spending on Limited GoG funding available for basic services across all sanitation promotion as against solid waste management. (disaggregation of budget lines for sanitation sectors to be incorporated in new budget guidelines)

Underlying problems Possible explanations for why they exist Long-list of possible solutions

 EHSD have already started engagement with MoF and NDPC on establishing disaggregated Generous (and centrally determined) funding allocated for solid budget lines for sanitation to separately capture Sanitation promotion, Sanitation infrastructure and waste management (Zoomlion) makes arguments for additional Solid Waste Management. sanitation funding more difficult 4. Ghana ODF strategy used to engage political support and strengthen coordination at national and local General preference for hardware investments over software – level. which are hard to account for (this mainly affects sanitation  It was felt that this is long overdue and that it would help create wider to commitment to sanitation rather than water supply) at both national and local levels.

Limited influence of water supply and sanitation officials in the district management team

For sanitation, the influence and resource available for the EHSU are less than for water supply – although this may change with new intergovernmental relations

General preference for hardware investments over monitoring – these activities are hard to account for 4) National MIS systems are Systematic monitoring is resource intensive, especially in not-updated / not 1. Rationalise indicators so that IT based monitoring systems are simpler, more robust making it easier for comparison to local government budgets for WASH instutionalised in local the local level to use essential information for analysis and planning. Identify support role from regional government activities- level to assist MMDA in establishing their monitoring system. meaning there is inadequate Traditionally the monitoring of water and sanitation services was 2. Improve local ownership of monitoring systems by tailoring them to the local needs and available data for equity focussed supported and financed by donors resources planning 3. Utilize EHSU staff to also collect water supply information Developed as end in itself rather than ends to a means

Projects tend to introduce their own monitoring systems rather than using GoG system

5) Although WASH sector Sector unable to secure funding for SIP so equity focus takes a goals are Water Supply and back seat 1. Leverage Ghana statistical service, and UNICEF influence, to include WASH equity issues in national Sanitation for all, it struggles household surveys. to measure its performance on reducing inequities An equity focus in national policies has not translated well to 2. Develop sector equity indicators as part of the PMF implementation strategies

Equity in sanitation

KIIs and FGDs

Households toilets Urban areas lack appropriate and affordable toilet options for poor and middle income households. Nationally there is no coherent policy or strategy addressing urban sanitation for the poor and local government opinions on the effective approaches vary. Sanitation policy discourages subsidies for household toiles, yet most municipal assembly respondents believe some form of subsidies (whether cash or with materials) are necessary to bridge the affordability gap. Furthermore, informants are also sceptical of the effectiveness of CLTS initiatives in urban areas due to issues of large-community sizes (limiting community cohesion) combined with low owner-occupier rates and the limited financial incentives for landlords to invest in sanitation – even if partial subsidies are available.

Public toilets The only safe sanitation option available to many urban poor is a public toilet and in general respondents see these as a necessary interim solution in the absence of affordable household toilets. However issues of accessibility and cost means the urban poor or vulnerable often revert to other unhygienic practices at different times. Reasons for occasional use include: inconvenience; not suitable for children; poor accessibility especially for elderly/disabled. Girls/women also cited risk of infections, safety and general conditions (smell, lighting) - so often preferred to defecate in a plastic bag and dispose in gutters/solid waste sites. Patterns of toilet use appears to vary by population sub-groups with male youths most likely to practice OD. Policies and strategies do not reflect the reality of public toilet use, nor their appropriateness and accessibility to vulnerable sub-groups. In some areas (such as Kwabre East in Ashanti), public latrine operators shunned poor or sparsely populated areas due to their lower commercial viability.

Underlying problems Possible explanations for why they exist Long-list of possible solutions

Paucity of low cost sanitation options for urban areas. Private sanitation is unaffordable for most urban households and especially so for the poor 1. Rigorously review current low cost toilet options available at the household level in terms of affordability and suitability in Low owner occupier rates in urban areas (Accra 32%). Landlords are not incentivised to construct latrines on meeting requirements of basic sanitation needs for urban behalf of their tenant poor in Ghana. Recommendations should guide the way forward on appropriate toilet options. 1) Lack of household Urbanisation combined with sharp rises in the price of houses leading to overcrowding of compound 2. MMDAs looking at urban sanitation options (as part of the sanitation facilities in urban houses; and the conversion of bathrooms/washrooms into additional rooms to be rented out Sanitation Challenge for Ghana) should ensure a focus on areas, particularly the urban low cost technology options which are affordable by the poor Sanitation bye-laws on household latrines are often not enforced in part due to capacity constraints and poor. partly due to space constraints, challenges of ‘retro-fitting’, and the owner-occupier dynamic described above 3. Introduce sustainable and replicable credit system for Public latrines are at least partially available as an alternate sanitation option sanitation that provides loans at a reasonable rates 4. Utilize LEAP database for targeting sanitation transfers to households Micro-credit schemes for household sanitation ineffective or not available at scale

Underlying problems Possible explanations for why they exist Long-list of possible solutions

No urban sanitation policy/strategy – existing framework does not address the reality of public latrines and they are not a sanctioned or approved option for urban households. National policy on sanitation and associated strategies should be developed (in the case of urban) and amended (in the case of Political resistance to changing stance on public sanitation facilities rural) to include guidance on public toilets such as: 2) Public toilets are not well addressed within the existing 1. Development of appropriate and simple normative criteria for Very little to no MMDA oversight of public sanitation facilities, as it’s not considered an priority responsibility the assessment and regulation of public latrines, with the aim policy and regulatory of environmental health teams framework – despite being a of improving physical accessibility, quality and safety of fundamental part of the these facilities. Lack of clarity on who would be responsible for public latrine regulation sanitation picture in Ghana. 2. Give guidance on approved appropriate management options with some income coming back to MMDA through Little sector data on how gender, age, and disability related inequities manifest themselves in public latrine license/lease arrangements. Price range should be set by These facilities are used by use and what need to be done to improve these nearly 70% of urban households, local authority and should reflect type of facility guided by a provide a mixed level of services framework for price regulation (which could include free and accessibility to the poor and Public latrines are preferentially cited in areas of commercial viability which may not overlap with low income service for selected groups (e.g. PWDs, children etc)). areas marginalised. Despite this they 3. Establish MMDA as performance regulator of public latrines are subject to very little with powers for enforcement through license/lease being oversight. The number of public latrines is limited by space and cost constraints, which means they become more revoke if standards not met. inaccessible to people with disabilities 4. The performance assessment of public toilets will be undertaken routinely by the MMDA. Public latrines are unaffordable and unsuitable for some (especially low income households, and those with less access to income – women / children)

1. Post monitoring of ODF communities includes some analysis on its impact on vulnerable groups such as disabled, elderly People with disabilities can be excluded 3) Potential equity risks of and female headed households Toilets not constructed with durable materials especially in the rural areas. Hence, in adverse weather CLTS interventions 2. Incremental and continuous upgrading of toilets to ensure conditions, a lot of such facilities risk being destroyed that they become more durable and are able to stand harsh weather conditions

Equity in water Secondary data analysis  Northern and Eastern regions contain the highest number of people unserved (around 1.1 million people representing 36% of the overall total unserved).  There are large swaths of the rural Ghana, and the Northern region in particular - which are not covered by formal water services and this appears to be linked to challenging hydro- geological conditions. ‘Pockets’ or underserved communities were also identified – such as among the poorest fifth of households in western region.  The lowest level of rural water-point sustainability are found in Nothern and Western regions – and the highest were in Upper East and Upper West regions.  Provision of piped water services is also very patchy between regions. At present the Ghana Water Company Limited (GWCL) estimates it’s able to meet 80% of water demand in Accra – however outside the capital this figure falls dramatically and GWCL is estimated to meet between a quarter and a third of demand.  The rapid rise in sachet water in Ghana doesn’t appear to be an equity risk, as consumption within poorer quintiles is minimal and overall it is drunk more as a refreshment than as the sole source of drinking water. KIIs and FGDs In community managed rural systems, access to and paying for water does not appear to lead to equity risks, as communities have come up with a variety of ways to ensure poor and vulnerable are able to access basic water services – should they exist. Nevertheless, the overall functionality of rural water and sanitation teams remains especially weak in a number of dimensions (such as tariff collection, and gender balance) which risk sustainability. In terms of resource allocation – respondents in Northern and Upper-West regions indicate that due to cost- effectiveness considerations donors have been unwilling to invest in certain hard to reach communities which risks perpetuating geographical inequities in WASH access driven by unequal funding allocations.In urban areas, GWCL strategies to target poor communities remain weak – despite recent progress. The life-line tariff is poorly targeted and access to the poor is not tracked as part of GWCL monitoring nor by the sector regulator. Most urban poor rely on standpipes (where available) as household connections often prove too expensive. However, GWCL staff perceive that there is less money to be made from investing in standpipes and GWCL’s which translates to a greater emphasis on in-house connections – at the cost of services in low income areas. For the urban poor, fewer standpipes mean increased time in water collection (distance and queuing) and greater reliance on alternative unsafe water sources as was found in Tamale in the Northern Region.

Underlying problems Possible explanations for why they exist Long-list of possible solutions

Commercial imperative to ensure sufficient financial resources are available to maintain performance and the sustainability of existing services

Pro-poor components of the GWCL compact and PURC social policy are not implemented 1. Strengthen the oversight role of MSWR on urban water services particularly in addressing the service provision to the urban poor through guidance to planning and investment. Link to PMF/SIS equity indicators for urban water Regulatory framework implemented by PURC does not have 1) The organizational culture equity focussed KPIs 2. A specific pro-poor indicator included in GWCL’s performance indicators and PURC regulatory of the GWCL is strongly framework, as suggested below: weighted towards commercial “% of water provided through standpipes over total amount of domestic water provided” considerations rather than GWCL performance monitoring does not report against any serving the poor – leading to equity sub-groups (i.e. services for the poor) 3. Tariff increase based on the extending water access to low income areas persistent service gaps 4. Donor support to urban water to follow (OBA) type of arrangement to ensure services reach the poor GWCL does not have a working definition of the ‘poor’ or a spatial map defining the poor within or on the edge service 5. Continue strengthening GWCL on pro-poor support nationwide area nationwide. 6. The above could also be applicable to CWSA in their new institutional role

Most urban poor rely on standpipes and cannot afford household connections but there is resistance from GWCL and policy makers to increase standpipe services as household connections are the preferred option.

Low owner occupier rates in urban areas (e.g. Accra 32%). Landlords are not incentivised to connect to the systems and 1. Ensure the LICSU continues to evaluate and scale up nationwide suitable options for addressing proof of property ownership to one of the criteria for household water needs of the poor: connection. a) Separate meters for tenants;

2) Barriers to connection for Unaffordable water supply connection costs b) GWCL life-line tariff for tenants sharing meter so bill divided by number of tenants (each the poor getting lifeline tariff) Distribution system not being extended to areas with the c) GWCL life-line tariff applied to all standposts unserved poor d) Repayment plan for connection fees for the poor Standpipes operators can exploit water pricing in times of high 2. Improve GWCL oversight of standpipe operators demand

Traditional cultural and social dynamics inhibiting female 3) Women are being excluded leadership roles within the community – especially in the from positions of leadership in northern regions WASH – especially at the 1. Strengthen support to Community Based Management in both training and establishment of WSMT community level – and it impacts on WASH service Lack of sufficient gender mainstreaming at the formation at all sustainability. levels in the sector

NCWSS guidance not implemented (mapping of the unserved, cost estimates to serve the hard to reach, and better information on groundwater availability shared with MMDAs.)

VfM and cost effectiveness considerations disincentivise donor /GoG investments in hard to reach areas 4) The most expensive and 1. Decentralised SIP takes into account higher costs of providing water supply services in hydrologically hard to reach communities in No clear framework in the sector for reviewing progress in challenged areas and used to advocated for increase funding allocation remote and hydro-geologically meeting access goals and making key sector adjustments to 2. Mobilisation of remote unserved communities to demand water services challenged area will remain improve performance unserved 3. Increased ownership rural water monitoring systems DiMES monitoring data can be unreliable, and is not mainstreamed in donor or local planning process

Remote communities are isolated from local government agencies and are not considered and can be marginalized in local planning processes

5.2 Prioritising recommendations

The long list of recommendations were subsequently assessed and priortised according to their effectiveness to address equity issues and feasibility in terms of the likelihood that these will be implemented. This assessment was done through consultation with sector experts during the validation workshop, and via further discussion within the consultancy teams. A visual representation of the priority recommendations are presented in the figures below, and these are accompanied by further explanation of how these could be implemented.

5.2.1 Sector coordination, financing, sub-national planning and monitoring

Although the Government of Ghana has a vision of water and sanitation for all, the above findings highlight a number of areas limiting progress towards this goal. In addressing these inequities there is a clear need for more effective mechanisms for measuring and analysing progress towards equity which will in turn help guide more effective investment planning and strategy development towards meeting this goal.

5.2.1.1 Recommendations

1) Strengthen Sector Coordination and Planning for achieving goal of sustainable water and basic sanitation for all a) Define sector level indicators for measuring and tracking sector performance in an equity focussed performance measurement framework. The indicators would define sector performance in meeting annual targets and the goal of sustainable water and sanitation access for all, and must therefore incorporate indicators tracking progress among disadvantaged groups. Typically 8 – 10 headline indicators would provide the structure for an annual Sector Performance Reports (SPR) and we recommend that at least half of

these would report on equity issues31. Specific indicators to be considered have been outlined in the monitoring section and include: i. Rural water supply coverage to people living in hydro-geologically challenged areas ii. Proportion of urban water supplied by GWCL through public standposts iii. Proportion of MMDA funds spent on sanitation promotion iv. Public toilets providing a standard level of service (access) and usage b) Revitalize an annual Sector Performance Report with strong equity focus. The SPR should provide an analysis of annual progress against sector targets. As well as the headline indicators outlined above, the SPR should routinely incorporate data from periodic survey or studies to highlight specific issues regarding the poor or disadvantaged groups. c) Revive the annual Joint Sector Review (JSR) framed around the SPR findings and recommendations. The JSR provides a forum for sector stakeholders to review progress and discuss adjustments to be made to sector strategies and plans, implementation approaches and resource allocation. The main output from JSR deliberations would ideally take the form no more than 5 realistic key sector undertakings chosen from the long list provided in the SPR. The idea is that the undertaking are achievable within one year and their status rigorously scrutinized by the sector working group and next JSR. d) Develop a realistic Sector Investment Plan (SIP) including rigorous costing to reach vulnerable groups (e.g. peri-urban poor) and difficult to reach locations (e.g. hydrologically challenged/sparsely populated areas). This provide annual estimates of required water and sanitation investments disaggregated by district based on the size of unserved population and the estimated per capita cost of water and sanitation access - differentiated by service level, type of group and location. e) Develop an ODF Ghana Strategy with simple framework but high level launch. This is aimed at harnessing political and public commitment to prioritise sanitation at all levels. The launch should include a strong publicity component including an ODF Ghana logo, IEC support materials, mass media and profiling of sanitation champions from public and private domains. 2) Strengthen equity in monitoring by improving information flow for more functional SIS and quality of equity information for selected indicators

31 An alternative option would be to create a performance management framework solely focussed on equity indicators. As it stands the recommendation purposely embeds equity issues alongside other performance indicators as part of a push to mainstreamed sector performance report. The authors feel that this will help insure equity are not marginalised in further reporting cycles.

Next steps to establishing these recommendations:

iii) Develop an approach and associated guideline for updating the decentralized sector investment plan at district level. This should incorporate local coverage targets, different technology options, and cost estimates of service provision for difficult to reach groups and would be used to engage with NDPC and MoF on more equitable resource allocation at the district level

5.2.2 Equity in Sanitation

5.2.2.1 Recommendations

1) National policy on sanitation and associated strategies should be developed to include guidance on public toilets in urban areas

the provision of these facilities in unserved and poor areas and explore options for reducing the cost of access for the poor (including free access for children), and vulnerable.

Next steps to establishing these recommendations

II. Conduct further research and consultation on best practice including management and regulatory arrangement for public toilets operating in urban areas

5.2.3 Equity in water

5.2.3.1 Recommendations

1) Establish a dedicated budget line reporting on investments in hard to reach areas in rural areas – this will be informed by the costing analysis undertaken as part of the decentralised sector investment plan (-see recommendation 1d) 2) Improve the equity focus of Ghana Water Company Limited (GWCL) to ensure continuous expansion of services to the urban poor, through the following actions:

Next steps to establishing these recommendation:

6 References

 Akumatey et al., (unpublished 2016), Accelerated Sanitation in Northern Ghana Project – baseline survey for 13 districts and small towns

 CONIWAS (2014), Analysis of 2014 Budgetary Allocations to Water, Sanitation and Hygiene (WASH) Sector

 Exley J, Liseka B, Cumming O, Ensink J (2015), The sanitation ladder, what constitutes an improved form of sanitation? Environ Svi Technol;49:1086–94

 Ghulamali, Sabah Qutbuddin (2016); Program Evaluation of a Gender Mainstreaming and WASH Intervention in Upper West, Ghana, PhD Thesis, Emory University

 Giné Garriga, R; Jimenz, A, Perez Foguet, A (2011), A closer look at the sanitation ladders of issues of monitoring in the sector, 35th Annual WEDC conference, Loughborough University

 Heijnen, M., Cumming, O., Peletz, R., Chan, G.K.S., Brown, J., Baker, K. and Clasen, T., 2014. Shared sanitation versus individual household latrines: a systematic review of health outcomes. PLoS One, 9(4), p.e93300.

 IRC Ghana (2015), Factsheets on rural and small towns water services in Brong Ahafo Region, Central Region, Northern Region, Upper East Region, Upper West Region, and Western Region

 Ivens, S, (2008), "Does Increased Water Access Empower Women?" Development 51.1; 63-67

 Marieke Adank, Bertha Darteh, Patrick Moriarty, Henrietta Osei-Tutu, David, Assan, Daan van Rooijen (2011), Towards integrated urban water management in the Greater Accra Metropolitan Area: Current status and strategic directions for the future

 Mazuea, A (2013), No toilet at home: implementation, usage and acceptability of shared toilets in urban Ghana, PhD Thesis, Loughborough University

 Peprah, D., Baker, K.K., Moe, C., Robb, K., Wellington, N., Yakubu, H. and Null, C., (2015) ‘Public toilets and their customers in low-income Accra’, Ghana. Environment and urbanization

 Van Der Geest, S. and Obirih-Opareh, N., 2008. Liquid waste management in urban and rural Ghana: privatisation as governance?. In The Governance of Daily Life in Africa (pp. 205-222).

 WHO/UNICEF (2012), Progress update on drinking water and sanitation, Joint Monitoring Prgramme, Geneva, Switzerland

 WHO/UNICEF (2017), JMP Country File Ghana: Estimates on the use of water, sanitation and hygiene facilities – January 2017, Joint Monitoring Prgramme, Geneva, Switzerland

 Wilbur, J, and Jones, H, (2014), Disability: Making CLTS Fully inclusive’ CLTS knowledge Hub, Institutie of development studies

 World Bank (2016), Effective Joint Sector Reviews for Water, Sanitation and Hygiene (WASH), Washington DC, USA

Policies and strategies reviewed

 National Community Water and Sanitation Strategy (NCWSS)

 National Environmental Sanitation Strategy and Action Plan (NESSAP)

 Rural Sanitation Model and Strategy (RSMS) 2011

 National Environmental Sanitation Policy (NESP)

 CWSA Corporate Plan

 CWCL Corporate Plan

 Water Sector Strategic Development Plan (WSSDP)

 National Water Policy (NWP)

Annex A Methodology – secondary data analysis

A.1 Objectives

This objective of the secondary analysis was to assess the current status of inequalities in access to WASH services in Ghana:

 which indicators (as currently defined in the evolving SDG WASH indicators guidance2) show the greatest level of disparity in coverage?

 how has this status changed over time? A.2 Overview of data

In order to conduct this secondary data analysis, we consider nationally representative, cross- sectional data from large surveys. The ToR identified the set of household survey data which will form the basis of the secondary data analysis. These are the: DHS (2008 & 2014), MICS (2006 & 2011) and GLSS (2006 & 2013) survey datasets. The key characteristics of each of these datasets is presented in Error! Reference source not found. below:

Table 8 Available quantitative data

Sample Wealth Sanitation Water Survey Disaggregation* Size Quintiles Categories Categories

Ghana Demographic 11,778 Health Survey JMP core (GDHS) 2008. 10 x regions, Assets JMP core questions, urban/rural, wealth Ghana (wealth) questions only drinking quintiles Demographic water 11,835 Health Survey (GDHS) 2014.

Multiple Indicator Cluster Survey 5,939 Very similar (MICS) 2006. 10 x regions, Very similar to JMP core Assets urban/rural, wealth to JMP core questions, (wealth) Multiple Indicator quintiles questions only drinking Cluster Survey 11,925 water (MICS) 2011.

No facilities, Ghana Living Very similar W.C., Pit Standards Survey 8,687 Accra / Other to JMP core latrine, KVIP, (GLSS) 2006. Urban / Rural questions, Consumption Bucket/Pan, Coastal / Rural separately (poverty) Public toilet, Forest / Rural for drinking Ghana Living (WC, KVIP, Savannah and general Standards Survey 16,772 Pit, Pan, use (GLSS) 2013. etc.), Other

* Although DHS 2008 and 2014 have variables for regional and wealth quintile stratification, the sample in the survey is not necessarily representative of the population distribution within these specific strata.

As discussed in the technical proposal, we characterise two levels of analysis for the quantitative assessment of secondary household survey data. Level 1 – analysing existing data tables in the respective survey reports, producing our own graphs in Excel where necessary, and Level 2 - uploading the raw data files into Stata and re-analysing it to get additional insight which is not in the survey report itself along the key equity dimensions. During the finalisation of the project work-plan with UNICEF, the scope of analysis was agreed to cover a Level 1 analysis of all 6 of the relevant surveys, plus a detailed Level 2 ‘deep dive’ analysis of DHS surveys in 2008 and 2014 (-described below).

DHS 2008 and DHS 2014

The Ghana DHS 2008 and 2014 are the fifth and sixth in a series of population and health surveys conducted in the country as part of the global DHS program, respectively. The surveys were implemented by the Ghana Statistical Service (GSS) in collaboration with the Ghana Health Service (GHS). DHS 2014 was also implemented with the assistance of the National Public Health Reference Laboratory (NPHRL) of the GHS.

Data collection of the DHS 2008 was carried out between early September and late November 2008. The survey encompassed an overall sample of 12,323 households, of which only 11,778 were successfully interviewed. These households represented 412 clusters from the master sampling frame. Data collection for the DHS 2014 was carried out from early September to mid-December 2014. The survey encompassed covered 12831 households, of which only 11,835 were successfully interviewed. They represent 427 clusters (216 urban and 211 rural).

Both surveys used a two-stage sample design based on an updated sampling framework from the 2000 and 2010 Ghana Population and Housing Census, respectively. These frameworks were intended to allow estimates of key indicators at the national level and for each of Ghana’s ten administrative regions, allowing for separate estimation for urban and rural populations. The first stage involved cluster selection using systematic sampling with probability proportional to size. The second stage involved a further systematic sampling of households, where about 30 households were randomly selected from each cluster. Since each region was approximately equally represented, the sample is not self-weighting at the national level. Weighting factors have been added to the data files. The GDHS reports advise the use of importance weighting in Stata when using the datasets.

A.2.1.1 Scope of the analysis The purpose of the secondary data quantitative analysis in this project is to help identify the status of inequalities to access of WASH services in Ghana. This is achieved by investigating:

 The household and population distribution of the water provision services

 The household and population distribution of the sanitation facility services

The analysis is primarily descriptive, dissecting the chosen sample of nationally representative data across various dimensions in order to improve our knowledge of the temporal evolution and present conditions of these WASH services. In particular, we construct various frequency tabulations of the sample distribution for the relevant WASH indicators. Our ‘deep-dive’ level 2 analysis, employs the following key WASH indicators that are available in the GDHS (2008, 2014) surveys: source of

© Oxford Policy Management, August 2017 WASH Sector Equity Analyses for Ghana –Final report drinking water, time to get to water source, type of sanitation facility used, location of sanitation facility, sharing of the sanitation facility and time to commute to sanitation facility.

A.2.2 Overview of analysis

Level 1 analysis

All these were used as comparators for the DHS data, insofar as the reported indicators allow:

MICS 2006 + 2011 (all stratified by region, rural/urban, wealth quintile32)

- Main drinking water source (including bottle and sachet water)

- Round trip time to source of water

- Type of sanitation facility accessed

MICS 2011 only (stratified by region, rural/urban, wealth quintile)

- Reports two separate sanitation categories – access to a ‘Public latrine’ and access to an improved sanitation facility shared by <5 or >5 households. We’re able to use this data to compare with the sharing data we have in our DHS analysis. The indicators are not directly analogous as DHS doesn’t report on public latrines, but we can make a comparison based on the assumption in DHS that a latrine shared by more than ten households is de facto ‘public.'

GLSS 2006 + 2013 (stratified by Accra/other, rural/urban, coastal/rural Forest/rural Savannah)

• These provide a slightly different perspective that either DHS or MICS as it reports access slightly different administrative disaggregation. Urban areas are divided into two sub- groups (Greater Accra and ‘other urban), rural is sub-divided into three ecological zones (Coastal, Forest, and Savanah). Direct comparisons on coverage are only possible at area levels only (national, urban, rural); but we will also report the ‘zone’ figures as part of our overall landscaping of the WASH data.

Level 2 analysis

At this level, we first uploaded the raw data files obtained from the DHS website into Stata (OPM’s preferred software for analysis). In the analysis we have used various combinations of population stratification from the following: 1) area (urban/rural), 2) region, 3) wealth quintiles 4) gender of the household head and 5) education level of the household head.

In the water subsector, we analysed the distribution of households and a de-jure population of the country by 1) main drinking water source (including bottle and sachet water) and 2) round trip time to the source of water. In the sanitation subsector, we analysed the same distributions by 1) type of sanitation facility accessed and 2) round trip time to latrine facility (DHS 2014 only).

Our primary procedures included sample tabulations of access and round trip times to water and sanitation facilities by:

• Regions and Area

32 Note the MICS quintiles are consumption not asset based, and therefore is not directly analogous to the quintile generated in DHS

• Wealth Quintiles, Region, and Area

• Gender of the household head, Region and Area

• Education level of the household head, Region and Area

Furthermore, we extended our analyses to include:

- Investigation of the distribution of households that share latrine facilities for all types of such facilities. With this data, we’re also able to discuss various thresholds for what may be considered an acceptable level of sharing (i.e. with more or less than four households to align with current SDG thinking).

- Identification of the distribution of sample clusters that are open-defecation free versus the proportion of households that report ODF practices.

- Hypothesis tests to evaluate the significance of differences in access to improved water and sanitation facilities across regions and wealth quintiles .

- Reconstruction of the DHS wealth index for isolated investigation of rural and urban populations in order to unveil hidden inequalities to a water source and sanitation facility access.

- Summary analysis of hygiene (as outlined in section 1.1 of the report)

Some of these extensions are worthy of additional explanation and are illustrated as follows.

Open-defecation free (ODF) clusters

This extension was designed to identify clusters in the sample that are free from households that openly defecate, as well as the magnitude of the open-defecation problem faced by clusters that are not free from it. We choose to analyse ODF at the level of the cluster since they comprise roughly 30-odd randomly samples households, which are close enough to affect one another’s hygiene conditions. Learning about the distribution of ODF or non-ODF clusters is very informative from a policy perspective for equity.

Hypothesis testing for differences in water and sanitation access

Here, we conduct simple hypothesis (t-test) tests that could be broadly classified into two parts. First, we seek to identify the significance of the differences in mean improved water source access between the wealth quintiles for the whole DHS sample, as well as for each region separately. We test these differences for all possible pairs of quintiles. Second, we test for differences in mean improved water source and mean improved sanitation facility access between the 10 regions. Here too, all possible pairs of regions are tested. These significance tests enable us to ascertain whether estimated mean differences are in fact non-trivial and representative of the true population or whether they are negligible and a likely random draw.

Wealth index for isolated urban/rural investigation

The wealth index is a composite measure of a household’s cumulative living standard. The DHS wealth index is based on data collected in the household questionnaire. It is calculated using asset- based data such as televisions, bicycles, materials for housing, and also includes types of water access and types of sanitation facilities, etc. (DHS, 2016). These assets are used to construct an

© Oxford Policy Management, August 2017 WASH Sector Equity Analyses for Ghana –Final report asset index using Principal Components Analysis (PCA) (Filmer and Pritcett 2001; Rutstein and Johnson 2004). This score is then converted into quintiles that rank households based on wealth.

It is acknowledged here, as has been done by others, that as the PCA calculations include water and sanitation as assets, it creates a risk of or biasing the results when analysing the distribution of water and sanitation outcomes by quintile. Although this remains a potential confounding factor in undertaking WASH analysis using the DHS quintiles, recent studies have shown the DHS, and MICS indices remain good proxies for the distribution of disparities in improved sanitation, and moreover, their standardisation enables comparison with other equity analyses (Rheingans et al., 2013).

A more fundamental limitation with such indices is that they are often created on the basis of a national sample population whereas wealth is strongly related to either urban or rural setting. The DHS wealth index construction handles this concern by adopting a 3-step approach in its procedure. This involves the construction of separate indices for urban and rural households using PCA, which are then combined into a national index by using regression analysis (Rheingans et al., 2013).

In our analysis, we initially used the DHS reported national wealth quintiles (-i.e. including water and sanitation as assets) to assess relationships between wealth and water and sanitation access. However, we found that this national-level analysis is not able to provide us with a clear perspective on the true WASH conditions for some sections of society, for instance, the urban poor. Therefore, we conducted a discrete analysis of urban and rural quintiles in order to assess coverage and track progress in both settings in a more effective manner.

These area-specific quintiles were constructed using the standard PCA procedure, implemented in Stata. It is worth noting that our method is a more basic version to that used for the original DHS wealth index, and hence yields different results. For estimation of the principal components, we considered all but one (whether or not the house is owned by its members) of the variables as in the original DHS wealth index. Furthermore, our procedure was more elementary in that than we simply used the raw factor loadings from the PCA for predicting the wealth scores. On the contrary, the original index uses a normalized version of the factor loadings for the same task.

Annex B Methodology – fieldwork

B.1 Objectives and data collection tools

This work was undertaken using two data collection instruments suggested in the ToR – focus group discussions and key informant interviews – as well as through individual case studies. The approach to each instrument is set out below, alongside detail on the logistics, conduct and limitations of the fieldwork.

6.1.1 Objectives of the primary data collection

The primary data collection was used to further explore the equity dimensions of the WASH secndar data analysis under Component A and equity policies under Component B, with the following aims:

 Are there regional differences in awareness of national WASH policies and strategies?  Which political-economy dimensions drive observed disparities in financing of WASH initiatives in different regions?  What drives the regional differences in the implementation of WASH programmes by government and donors?  To what extent do the WASH programmes implemented have an explicit equity focus?  Which impacts do WASH inequalities have on different groups within communities?

These aims will be further explored through KIIs at national, regional and municipal/district level, and well as through FGD at community level. These tools are discussed in turn below.

6.1.2 Tools: Key informant interviews (KIIs)

KIIs set out to explore the challenges behind WASH planning, in order to understand how these would affect inequities in service provision. The following key themes were covered though a combination of open-ended and closed questions asked during the interview:

 Planning/budgeting for WASH in their Region/District;  Types of WASH interventions undertaken (by government agencies, NGOs and private actors) in their Region/District, probing on pro-poor exemptions and disability provisions; and  Extent of monitoring of WASH access.

These KIIs were undertaken at three levels, allowing cross-checking and triangulation of information across different levels:

 At national level, informants included staff from the three National Government Ministries (MLGRD, MOF, and MWRWH) and relevant government bodies (GWCL, CWSA and PURC) responsibility for water and sanitation and financing, decentralisation (the NDPC) and national statistics (Ghana Statistical Service). We also interviewed staff from several NGOs active in the sector.  At Regional level, we interviewed regional staff of the GWCL, CWSA and REHSU in every region visited.  At Municipality/District level, we held a group discussion with key staff of the Municipal Assembly Office (in urban areas) and of the District Assembly Office (in rural areas) in every district visited. Key staff included the Coordinating Director, WASH Engineer, Environmental health officer, Finance officer, and Planning officer.

Further detail on sampling and sample sizes is given in Section 6.1.6 in the Annex below, with the full semi-structured interview guides for KIIs at different levels presented in Annex D.

6.1.3 Tools: Focus Group Discussions (FGDs)

The Focus Group Discussions (FGDs) set out to explore whether there were inequities in WASH access and use within the community, and what impact these had on different community members. Focus group discussions offered the possibility to discuss different and similar experiences within the study communities. As a secondary aim, the extent of WASH coverage documented through the FGDs could also be triangulated with the analysis of service levels under Component A.

The following key themes were covered in FGDs, with discussions centred around a participatory mapping exercise33 of the community:

 Main types of water sources used – exploring affordability, reliability of service, distance to source, exemption of fees for the poor, and accessibility for the disabled/elderly;  Main types of sanitation options used – exploring affordability, distance to latrine, exemption of fees for the poor, preferences of women/adolescent girls, attitudes towards open- defecation, perceptions on latrine sharing, awareness of different latrine designs, accessibility for the disabled/elderly, and attitudes to handwashing;  Extent of community participation in water point and public latrine siting;  Exploring the affordability and demand for improved water sources and improved latrines;  Extent of community mobilisation received on sanitation and hygiene behaviour change;  Extent of contact with District/Municipal assembly re accountability for service provision.

As there was unfortunately not enough time and budget to hold separate FGDs with men and women, gender-sensitive issues which particularly concerned women and girls were explored with the remaining female participants separately, through a separate follow-on discussion after the FGD. The topics covered were:

 Concerns around access to public latrines for women

 Concerns around hygiene and safety and

 Menstrual hygiene aspects34.

Further detail on sampling and sample sizes is given in Section 6.1.7 in the Annex below, with the full FDG discussion guides presented in Annex D.

6.1.4 Tools: Individual case studies

Each FGD threw up certain issues which merited further exploration. To achieve this, we followed up every FGD with a number of individual case studies, depending on the time available, to explore particular aspects of WASH service provision at community-level in more detail. These case studies allowed the research to paint a richer picture of WASH inequalities. Case studies entailed short one- to-one conversations with the following:

33 A community member was asked to draw the outline of the community, indicate the location of roads, major settlements, rivers, public water points, public latrines and areas of open defecation. This information was drawn in a participatory manner with frequent validation by all FGD participants. The map was used as a tool to stimulate discussions around access and equity. 34 The time burden of fetching water was not included as it was beyond the scope of the research. Future topics for research could include gender differences in willingness to invest in sanitation, and to pay for water.

 Households visits to observe the type of private household latrine constructed, discuss construction costs and other aspects of use and maintenance.  Conversations with urban tenants around particular issues related to the provision of water or sanitation facilities by their landlord.  Private water sellers – exploring how much income they could gain on a daily basis, what their maintenance costs were and any issues faced in providing their service.  Public water point operators – exploring how much income they could gain on a daily basis, what their maintenance costs were and any issues faced in providing their service.  Public latrine operators – exploring how much income they could gain on a daily basis, what their maintenance costs were and any issues faced in providing their service. B.2 Selection of fieldwork sites and respondents

6.1.5 Fieldwork site selection

The fieldwork took place in five regions (see Figure 18), covering both an urban area (Municipal Assembly) and a rural area (District Assembly) in each region to obtain information from both of these different contexts – with the exception of the Greater Accra and Upper West Regions35. In total eight municipalities/districts were covered, with two communities visited in each municipality/district.

Given that the growth of new urban areas at the edge of cities presents a slightly separate set of WASH challenges and equity issues, the communities chosen covered both urban, peri-urban and rural settings. The peri-urban areas that were sampled were densely popluated areas at the edge of large towns (Accra, Kumasi, Tamale and Takoradi) which were largely not (yet) covered by Ghana Water Company. Small towns in rural settings were not included in our sample due to time- limitationms.

The final sample size it set out in Table 9. We reiterate that qualitative research does not intend to be representative. However, in order to give a broad idea of conditions and challenges across the study regions, we aimed to visit communities across a range of typologies. That way we obtained a range of responses within each of these typologies, but did not aim for equal numbers in each category.

35 In the Greater Accra Region, we will only visit an urban community, while we will only visit a rural community in the Upper West region

Figure 18. Map of sites Table 9. Number of communities sampled per site Region Urban Peri-urban Rural Greater Accra 2 Ashanti 2 2 Northern 2 2 Western 1* 2 Upper West 2 TOTAL 5 4 6 (*) The second community was unsuccessful

The selection of regions, and municipalities/districts within regions, was undertaken purposively to deliberately explore both outliers and interesting case studies on WASH access. Given that the budget only allowed communities within eight municipalities/districts to be visited, the following factors were used to determine the selection of field sites. All sampling was undertaken in consultation with MAPLE and UNICEF:

(i) targeting districts/communities exhibiting positive / negative deviance in terms of water and/or sanitation access (for the poor) in both rural and urban communities; (ii) targeting areas which a priori will make interesting case study examples or comparisons (for example: approaches for the public provision of sanitation services for the poor in urban Ashanti and urban Accra); (iii) following service ‘gaps’ identified in secondary data analysis (for example – notably poor services for the poorest in rural parts of the western region), and (iv) ensuring feasibility of access and minimising travel time in order to maximise time spent with communities.

The rationale for the final site-selection is given in Table 10 below.

The selection of the 16 communities visited (two per municipality/district) was made in consultation with the MMDA, who selected urban, peri-urban or rural communities with different types of available water and sanitation facilities, and different types of WASH interventions (e.g. CLTS interventions). Two communities were visited within each municipality/district in order to be able to compare between the experiences of two communities served by the same municipality/district. Fieldwork logistics limited the location to within one hour of the MMDA.

In our experience, it is best to work with the district officials who notified the communities and also accompanied the team on community visits. The coordination with the district officials was organised by UNICEF and the MLGRD.

Table 10. Rationale for fieldwork site selection

Regio # District Area Rationale Community Population profile n Ethnicity / Price of Sanitation options Price of toilet Population Water sources used Religion water used visit ? private piped 30% HH toilets Asokore Ashanti 1 ? 2 GW standpipes 20p/bucket 3 public toilets (DA) DA: 50-60p Presence of WSUP urban Mampong (Christian) Asokore 1 HPBH (by NGO) 50% OD sanitation project focused Mampong Urban 20% HH toilets on public latrine ? private piped MA Aboabo Ashanti 7 public toilets (DA) DA: 20p 2 management models ? 5 GW standpipes 20p/bucket Number 2 (Muslim) 1 public (private) Private: 40p 1 HPBH (by ?) ? OD 15% HH toilets Ashan 10% private piped 50c connect 3 public KVIP (DA) ti 6500 Ashanti 4 HPBH Free KVIP: 20p 3 Adanwomase 1 public (NGO) people (Christian) 4 MBH 10p/bucket NGO: free Communal trench Potential exploration of 6 standpipe (NGO) 20p/bucket Kwabre Peri- ? OD small town East DA urban 35% HH toilets services/equity issues. 1% private piped 500c connect 2 public KVIP (DA, 5636 Ashanti (2 private sellers) Price? 4 Asomomaso NGO) ?? people (Christian) 4 HPBH (by DA) 20p/3buckets Communal trench 6 MBH (by NGO) 20p/1bucket ? OD 1% HH toilets 15% private piped 1200c conn KVIP: 20p Ga/mix 2 public toilets (DA) 5 Old Tulaku ? (many private sellers) Price? Pour-flush: 40p (mixed) 8 public (private) 12 GW standpipes 30-50p/b Private: 50-70p Greate 15% OD Ashaiman The presence of WB r Urban 5% HH toilets MA GAMA project (W+S) 15% private piped Acccra 1 public (private) Moni 12,000 Ga/mix (5 private sellers) Public: 30p 6 50p/bucket Some public (in Obaanye people (mixed) In house: 50-70p house) No GW ~30% OD Free Dagomba 100% HH toilets 7 Yiziiri 760 people 5 HPBH (NGO+DA) (contribute Free Presence of UNICEF rural (Muslim) no OD c2-5/month) Upper Nadowali CLTS project, with Rural Free West DA significant water 11 families Dagomba 1 HPBH (by UNICEF) (contribute 100% HH toilets 8 investments by NGOs Gboboyiri (~150 Free (Christian) Use stream c2-5/month no OD people) & if broken) Free North Presence of UNICEF rural Kusasi 1 HPBH (by DA) 100% HH toilets 9 Mion DA Rural DarSalam 20 families (contribute if Free ern CLTS project, with (Christian) Use stream (far) no OD broken)

hydrological challenges Free Kusasi 1 HPBH (by NGO) 80% HH toilets 10 for water provision Warvi-yepala 25 families (contribute if Free (Christian) Use pond & stream some OD broken) 1 HPBH (by NGO) ?? 5 GW standpipes 11 Dungu Presence of UNICEF urban (Muslim) 10 shallow wells Tamale MA Peri- CLTS pilot projects Use small dam urban ?? 12 Kabonayiri (Muslim) Western region has ~2000 Ahantas 13 Sekondi Ngyiresia Peri- shown considerable water people ? Takoradi urban and sanitation changes in 14 MA Cancelled recent years (HPBH free) Secondary data showed a (broken HPBH) 80% HH toilets 20p + Weste considerable disparity ~3000 Sefhwi 1 MBH 2 public toilets (DA, 15 Antobia contribute if Public: free rn between the poorest and people ? community) broken all other quintiles in the Private MBHs 15% OD Juaboso DA Rural 30p western region – and the 25% HH toilets Juaboso enclave was ~3500 Sefhwi 1 HPBH HPBH free 1 public toilets 16 identified as potential Nkwanta Public: free people ? 2 private MBH 20p/bucket (community-built) data 60% OD .

6.1.6 Selection of KII informants

KIIs were held with a range of stakeholders who have a role or interest in WASH policy. Selection was based on the stakeholder mapping undertaken with MAPLE Consult during the inception visit. Respondents were prioritised based on their institutional responsibilities and perception of importance as government, donor, and NGO stakeholders within the sector. A full list of interviewees is set out in Annex B.

 At national level, 15-20 KIIs were undertaken (1h long), depending on the availability of reliable data from other sources. Namely, some stakeholders may be able to identify other stakeholders, who would then be interviewed at a later stage to gain additional insights. Therefore snowball-based sampling was used based on advice on who to interview received from previous KIIs. The principle of an information saturation curve (see Figure 19) was used to determine whether further KIIs are needed, following careful consultation with the Project Manager regarding the remaining time and resources available. National-level KIIs also facilitated further data collection, including providing specific documents/ ‘grey literature’ relevant to the policy analysis under and Component B.

 At regional level, a minimum of 15 KIIs were undertaken (1h long) with at least one regional staff member of the GWCL, CWSA and REHSU, in each region36. Where additional information was required, brief inteviews with additionals individuals from these regional agencies were undertaken.

 At Municipality/District level, 8 group discussion (1.5-2h long) with key staff of the Municipal Assembly Office (in urban areas) and of the District Assembly Office (in rural areas) were held in every district visited. The staff participating in the discussion were selected by the Director, including at a minimum the Coordinating Director, WASH Engineer, Environmental health officer, Finance officer, and Planning officer.

Figure 19. Information saturation curve

36 The interviews with the GWCL, CWSA and EHSD of the Greater Accra Region were undertaken in December 2016 © Oxford Policy Management, March 2017 59

WASH Sector Equity Analysis for Ghana – Fieldwork report

6.1.7 Selection of FGD participants

The time available for fieldwork limited the number of FGDs that could be undertaken in a given community to two, resulting in 16 FGDs across the 16 urban and rural communities. MMDA representatives invited the FGD participants, aiming for 6-8 participants who were broadly representative of people living in that area. Participants entailed both adult men and women.

Table 11. Final sample of FGD participants

# Region Area District Community FGD participants # men # women Total# 1 Asokore Mampong 22 10 32 Urban Asokore Mampong MA 2 Aboabo Number 2 6 9 15 Ashanti 3 Adanwomase 4 2 6 Peri-urban Kwabre East DA 4 Asomomaso 1 2 3 5 Greater Old Tulaku 5 4 9 Urban Ashaiman MA 6 Acccra Moni Obaanye 7 6 13 7 Upper Yiziiri 13 2 15 Rural Nadowali DA 8 West Gboboyiri 6 5 11 9 DarSalam 16 8 24 Rural Mion DA 10 Warvi-yepala 16 6 22 Northern 11 Urban / Dungu 4 0 4 Tamale MA 12 Peri-urban Kabonayiri 3 0 3 13 Urban / Ngyiresia 8 0 8 Sekondi Takoradi MA 14 Peri-urban Cancelled Western 15 Antobia 12 3 15 Rural Juaboso DA 16 Nkwanta 6 0 6 Total 69% 31% 186

Two researchers managed each FGD, one leading the discussion in the local dialect and the other taking notes, and providing period translations for the International team member. FGDs lasted 1.5- 2h, covering both water and sanitation aspects. Hygiene was only briefly touched upon. B.3 Fieldwork logistics

6.1.8 Piloting and training

The methodological design and implementation process is shown in Figure 20 below. The questions in the KII and FGD guide were adapted and reworded into the appropriate vocabulary of the local dialect by the MAPLE team, to ease the burden on researchers of having to translate in the field.

The national staff are not fluent in the dialects in the Northern regions, and will, therefore, work through the MMDA official as a translator. All interviews at MMDA levels will be conducted in English.

Once translated, the FGD questions were pre-tested by MAPLE in the local dialect in early January. This allowed the suitability and comprehension of questions to be checked – as well as highlighting any potential areas of confusion. After pretesting, the FGD questions were modified, before training.

WASH Sector Equity Analysis for Ghana – Fieldwork report

Figure 20. Process leading up to data collection Instrument Pre-testing Training Data collection design

Training of the fieldwork team took place over one day (25 January 2017), as only two team members need to be trained. Training covered the objectives of the study, sampling approach, the data collection process, adapting/editing of questions, advice on how to facilitate FGDs and KIIs, how to take notes, and ethics. The first Region was considered as a pilot site, after which minor wording changes were made to the FGD and KII guides.

6.1.9 Fieldwork team

The primary data will be collected by our team of one international (Lucrezia Tincani) and two nationals (Christopher Sackeyfio and Gertrude Asokwah Amissah). Both national team members are fluent in the local languages necessary for community level interview in most regions – when this is not the case the project team with engage the service of a translator either from the MMDA or hired by the project team. Christopher and Gertrude also have appropriate experience and skills to both facilitate and take notes during the FGDs. The national team members consist of one man and one woman, in the unlikely event that certain sensitive topics arise which can only be discussed in the presence of a woman.

In the first “pilot” region, this team will be accompanied by the Team Leader. For the subsequent three regions, the three person team will carry out the interviews at the regional office of REHSU, MMDAs, and communities (dividing labour where appropriate). For the last region, we propose that our two nationals can carry out interviews alone, saving costs on the international.

We are confident that by sequencing the work in the different regions, the data collected will be of high quality as the team will have had a chance to learn a consistent methodology.

6.1.10 Logistics of data collection

Overall, the fieldwork team spent three days in each Region, with Day 1 entailing interviews at regional level, Day 2 interviews with the MMA and visit of two urban communities and travel to the rural DA, and Day 3 entailing interviews with the DA and visit of rural urban communities.

Table 12 gives and overview of the fieldwork schedule. This schedule was tight, but achievable through early engagement with MMDA officials, who informed communities of the planned visits.

Table 12. Summary of fieldwork schedule Dec early Jan w/c 23rd Jan w/c 30th Jan w/c 6 Feb KII national-level Ashanti Region Greater Accra Region Northern Region Upper West Region Western Region

WASH Sector Equity Analysis for Ghana – Fieldwork report

B.4 Data analysis and limitations

6.1.11 Quality control, data management, and analysis for the FGDs

FGDs were run by teams of two people: One person facilitated the discussion, while the other person took notes.

FGDs should take place in a convenient, quiet and comfortable location for participants. The availability and accessibility for women and other vulnerable groups was considered when planning the locations and times at which to hold the FGDs. FGDs typically last no longer than 1.5-2 hour with the duration of each discussion varying depending on the dynamic of the group and number of participants. FGDs were semi-structured in nature; facilitators let the conversation continue so long as participants are on topic, interjecting questions when conversation halts. Participants were notified of the expected duration, and the facilitator should not run over this time.

Focus groups are typically 5-8 participants however researchers need to anticipate likely ‘no-shows’ and recruit accordingly, aiming for no more than 10 participants. The project team utilised MMDA personnel to mobilise community members.

Quality control and risk management

The management of FGDs followed commonly adopted good-practice, including:

 Prepare: select and invite the right participants;  Set an appropriate venue, time and duration;  (Re-) explain the purpose of the FGD at the start and gain approval from participants to continue;  Seek agreement on ground rules with participants (one person speaks at a time, everyone’s views are important, there are no right or wrong answers, etc.);  Allow everyone the opportunity to participate and no-one to dominate;  Summarise key messages received with participants before ending;  Re-state what will happen to the data, they have supplied.

Data management and analysis

All details relating to the FGD, together with the discussion during each FGD, were recorded by the note-taker. A simple WORD template was prepared to consistently capture the characteristics of the FGD participants and the issues raised (already translated into English). This template has a unique identification number to clearly identify the location of the FGD, nature of the group, the commune, and the date and time.

As tape-recording and transcribing FGDs is time-consuming, the analysis was done on the basis of computer-typed KII summaries and hand-written FGD notes (translated into English), and debriefs held with the fieldwork team every evening.

The international team member facilitated the evening debriefs: these gave the researchers time to reflect and discuss the findings from the day’s field work and begin to draw out the analytical implications of these findings. These sessions were also used to discuss what went well that day, what could be changed and logistics for the next day.

WASH Sector Equity Analysis for Ghana – Fieldwork report

6.1.12 Quality control, data management, and analysis for the KIIs

KII interviews took place in English. They were conducted by different team members depending on the context, e.g. an international consultant alone or alongside the national consultant or by the national consultant alone. The length of interviews varied but was 60-90 minutes.

Quality control

KIIs followed commonly adopted good-practice, including:  Pre-arrange interviews, to ensure the most appropriate interviewee is available. A reminder phone call will be made a day in advance;  Follow-up the interview with an email or phone call if required, to obtain further detail/ clarity if appropriate;  Provide a summary note of the interview, if requested.

If the interviewee invites other participants to join the interview, be aware of their appropriateness to the subject matter and any possible disruption this may cause to the exchange of information. If the researcher feels that this other participant’s involvement is influencing the views voiced from the intended interviewee, that extra person should politely be asked to leave and possibly to be interviewed on another occasion. If they have valid contributions to make to the interview, incorporate these into the notes and clearly identify in the write-up who else participated in a broader discussion, or observed the interview.

Data Management Consistent note-taking formats were used, with a WORD template following the semi-structured interview guide, for easy cross-referencing of topics across different interviewees. Comprehensive notes were captured electronically – either during the interview itself or within 24 hours of the interview. Key points relating to the main topic areas of the interview were identified and shared with the rest of the team during the daily debrief.

A separate WORD document was developed for each interview write-up (in English), with a unique code that identifies the document – namely the location, date of the interview and a unique number to distinguish the document from others.

Data Analysis The analysis was be done with respect to key questions in the research framework, looking across material from all relevant interviews.

6.1.13 Ethical considerations

The important ethics issues related to this study are described below. As there are no specific ethical dilemmas for this study, the points below follow standard good-practice:

For FGDs, the following aspects were followed:  Informed voluntary participation: Informed oral consent was obtained from participants before FGDs are run. Team members and FGD participants were informed about the purpose, methods, risks, benefits and intended possible uses of the FGD results.  Right to refuse or withdraw: The participants were informed that they are free to leave the FGD at any point, or may refuse to answer any questions. They had the right to ask questions at any point before, during or after the FGD is completed.  Confidentiality and privacy: No personal identifiers were used in any form of reporting or dissemination. No information was published that could identify the respondents.  Risks and benefits: The risk of participation in the FGD was considered minimal as there will be no collecting of any sensitive information or biological samples. The respondents will

WASH Sector Equity Analysis for Ghana – Fieldwork report

not directly benefit from participating. However the information that they will provide us may give some important information to the policy makers to improve the overall water, sanitation and hygiene condition of their city and they may eventually have an indirect benefit from that. However it is important to stress that this is not a guarantee, and no promises can be made in this regard.  Payment: There was no financial compensation to the participants and nor will they have to pay us to participate in the study. FGDs will be held in the target area to avoid any participant transport costs.

For KIIs, the following aspects were followed:  State the purpose of the interview and use of findings, before starting.  Offer anonymity – and ensure it is followed if requested.  Gain verbal permission to start the interview and note this on the interview write-up.  Allow the interviewee to “pass” on specific questions.  Provide a write-up of the interview, if requested.  Indicate next steps or possible follow up, if appropriate.

WASH Sector Equity Analysis for Ghana – Fieldwork report

B.5 List of Donor and NGO projects included in the financial analysis

Donor Project name / activity description Start year End Year

AFD Water and Sanitation Project in Brong Ahafo Region 2008 2014

A Business Approach for Improved Sanitation in Ghana 2013 2018

African development bank Re-optimisation of Akosombo and Kpong Dams 2010 2016

Sogakope-Lome Water Transfer Project 2013 2018

Enhanced WASH in Schools 2012/2013 2018/2019

NORST 2011/2012 2015/16 Global Affairs Canada Rural and small town project 2010/2011 2014/15

Rural Sanitation and Market Development 2014/2015 2020

JICA General WASH expenditure 2013 2014

Safe Water Network Provision of water stations 2010 2016

Ghana / Netherlands WASH project 2013 2019 The Netherlands Government Other funding through DGIS 2013 2014

Football for WASH 2013 2013

Hilton Foundation funding 2013 2014

UNICEF, Ghana National Committee of UNICEF in Germany 2013 2013

UNICEF Funds 2013 2014

Unilever 2013 2014

Additional Financing for the Urban Water Project 2012 2015

GAMA Sanitation and Water Project 2013 2018

World Bank OBA Urban Sanitation Facility for the GAMA 2013 2018

Results Based Financing for Sanitation and Hygiene 2013 2017

Sustainable Rural Water and Sanitation Project 2010 2017 (SRWSP)

WASH Sector Equity Analysis for Ghana – Fieldwork report

Annex C Fieldwork findings

C.1 Summary of Government Policies and strategies on WASH

Table 13. Comparison of equity focus on water-related government policies and strategies GWCL Corporate CWSA Corporate Water Sector Strategic National Community Water and National Water Policy (NWP) Plan Plan Development Plan (WSSDP) Sanitation Strategy (NCWSS)

Aims to achieve “affordable and Recognition that poorer users are sustainable provision of and access to less able to repair water points, potable water to rural communities and and therefore more likely to revert small towns, mindful of the need to Key activities include GWCL has set up to unimproved sources. Weak ensure affordability, equity and construction and LICSU to provide culture of paying water tariffs in fairness for the poor and vulnerable”. rehabilitation of improved services rural areas is seen as a barrier to Pro-poor Service norms and future adaptations boreholes, to targeted low raising enough revenue to targeting on are not explicitly recognised in the construction of multi- (only mention of urban poor – see income maintain water points. Low water national policy. village schemes below) communities as demand for small town water provision Recommendations include promoting target rural well as systems, which as a result are not a demand responsive approach where communities which marginalised able to meet O&M costs. communities choose services that fit are seen to be groups. Recommend mapping the their needs; and providing better generally poor. unserved and assessing the cost information on ground-water of reaching these, and developing occurrence and availability (quantity RBF schemes which link and quality). payments to performance.

Aim for 100% water coverage in urban areas by 2025. Recognition Challenge of affordable tariff setting for Recognises the that the majority of urban poor are the urban poor and inadequate need to formulate served by informal services not investment in urban infrastructure is and implement GWCL; recognition that the lifeline Provision for Recognition that there is a lack of noted. Recommends more private strategies tariff benefits the rich not the poor. the urban None clarity on service delivery for the sector involvement in urban water specifically aimed Recommend mapping which poor poor urban poor by CWSA and GWCL services to generate a range of at extending urban areas are unserved, affordable options and review of services to low development of ‘social policy’ by GWCL financing and cost recovery. income citizens PURC; and cooperation between CWSA and GWCL on reaching the urban poor. Exception for Recognition that the ‘pay as you the poor on None None None None fetch model’ should take into water account ability to pay.

WASH Sector Equity Analysis for Ghana – Fieldwork report

The policy identifies the challenges The NCWSS recommends three with use of ground water including options/ strategies to tackle saline intrusions along the coastal The plan proposes Investment difficult hydro-geological areas zones, low yield from boreholes in the development of options in - Explore the use of other ground parts of Northern, Upper East and multi village hydro water siting techniques. Upper West etc. There are however no None schemes to serve None geologically - Expand the distance of provisions in the policy that focuses on communities with challenging exploration for ground water. If strategies to be adopted for the hydro-geological areas any is successful, develop and provision of water to hydro-geologically difficulties. supply. challenged areas and areas with - Explore surface water options. unacceptable water quality. Recognition that the needs of the Provisions for physically challenged should be the elderly/ Recommendation to develop ‘protected’, and that some None None None physically disability friendly technology options communities are less able to pay for challenged spare parts Recognition that improved water services enhances women’s dignity, Recommendation to increase Recognition of school attendance of girls, reduces participation of women in WSMT and gender health risks for women and girls. None None intensify efforts of ‘mainstreaming None aspects Recommends increased participation gender issues’ in WASH services of women in WSMT and ‘gender delivery. sensitive’ policy delivery by GWCL

WASH Sector Equity Analysis for Ghana – Fieldwork report

Table 14. Comparison of equity focus on sanitation-related government policies and strategies National Environmental National Environmental Sanitation Policy Rural Sanitation Model and National Community Water and Sanitation Strategy and (NESP) Strategy (RSMS) Sanitation Strategy (NCWSS) Action Plan (NESSAP) Recognition of appropriate technology to meet the needs of the poor and vulnerable, Recognises the different The strategy proposes the and that the poor use more public/communal abilities/needs of the extremely development of cheaper cost latrine Pro-poor toilets because they have fewer private poor Aim of gradual improvement of technology options that meet the targeting on household latrines. However how policy it is service, while making provision demand and needs of people. This is sanitation implemented is left at the discretion of the Recommends micro-credit for the needs of the vulnerable to be achieved through the use of provision MMDA. Recommendation of a study to schemes to support the poor with local materials for the construction of assess demand for different sanitation latrine construction costs latrines. options.

The NCWSS subscribes to the One of the basic elements for promotion of innovative ways for effective CLTS outlined in the financing the construction of toilets No mention of toilet subsidies in the policy; The RSMS proposes a ‘no NESSAP is the avoidance of entirely by households without project Toilet subsidies the emphasis is on promotion of the subsidy’ approach to household project type-subsidy for support. This includes micro-finance, construction and use of household toilets latrine construction in rural areas. household latrine construction. village-level loans and savings This even includes subsidies schemes, or community-based for demonstration toilets. establishment of revolving funds.

The focus is on ‘communal toilets’. Public toilets should be constructed in public As part of activities to create the places viz. central business districts, major enabling environment for CLTS, commercial and light industrial areas, local There is no reference made to public Public toilets the model proposes ending [Same as the NESP] markets and public transport terminals. toilets construction of ‘communal toilets’ Public toilets should be franchised or under a through consensus at the national, BOT model. regional and district levels

There are no prescribed sanitation Sanitation approaches for rural areas in the policy. The CLTS – for achieving basic approaches – policy proposals are on Information, CLTS/Sanitation marketing sanitation as well as upgrading CLTS/Sanitation Marketing for rural areas Education and Communication and service levels. Awareness Raising

There are no prescribed sanitation Implementation of an effective Sanitation approaches for urban areas in the policy. country wide programme to approaches – The policy proposals are on Information, None overcome the over reliance on None for the urban Education and Communication and public toilets in low-income poor Awareness Raising urban communities

WASH Sector Equity Analysis for Ghana – Fieldwork report

Recommend 'approved' latrine technologies Sanitation (water closet and septic tank system; pour Promotes the traditional pit latrine approaches – flush latrines, ventilated improved pit latrine, with exception of areas with rocky for areas with and aqua privy) and other “proven None None or unstable soils where ‘arborloo’ challenging soil technologies recommended by the Ministry pit latrines could be built. conditions of Local Government and Rural Development”. Promotes demonstration toilets for Recognises that services should be the aged, ultra-poor or Recognises that CLTS should Provisions for designed to suit the demand of different handicapped be tailored to context and the the elderly/ populations, including rural, small towns and Recognises the different needs of the needs of the None physically urban, and the vulnerable and physically abilities/needs of the extremely vulnerable (including the challenged challenged. poor, elderly, disabled and those disabled) with HIV Recognition that women and children are more affected by poor sanitation services (loss of dignity, school dropout, The model requires CLTS health risks). Recognition that facilitators to undertake a gender Women tend to demand Recognition of Recognition that women and children are profiling to identify the merits or sanitation more than men, but None gender aspects more at risk of diseases. otherwise having women or men make fewer household as natural leaders at the spending decisions (UNDP community level. HDR 2006). Recommend micro-credit schemes to support female-headed households and women cooperatives.

WASH Sector Equity Analysis for Ghana – Fieldwork report

C.2 Summary of Equity focus of donors

Table 15. Comparison of WASH activities by key donors and NGOs Type of water initiatives Type of sanitation initiatives Focus on other equity Degree of pro-poor approach Geographic focus funded funded aspects Donors Support districts to develop strategic sanitation plans Construction of potable Central, Northern and water supply Construction of institutional Agence Française Brong Ahafo infrastructure i.e. hand- toilets de Développement n/a n/a Focus on rural, small dug wells, boreholes, (AFD) towns and peri-urban extension and Information, education and areas construction of networks communication activities targeted on hygiene and sanitation. Expansion and rehabilitation of GWCL Community-Led Total Sanitation Five urban Embassy of the networks (CLTS) Recognition that access to water Water Resources municipalities in Kingdom of the and sanitation is a challenge Management Accra, Elmina and Netherlands (EKN) Micro finance for household particularly in poorer urban areas Promotion of private Cape-Coast. latrine construction sector involvement / local entrepreneurship Recognition that there are regional disparities between the CLTS north and the south, Focus on women, Global Affairs Small Town Water children (new-born), The Northern Canada (GAC) Systems, Boreholes Construction of disaster resilient Support Ghana's efforts to youth and vulnerable Regions WASH facilities address the multiple challenges communities affecting the north and other deprived areas’. Small Town Water CLTS in rural areas Systems, Household latrine construction in Upper East, Upper Boreholes fitted with the Greater Accra Metropolitan Provision of 50% subsidy for West, Northern, Faecal sludge World Bank pumps, Area (GAMA) households in low income urban Brong Ahafo, Central management communities in GAMA Western, Greater Extension and Accra rehabilitation of GWCL Construction of institutional water systems latrines and BCC Campaigns

WASH Sector Equity Analysis for Ghana – Fieldwork report

CLTS in rural areas, sanitation CLTS in Northern, marketing, hygiene and Upper West, Upper behaviour change campaigns UNICEF mainstreams East, Volta and gender in the Central Regions Supporting the Government of Focus on increasing access to implementation of their Ghana to pilot Community-Led improved sanitation and water programmes and UNICEF community-based IWRM Urban Environmental Sanitation services to disadvantaged projects. Urban Sanitation Pilot (CLUES) in Ashaiman, communities’. Project in Ho Community Development for Focus on women, Municipal, Tamale Health (CDH) in Ho and Urban children and youth Metro and Ashaiman CLTS in Tamale. Municipal

Rural and peri-urban Small Town Pipe CLTS communities in Adoption of a low-subsidy Schemes, boreholes and Training of local artisans Focus on children and Western, Central, USAID approach for household latrine hand-dug wells, rainwater Household and institutional water quality Greater Accra, Volta, construction harvesting, water kiosks latrine construction Eastern and the three Northern regions. NGOs Urban CLTS Recognises that the informal focused on the urban Rural CLTS nature of urban poor poor/slum communities/ slums is a barrier to Small Town Water communities and also Village Savings and Loans water supply Global Systems, Water Focus on women, rural areas/small Associations (VSLAs) for latrine Communities Kiosks/Points, household children, youth towns, in Northern, construction Recognition that access to water connections Volta, Greater Accra, improved toilet facilities is a Central and Western Promotion of low-cost latrine challenge within slum Regions with plastic pit lining communities

CLTS approach without Upper west, Northern, community managed Interventions target poor and subsidies projects to build vulnerable families to enable Central, Eastern and Plan Ghana Focus on children boreholes and water them take care and support their Volta regions community managed projects to facilities for communities children build latrines in schools

addressing issues that Aims to increase access to and rural communities in relate to the reliability of use of sustainable, equitable and CLTS/ sanitation marketing; the Northern, Upper water supply, the affordable water, sanitation and Village Savings and Loans Focus on women and East, Upper West,, SNV sustainability of water hygiene services for improved Upper East, Central, systems, the affordability Schemes; ‘Safi Latrine’ - low cost health, livelihoods and economic persons with disability Volta and Greater of services, and equitable technology well-being in rural, peri-urban Accra Regions access to water for all. areas and schools in Ghana

WASH Sector Equity Analysis for Ghana – Fieldwork report

partnership with Fidelity Bank to provide loans for i) pipe connection to households ii) construction of Septic Tank iii) construction of household toilet iii) household hand washing facility iv) faecal desludging v) borehole construction and mechanisation vi) household water retooling/ spare parts. Strong focus on Equity and Inclusion, District Wide Approach (DWA)37, Endogenous Increase sustainable and Increased focus on sanitation: in Development (ED)38, Boreholes fitted with iron equitable WASH for all in targeted schools, clinics and public Human Rights Based Five regions; Upper removal plants Local Government Authorities by spaces. Approach (HRBA)39 East, Upper West, (new/rehabilitation) 2021. and Learning & Greater Accra, Water Aid developing innovative Knowledge Pipe borne connections The strategy document Eastern and Western approaches and technologies Management. Equity recognises that ‘most of the Regions. and Inclusion is central Water kiosks unserved/underserved live in CLTS approach to WaterAid’s projects, rural areas and urban slums’. which therefore target the most hard to reach and underserved communities. Aim is that ‘all children especially the most vulnerable and their Construction of families have improved WASH demonstration latrines water treatment for consumption, production and technique to remove processing for persons with CLTS approach (no subsidies) excess fluoride and disability, the aged or All the ten regions of

World Vision arsenic Provision of water in ‘hard to female headed Ghana and mainly in and the construction of reach’, marginalised and rural areas. institutional latrines households. solar powered water unserved communities. WV aims systems to provide water to communities Developed disability which others have abandoned friendly toilet designs due to difficulties of getting ground water through boreholes

37 DWA- ‘is a programmatic approach that shifts from service delivery to sector strengthening and collaborating with more and differentiated strategic partnerships. It takes the district as the central geo-political location and critical nexus space for change towards universal access to WASH’. 38 ED- working with districts/communities to develop context specific solutions (harnessing local resources) to hygiene and sanitation challenges that can inform sustainable behaviour change policies and practice. 39 HRBA- A rights-based approach is a transformational development process in which people are the drivers and subjects of their own development. © Oxford Policy Management, March 2017 59

WASH Sector Equity Analysis for Ghana – Fieldwork report

under their WASH and Disability Project.

WASH Sector Equity Analysis for Ghana – Fieldwork report

C.3 Fieldwork findings

C.3.1 Planning, funding and monitoring

In this section we discuss how overlapping mandates and individual priorities of donors and NGOs can affect the planning and funding of WASH activities. How water and sanitation activities were implemented in practice is covered by Sections C.4 and C.5, respectfully.

C.3.2 Planning of WASH initiatives

Planning of WASH initiatives is led by the two bodies implementing WASH initiatives (MMDA and GWCL). In contrast, CWSA and EHSD play a very minor role in planning, merely identifying broad priority themes at national level in their respective Corporate Plans.

C.3.2.1 Drawing up of MMDA mid-term plans (urban and rural) In line with Ghana’s decentralised structure, WASH planning is a bottom-up process, starting with the MMDA who prepare a four-year District medium-term development plan (DMTDP) which includes a section on WASH. Drawing up a DMTDP is a legislative requirement for every district40. DMTDPs are reviewed by the Regional Planning and Coordination and Unit (RPCU) at regional level. The DMTDP is then budgeted every year, in the form of an Annual Action Plan (AAP), with expenditure tracked in the Annual Composite Budget.

The DMTDP is supplemented by sector-specific action plans (the DWSP or DESSAP) for water and sanitation in some MMDAs. Where both the DMTDP and sector-specific action plans exist these can confuse the planning process as it is not clear which prioritised plan is meant ot be used to plan WASH activities in that District. The DESSAP (District Environmental Sanitation Strategy and Action Plan) introduced by the Dutch Embassy and is now a key performance criteria of the FOAT, to be updated every three years (Functional and Organisational Assessment Tool) and is therefore linked to districts. This has incentivised districts, and now most have formulated one41. In addition, through DANIDA’s Sector Programme Support (2004-2008) in the Greater Accra, Volta, Eastern and Central regions districts were encouraged to develop District Water and Sanitation Plans (DWSP). This initiative has been taken forwarded by the World Bank (WB) as part of its Small Towns Water Project (2007-2010), and DWSPs were prepared in several across Ghana. Even though the preparations of these DWSP plans have not been rolled out nationally because they are not a formal government requirement, we could safely say that CWSA and MMDAs have accepted the concept; the challenge is the sustainability of the activities as a result of lack of financial resources for the development of the DWSP plans. Where they exist, DWSPs overlap with the DESSAP because they cover both water and sanitation, thus confusing how WASH initiatives are prioritised. A key question is how relevant are these sectoral plans (DWSP and DESSAP) when the DMTDP is the guiding document for planning and development in the MMDA.

While they may confuse planning, District staff suggested that the absence of a DWSP or DESSAP risks limiting the funding secured for WASH activities at district level, which affects the ability of district to address inequities in WASH access. WASH initiatives are planned by the WASH Unit within the District Works Department. In an attempt to increase the visibility of WASH in district-level planning, different donors have introduced various sector-specific action plans for water and sanitation42.

40 It is prepared based on guidelines issued by the National Development Planning Commission. 41 We could not check with our small study sample if this is indeed the case. 42 In some districts, donors also created a parallel structure called the District Water and Sanitation Team (DWST). © Oxford Policy Management, March 2017 59

WASH Sector Equity Analysis for Ghana – Fieldwork report

The DMTDPs reviewed do not have an explicit equity focus. The planning process appears to be done without detailed guidance from EHSD and CWSA. This limits the ability of EHSD and CWSA in ensuring that the DMTDP takes into account any equity principles indicated in national WASH policies and strategies. While it is EHSD’s role to advise on the design of the DESSAP, EHSD staff explained that lack of operational funds are a fundamental constraint, limiting their ability to travel to the districts to advise them on producing these plans. Their role is therefore often limited to simply collating the sanitation coverage data contained in the DESSAP, once these have been submitted to the REHSU. CWSA staff also explained that their role is largely limited to collating the water coverage data collected by the districts through the DIMES platform. In the past, WASH plans were not even shared with the CWSA, let alone accompanied by advice.

“Yes the EHSD supports the DESSAP – in some case we even helped write it for them. But the problem is that sanitation is not prioritised within the DA budget, so plans rarely get implemented”. (REHSU Western Region)

“We only advise the MMDA in the implementation of their DESSAP. We can make suggestions of what to add to the DESSAP but they can take or leave it. We have no way of enforcing it”. (REHSU Ashanti Region)

“In the past, districts here planned through the NDPC – it was not linked up with our CWSA plans. But thanks to SmarterWASH now the districts send CWSA their WASH data they collect [DIMES data on water coverage] and then we [CWSA] collate it all to get region-wide data”. (CWSA Northern Region)

A key part of the district’s medium-term planning process is undertaking a ‘situation analysis’ to establish WASH coverage gaps. Poverty levels and the specific needs of age-groups or gender groups are not assessed as part of this planning step. The rigour of this exercise however appears to vary from district to district. The DMTDP includes a chapter with a ‘situation analysis’ of existing/known public water facilities and public sanitation facilities (see example in Table 16), with the notable exception of urban water facilities (which are counted by GWCL, see Section C.3.2.4). A similar process is followed for the DESSAP (for sanitation facilities only, including a ‘census’ of known private household latrines). Using these existing facilities as a reference point, the DMTDP then set out the WASH facilities that need to be planned in future43 and costs these in the plan, alongside a prioritised list of actions across all sectors. The inventory of existing water and sanitation facilities is however not drawn up in a systematic manner: while area-councils are meant to provide the data, in reality, the inventory is prepared by District staff ‘walking around’ communities to count facilities. Accessibility of these facilities is not a focus. Facilities are not mapped with GPS coordinates. It is unclear whether this time-intensive exercise is done for every community for each new MTDP is made (every four years) or whether the inventory is updated iteratively each time the district adds a new facility, or a community happens to be visited. It is also unclear if facilities which are no longer functional are removed from the inventory. District staff also explained that they are likely to miss facilities which they are not aware of, for example if an MP, church, NGO or private operator constructs a new facility without informing the district. The accuracy of coverage data is therefore questionable.

Table 16. Example of district-level ‘situation analysis’ of existing facilities Area council Sources of water Sang Kpabia Jimle Total Water Ponds 54 38 12 104 Stream 152 32 32 169

43 Based on interviews held with district staff there doesn’t seem to be a systematic way of estimating the future facilities that are needed. It depends on a case by case basis and follows the demand-led approach set out in Section C.3.2.2. © Oxford Policy Management, March 2017 59

WASH Sector Equity Analysis for Ghana – Fieldwork report

River 1 0 0 1 Spring 4 0 0 4 Hand dug wells 3 0 1 4 Boreholes 85 23 17 125 Stand pipes) 3 0 0 3 Total 309 102 81 435 Sanitation Acqua –privy 0 0 0 0 VIP 64 71 106 241 KVIP 3 4 1 8 Water Closet 6 0 0 6 Institutional Latrines 13 4 1 18 Total 82 79 108 269 Source: Mion DMTDP

C.3.2.2 No clear prioritisation of WASH interventions according to need The district’s MTDP includes a prioritised list of interventions to be funded covering WASH as well as other sectors. According to district informants WASH interventions tend to be prioritised in a participatory demand-led way based on level of interest and demand from the community as well as a rough assessment of need and the severity of water-borne or hygiene related disease outbreaks. District staff explained that following a demand-led approach was essential in order to establish if communities really wanted a facility and would therefore be more willing to maintain it – this is in line with the process recommended by national WASH policy. There is a risk that this approach would exclude less vocal communities, or those further away for the district capital, perpetuating inequities in WASH access. However, one CWSA staff member maintained that if a community had known coverage gaps but had not requested any facilities, efforts would be taken by the district to sensitise them and mobilise demand. It is not known how widespread such efforts are.

The process for provision of water facilities for example tends to run as follows:  Communities make requests for new facilities to the district  The district WASH team then visit the community to do an inventory of facilities (including establishing if these are still functional) and also assess the population levels to establish if there was a coverage gap.

In short, prioritisation begins with a community request, followed by an assessment of the coverage gap – rather than WASH coverage data being used to identify pockets of unserved, followed by a community outreach by the district. Section C.3.4 explains the way coverage levels are calculated using average population benchmarks can mask the pockets of unserved at district level.

“Will they be able to maintain [the water point]? If the community is not committed, the investment will perish because they will not maintain it”. (MMA Kumasi)

“We prioritise construction (in unserved areas) over rehabilitation: we need to first meet the demands of those who don’t have any water points. Next we go to areas which have a borehole but population is too high. Lastly we go to communities which have several boreholes but some need repair. We decide together with DA”. (CWSA western region)

Poverty levels do not play a role in the prioritisation of certain communities over others. This means inequities by wealth quintiles are not explicitly being addressed. District staff, as well as REHSU, CWSA and GWCL staff unanimously explained that they were not aware of secondary

WASH Sector Equity Analysis for Ghana – Fieldwork report data on poverty incidence44, disaggregated to the community level, and that they did not possess a methodology to measure poverty, nor the means to carry out such a survey.

“CWSA’s criteria [for prioritisation] are looking where there is low coverage – we don’t look if the area is poor. We only look at poverty when we set the tariff level. Here the poor are everywhere, they are not clustered”. (CWSA western region)

Political interests regularly interfere with WASH planning by adding communities to the DMTDP which had not been identified through the demand-led approach. This risks perpetuating inequities in WASH access driven by socio-political factors. During the process of DMTDP sign-off by the Executive Committee district staff reported that often additional initiatives were added to the DMTDP, in order to favour individuals or communities which supported the political party in power. This resulted in fewer funds remaining for the communities which had already been prioritised in the DMTDP.

“Politicians also play a role… the DMTDP is not a scientific government… the elected general committee of the Assembly will review the plan and then approve it. That step can result in changes to the plan”. (MA Kumasi)

“When you ride your bicycle you also expect to get fresh air” – meaning people expect to receive added benefits for their area after their party gets elected. (MA Ashaiman)

C.3.2.3 Donor funding affected by cost-effectiveness considerations Most donors and NGOs are aligned with sector priorities and see equity aspects as a key consideration (see Section 4.2.4). The majority align to district DMTDP and priorities, though some smaller actors implement independently without MMDA consent. For larger donor programmes, the regional offices are the entry point for coordinating WASH interventions, but some donors go through CWSA and others through REHSU. CWSA/REHSU then engage with the districts on selection of activities and intervention areas, and ensure plans are jointly agreed with the districts. Smaller NGOs usually contact the districts directly to jointly agree on plans. Despite these efforts, it is clear that the priorities and historical interventions of donors and NGOs influenced which regions they worked in, and what type of WASH work they focussed on. One CWSA officer suggested that districts have more say when donor projects are loan-based than grant-based. Districts also reported of smaller NGO initiatives which were done independently without any MMDA consent or alignment to MMDA priorities.

“NGOs usually approach the district directly. But we are trying to encourage partners to come to the region first, so that they can tell them which areas have received less support”. (REHSU Northern Region)

“Several NGOs work here – but the big problem is coordinating them. They don’t come to RCC/REHSU. Nobody starts from where the other NGO has ended, but instead launches its own thing. There is no sustainability”. (REHSU Western Region)

44 It is the mandate of the MMDA, RCC and the NDPC to determine poverty levels. © Oxford Policy Management, March 2017 59

WASH Sector Equity Analysis for Ghana – Fieldwork report

Donor projects are prioritised not only based on demand and need, but also based on cost- effectiveness considerations. CWSA staff explained that prioritisation under donor water projects could either follow a demand-led approach (where communities submitted applications for facilities, which were checked against existing coverage levels) or a need-based approach (where DIMES data was used to identify areas with low coverage, and community leaders where then approached to establish demand). Under the former, one CWSA officer explained that it double-checked the final selection to ensure none had been prioritised for political reasons; but this check does not take place if there is no donor project. Importantly, cost-effectiveness considerations also played a key part, with CWSA officers in the Northern and Upper West regions giving examples where donors were undertanbly less willing to invest in hard-to-reach areas because the cost of drilling was high, or in areas with lower population density (resulting in higher costs per person served). Figure 21 showcases the challenge of reaching 100% water coverage in one of the districts in the Northern Region (red circled) where there are few water points because the drilling success rate is low and population density is low. Both drive up the cost per person served and pose a challenge for reaching the unserved. Cost-effectiveness considerations therefore risk perpetuating geographical inequities in WASH access driven by unequal funding allocations.

“Other regions got more donor funds for sanitation & hygiene than us because of disease risk: Volta had bilharzia outbreak; Northern had guinea worm outbreaks in the past! Large donors funds today are because of that legacy – donors continued to work in the areas they started in”. (REHSU Western Region)

“Water points are only built in ODF communities here, as rewards. Yes also non-ODF communities need water – but we don’t have our own [district] funds. So we need to follow the NGO’s priorities [to promote ODF]”. (DA Mion)

WASH Sector Equity Analysis for Ghana – Fieldwork report

Figure 21. Comparison of water point functionality, population density and drilling success rates – for the Northern Region Water point functionality Population density map

Drilling success rates

WASH Sector Equity Analysis for Ghana – Fieldwork report

C.3.2.4 GWCL as a commercial entity is less able to achieve universal coverage for all urban communities GWCL plans largely independently of MMDA priorities, based on its own demand estimations and assessments of commercial viability. As GWCL leads implementation of urban water initiatives, MMDAs reported not carrying out any assessment of urban water demand or coverage gaps. GWCL carries out its own demand estimations based on population projections and projections of industry demand. Commercial viability is also considered when making a business case of whether to extend systems to cover an additional town, based on the size of the potential customer based. Poverty levels do not play a role in the prioritisation; meaning that the ability to pay the water bill does not factor in GWCL’s calculation of commercial viability. The fact that urban water priorities are driven by GWCL, a commercial entity, rather than the MMDAs which have a social mandate will affect the priority given to resolving inequities in WASH access.

Network extensions are prioritised based on demand, and the availability of GWCL funds. GWCL staff explained that they are aware of where their piped network ends, and aim to extend networks when new settlements spring up at the edge of the town. GWCL is aiming for 100% urban water coverage by 2025. However, in practice those extensions are prioritised where a community submits an application (demand-led process), subject to availability of funds by GWCL. Otherwise the extension is planned for the next financial cycle. In unplanned slum areas where pipes cannot be laid, standpipes are provided nearby. Some communities reported paying for pipe extensions into their neighbourhood with their own funds, but this was only an option for affluent neighbourhoods. This poses clear equity risks for communities not able to afford a pipe extension, and is risks perpetuating WASH inequities across wealth quintiles.

“Even if we know an urban community needs water, we do not act. The MMDA doesn’t cover urban water. Communities go directly to GWCL to ask for pipeline extension. GWCL checks if it is within its budget for this year. If not, landlords need to pay for the extension themselves if they really want it sooner”. (Sekondi- Takoradi MA)

GWCL does not use data on coverage gaps to prioritise network extensions, as the total number of public and private water facilities are not monitored by GWCL. GWCL only monitors the number of private household connections and public standpipes constructed by GWCL. This data is not necessarily shared with the MMDA. Any facilities constructed by NGOs, MPs, private operators or the MMDA are not captured in a comprehensive urban water coverage database by GWCL. The number of standpipes to be provided is estimated based on average population ratios. This is in line with the notion that for GWCL, as a commercial entity, tracking coverage gaps is not the first priority.

Unclear service mandates between CWSA and GWLC undermines systematic planning for small towns and communities on the peri-urban fringe. Water supply services for small towns tends to be the domain of CWSA but there is no clear mechanism for CWSA and GWCL to coordinate the planning of water provision in the boundary of cities or for small towns. CWSA for instance operates in some communities with populations more than 30,000, whereas the GWCL also provides water to some communities with populations less than 5,000. Discussions with the regional CWSA and GWCL offices also revealed examples where GWCL branched into rural water provision, as well where CWSA played a role in urban water provision. GWCL may provide water for towns in areas with difficult hydrogeological conditions (where groundwater not readily accessible) or if a GWCL feeder pipeline runs near rural communities requiring water. On the other hand, CWSA may contribute to urban water provision supplied with production boreholes as found in Wa town where GWCL lines water supply had low yields. Such collaborations seemed to come about from ad-hoc discussions rather than any formal joint planning process.

This results in a potential service gap for hydrogeologically challenged areas which CWSA cannot supply, and GWCL is not willing to supply, as small towns are not viewed as being within GWCL’s mandate. This risks perpetuating WASH inequities between urban, peri-urban and rural areas. The one case where GWCL did supply small towns, this put a considerable strain on GWCL’s systems:

“We want to cover more small-towns, but struggling to provide them with just one treatment plant for the whole region”. (GWCL northern region)

“GWCL would never lay new lines to uncovered areas. They will not come – it is CWSA who lays lines & sets up small piped scheme, and then asks to connect these to GWCL lines”. (CWSA western) C.3.3 Funding allocation

Once district MTDPs are in place, it is the role of the MMDA to try to mobilise funding to implement this plan, as internal funds are largely insufficient to implement planned activities. Below first describes which internal and external funds are available to the MMDA, and what types of WASH initiatives these are generally used to finance.

C.3.3.1 Types of WASH initiatives funded The table below gives an overview of the types of funding sources, and types of WASH initiatives which the eight interviewed MMDAs said these were commonly associated with. Internal funds were felt to be grossly insufficient to cover WASH needs, which suggests that domestic resource mobilisation remains a major issue. This means that financial constraints are likely to perpetuate WASH inequities in geographical areas which receive less donor funding.

Broadly, districts explained that external funds were used as much as possible for larger water infrastructure investments, with internal funds used instead for rehabilitation and major repairs (minor water point repairs were covered by the communities themselves) and some sanitation behaviour change. In some cases where substantial donor funding was available, districts explained that no internal funds were earmarked for WASH.

“Because here we are lucky that we have much donor money that is why we don’t use our own government funds for basic WASH”. (Accra MA)

Table 17. Funding sources of WASH at MMDA Types of funding WASH initiatives commonly funded In theory 5-20% go into WASH, but in reality the majority used for solid waste management. Some funding of water point rehabilitation and public toilet construction. Hardly any sanitation Common Fund promotion. Internal MMDAs are meant to keep 2% of the common funds fund for CLTS & sanitation marketing

District Development Fund Not more than 10% used for WASH initiatives, (from the FOAT) from the such as for counterpart funding of capital costs MLGRD Internally generated funds45 (WASH initiatives rarely funded from IGF) Generally used more for water point construction External Donor & NGO funds (than rehabilitation), but can be both. Generally funds more rural than urban sanitation funding.

45 IGF stem from a variety of sources, including market tolls, property rates, business operating permits etc. Revenue from small town water schemes do not got the Assembly as IGF; these are managed at the community level.

See Section 4.2.4 for more detail Most common for water tap sellers (GWCL Private funds connection + polytank) and public latrine construction, but also for borehole construction Water point maintenance, private household Community level funds latrine construction (rarely also for communal latrine construction)

One reason for insufficient WASH funding at district level (see Figure 17 in Section 4.2.4.2) is due to the fact that solid waste management funding for Zoom Lion was deducted from the Common Fund at national level, before the funds are disbursed to the districts. However districts commented that this was not an effective arrangement, as ZoomLion was paid regardless of its performance, taking away the Districts’ ability to control and manage performance. This arrangement seems contrary to devolving budget management responsibilities to the districts.

It appears that as a result of sanitation staff not having a key position within the district management team, sanitation is often underfunded. This means that financial constraints are likely to perpetuate WASH inequities in geographical areas which receive less donor funding.

WASH initiatives are planned by the WASH Unit within the District Works Department; which consists of an engineer, a seconded Community Development and Social Welfare officer, and a seconded Environmental Health Officer. However, funding for sanitation still comes through the District Health Department, under which the District Environmental Health Officer sits. This doesn’t align with the new ministry set up at national level, and may contribute to reduced funding allocation.

“We have no local anchor in the district. There is little support for the DEHOs because the environmental health unit sits under the District Health Department – they don’t have their own department, so have less control over funds. We are beggars. We cannot force the district to budget for sanitation”. (REHSU Western Region)

C.3.3.2 Funding of GWCL initiatives Based on the information from officials of five regional GWCL offices, GWCL funding is managed centrally out of Accra, with each region given an annual budget envelope that is centrally allocated. The regional office can decide how to prioritise minor network extensions and funds for maintenance and repairs, but major network extensions are decided centrally. GWCL’s centralised structure therefore poses some risks to equity, as prioritisation is more likely to be made based on commercial considerations than on local coverage gaps.

GWCL is moving from a grant- to a loan-funded model, which may also pose risks to equity because poorer areas may be less able to justify the investment needed to allow GWCL to pay back its loans. According to the Low Income Consumer Support Unit (LICSU) within GWCL, water pipeline extensions into poorer neighbourhoods are often funded by donor programmes, and standpipes (known to be used by poorer households) are often funded by NGOs, rather than GWCL itself.

 PURC has set a pro-poor tariff structure for GWCL which entails a lifeline tariff for the initial 5000 litres of water consumption. This benefits poor households with low water consumption. However, many urban poor live in tenement housing with one water meter shared among several households, which means they pay for water at a rate 1.7x higher than the lifeline

tariff. While some GWCL office reported positive examples of trying to install multiple meters in tenement blocks, this ultimately relies on collaboration from the landlords. The LISCU indicated that they are planning to reform the tariff structure so that it does not penalise poor consumers living in compound housing.

C.3.3.3 Private sector operators are challenging to regulate It appears that the private sector engagement is largely restricted to densely-populated urban areas. The most common forms of engagement for individual entrepreneurs is through the construction of a pay-per use public toilet; the sale of GWLC water from a private household connection or from a polytank; and in some regions (especially Upper West) through the drilling of a private borehole. While private sector providers are not necessarily cheaper than public providers, they can fill a part of the service gap (see text box below). Private sector engagement is sometimes limited by land rights issues:

“We had some people interested to start private-built public latrines – but they asked the Assembly for land to build. We have no land to give them. There is no space”. (MA Tamale)

Private providers (both individuals and firms) were not felt to compete with public providers. However districts also found it impossible to regulate private providers which could pose risks to service quality. GWCL, CWSA and the MMDAs generally welcomed private providers as they were seen to complement publicly-constructed facilities, in some cases even pushing up service levels. GWCL directly benefitted from private providers as these could be charged water tariffs at commercial rates. Only one CWSA office mentioned an example where a private provider supplied an entire town with a small piped supply, which could not be regulated. Nonetheless, it appears that the fact that the regulatory framework doesn’t effectively cover both public and private providers – while it does not pose risks to equities in access – could pose risks to service quality. Districts do not have the technical ability to monitor water quality, and CWSA and the WRC cannot feasibly monitor water quality at every water point.

“If a CWSA small-town scheme is poorly managed by the WSMT and the private scheme is often better managed, then the private seller gets more customers. This can also encourage WSMT to improve their management level to get customers”. (CWSA western Region)

“We have no funds for transport to visit communities and check compliance. This means water schemes are done by the district and by private operators without CWSA sign off”. (CWSA Northern Region)

“Water quality is not monitored by the Assembly. Communities are also not informed of the need to periodically take samples of water from facilities for testing”. (DA Juaboso)

From interviewing several private water sellers and latrine operators, it is clear that profit levels can be quite high for public latrines but are less high for water sellers (see box below). District staff indicated that they lack the staff to regulate private providers. This poses a risk that water sellers charge higher rates, which particularly affects poorer households:

“Standpipe tariffs are set by the PURC. Previously, standpipe tariffs used to be lower than the lifeline [tariff] but this trend has changed. What we need to do now is to ensure that standpipe vendors do not charge more than the approved tariffs which usually results in consumers paying more than they ought to pay”. (GWCL LISCU official, Greater Accra Metropolitan Region)

Text Box: Case studies of two urban water sellers

In Sekondi-Takoradi MA we interviewed the operator of a “Dr Water” station (set up by NGO Water Health, funded by Dutch development funds). The NGO had constructed a mechanised borehole and uses reverse osmosis to produce extremely clean water. A refill of their 20litre canister (bought for a one-off cost of GHC 20) costs GHC2, which is half as expensive as sachet water (20litres would cost GHC 4.67 if sachets are bought in bulk; and GHC 8 if not bought in bulk). However, take up has been slow as households need to travel to the refill station to get water, whereas sachet sellers travel door to door.

In Ashaiman, we interviewed a private water seller with a GWCL connection, who sells water to her tenants and neighbours from her household tap. Her bill is GHC 500/month. She gains around GHC 20 per day (600 per month), translating into roughly GHC 100 profit which she uses for repairs. However, this does not compensate her for her time of having to serve people at the tap all day. She is thinking of stopping as the activity is not very lucrative. The community however indicated that she was an important water source for neighbours as few could afford a household connection and there were no GWCL standpipes in the unplanned settlement.

C.3.4 Approaches to sector monitoring

C.3.4.1 Water coverage monitoring Rural MMDAs collect data on rural water facilities, which are entered into the DIMES database. Districts however reported challenges in generating a comprehensive list of facilities: there were often cases of public facilities not provided through the MMDA that the district was not aware of; e.g. those built by private operators, smaller NGOs. As a result, coverage data is incomplete, limiting the ability of districts to deliberately prioritise areas of inequitable coverage.

Available facilities are compared to current population estimates (extrapolated from last census) to determine coverage gaps46. This data allowed the calculation of pockets of unserved areas at community level. However form our interviews it appears that this data is not used to prioritise planned water facilities, which are mainly planned on a demand-basis instead of a need-basis (see Section C.3.2.2) . Using GPS-referenced water point mapping data is more accurate as it can be compared to the population of the exact village within which the water point is located. The SmarterWASH Project has begun generating this data in several regions, and districts reported using it to improve their DIMES database. However water point mapping can be costly to implement and very costly to maintain especially given the budget constraint faced by district WASH unit.

Water quality is an important factor in consumer choice of water options but there is little evidence of water quality monitoring. District staff reported capacity constraints in enforcing quality standards for private water providers, for example (see Section C.3.3.3).

C.3.4.2 Sanitation coverage monitoring The sanitation coverage data collected as part of the DESSAP cover public toilet facilities. Some districts also reported including the proportion of households with private household latrines; but this is likely to be done only in CLTS areas. This data is held at the region by the REHSU, but does not seem to be shared with CWSA, which collects data on school sanitation facilities.

46 For example, a borehole is meant to serve 300 people; a hand dug well 150 people.

C.4 Implementation of urban and rural water initiatives

C.4.1 Demand for improved water in urban and rural areas

Community interviews showed widespread demand for improved water: Willingness to pay does not appear to create an equity risk; a limited sample of rural FGDs suggest a willingness to pay for higher service levels: Two out of the three47 rural/peri-urban communities which currently fetch water for free from a handpump-fitted borehole (HPBH), would be willing to pay 20p/bucket if a mechanised borehole with more reliable water supply year round was available. In some cases, however communities were not that willing to pay for a borehole service, which was likely to often break down – if reasonable unimproved alternatives exist.

“I prefer to fetch water from the MBH, yes its more expensive than the HPBH but you don’t need to pump, you can fill your bucket quickly and go. Its more convenient” (FGD in Kwabre East DA, Ashanti Region)

”The poor tend to use the river (closer, and free) – but in the dry season forced to use the standpipe”. (GWCL Upper West Region)

Table 18. Average prices paid at different water point types

Water point type Price (GHC) Average Price (GHC per m3)48 Hand pump Free or 10p/bucket Free or GHC 5/m3 Mechanised BH 20p/bucket GHC 10/m3 GW standpipe 20-50p/bucket GHC 10-25/m3

Figure 22. GWCL standpipe in Kumasi town

47 The third community mentioned that the women/wives don’t have an income so cannot pay more for water than 20p. 48 These calculations are based on the assumption that a bucket holds roughly 12 litres.

The exception were communities which were accustomed to MPs or churches or NGOs building free water points, and which felt no sense of ownership over these water points. These rural communities, located predominantly in the Northern and Upper West regions, were less willing to pay for water in monetary terms49. According to CWSA, the practice of providing free water points without setting up WSMTs, and the practice of politicians paying water bills of small pipes schemes around election times has contributed significantly to eroding the sense of community ownership and management. Too often the siting of water points is also done without community consultation50, further eroding the sense of community ownership and management. CWSA is strongly promoting that a WSMT be set up at every water point, and supports the districts in training of WSMTs and tariff setting. Where such unsustainable investments were made without creating a sense of community ownership, these may disproportionately affect poorer communities, who will be less able to cover repairs with their own funds.

Ability/willingness to pay for urban water provision was however lower: The urban poor communities explained that they used GWCL standpipes as their main source of water because the monthly bills for piped GWCL connections are seen as too expensive. However, analysis of volumetric rate shows that the standpipe tariff is 12% higher than the “lifeline tariff” for household connections (see Table 19). One CWSA office interviewed explained that for small piped schemes managed by CWSA, the standpipe tariff is always lower than tariff for household connections. While this practice could not be verified across a larger sample, it seems GWCL could still do more to keeps is standpipe tariffs lower or equal to the lifeline tariff.

Table 19. Average volumetric prices paid at standpipe versus a metered connection

Water point type Average Price (GHC per m3) Average Price (USD per m3) GW standpipe GHC 3.346 $0.802 Metered Domestic (0- GHC 2.982 $0.715 5000l “lifeline tariff”) Metered Domestic GHC 5.074 $1.217 (>5000 litres) Source: PURC water tariff rates

GWCL also indicated that poorer communities tend to use standpipes over household connections but that more could be done to provide these standpipes to poor communities:

“The standpipe policy dying in the cities but it’s the best for the poor. If you want to supply water for the poor, stand pipe is the best – because even if household connections are free, the poor cannot pay the bills at the end of the month. There have been instances where NGOs have subsidised household connections, but households are unable to pay bills at the end of the month. In the end they get disconnected. It is mainly NGOs who assist poor communities with standpipes. On rare occasions, GWCL also takes the initiative to provide standpipes for such communities”. (GWCL Greater Accra Region) C.4.2 Capacity to meet demand for water services

Urban water provision by GWCL is largely financially constrained by the significant infrastructure investments that are needed, which limits their ability to address geographical inequities in access. GWCL requires roughly $2 billion USD annually for infrastructure expansion. This is funded by a mixture of grants and loans. GWCL therefore feels that the greatest challenge is

49 There may however be an arrangement whereby community members contribute guinea fowl, millet and other items from their farms for sale on market days to generate income. 50 In the rural/peri-urban communities interviewed, almost all were not consulted on borehole siting, with it either located near the road or put by the chief’s house by an NGO (only one community chose siting to be the centre of the village).

© Oxford Policy Management, March 2017 5 WASH Sector Equity Analysis for Ghana – Fieldwork report being able to provide enough volume of water to meet demand, rather than it being an issue of accessibility. GWCL deems that the ‘last mile’ is affordable to urban households. Section C.4.1 discusses the willingness to pay of households.

“The tariff structure is basically designed to cater just for maintenance but not improvements. So when there are no donors or loans, GWCL on its own cannot undertake high cost investments”. (GWCL Greater Accra Region)

“We have little customer increase – only 30 new connections/month. Because we don’t have enough reliable sources to increase supply”. (GWCL Western Region)

“The main challenges in providing service for urban poor is raw water supply of surface and groundwater (not just rising population but also rising demand from urbanising areas!). Not a financing or infrastructure issue. We really need to put out heads together to find new water sources or use what we have more efficiently”. (GWCL Western Region)

Rural water provision by MMDA (and coordinated by CWSA) are also financially constrained but less so than urban provision – as boreholes are less expensive than urban schemes. Nonetheless, even these investments are still almost entirely dependent on donor funding. As a result, lack of capacity to coordinate the funding of a large number of sector stakeholders is a key constraint to addressing geographical inequities in access. Section 4.2.4 highlighted that the cost-effectiveness priorities of donors means that they are less willing to invest in remote, expensive and sparsely-populated areas. As a result, there are risks to equity in term of reaching hydrogeologically constrained and remote rural areas, where people often had to resort to unimproved sources.

Ability to meet demand for water is also affected by the deteriorating quality and increasing seasonality of water sources. GWCL staff in several regions reported that deteriorating raw water quality is increasing treatment costs and maintenance costs, because silted pumps break down more often. Pollution, rubbish dumping, and mining activities all contribute to deteriorating raw water quality. In addition, districts lack capacity and financing to do water quality monitoring (see Section C.3.3.3 and lack of water quality testing reported in Table 20 below). Increasingly seasonal water level fluctuations as a result of climate change also pose challenges to GWCL’s ability to supply enough water volumes all year round. Several cities regularly face water rationing. Deteriorating raw water quality is likely to affect the poorest more because they depend more on surface water sources.

C.4.3 Community management of boreholes and small piped schemes

Paying for water (by the bucket ‘as you fetch’, or through regular contributions) does not appear to lead to equity risks, as communities have come up with different ways to accommodate those less able to pay51. Each community decides its own management structure for its boreholes or small piped schemes, and signed off by the district. The arrangement is based

51 The research did not explore gender different in willingness to pay for water.

© Oxford Policy Management, March 2017 5 WASH Sector Equity Analysis for Ghana – Fieldwork report on the local dynamics and leadership structure in the community. It accommodates those less able to pay in the following ways:

 Under ‘pay as you fetch’ models, the very poorest are usually exempt from paying fees at handpumps, but not at mechanised boreholes (as the running costs of the pump need to be covered, and water usage is metered). However at mechanised boreholes, water can be fetched on credit.

 Under ‘monthly contribution’ models, only “working, able-bodied adults” were expected to pay, with both the poor and elderly exempt from contributing.

Whilst these models don’t appear to lead to strong inequities in access to water services, other issues may be at play. The research did not explore whether the financial contributions made under either of the above models some from men’s or women’s earnings within the same household (or a share of both earnings). Additional research is needed to understand if contributions stem largely from the person physically fetching the water (usually women) which could pose equity risks as women often have lower earnings than men.

In addition, it is common practice for family members to bring water to the elderly/disabled people who are unable to walk to the water point. However, based on analysis done across 6 regions by IRC, WSMTs do not always set a tariff (see Table 20).

Figure 23. Rural handpump in the Upper West Region

Weaker management structures, which are less able to organise collections and repair broken water point, may disproportionately affect poorer communities, who are less able to cover repairs with their own funds52. This may perpetuate inequities in access across wealth quintiles. Analysis done across 6 regions by IRC suggests that the majority of WSMTs are not well

52 The research did not explore gender different in willingness to pay for water point repairs.

© Oxford Policy Management, March 2017 5 WASH Sector Equity Analysis for Ghana – Fieldwork report trained (see Table 20). While CWSA recommends a ‘pay as you fetch’ model, it was not clear that this model will always be more sustainable. Of the five communities interviewed who followed a ‘monthly contribution’ model, this did not necessarily limit their ability to maintain the functionality of their water point. However, the IRC data also suggests that the majority of WSMTs are not able to maintain a positive revenue/expenditure balance and routine maintenance is only done sometimes (see Table 20).

In addition, the lack of a functioning supply chain for spare parts will disproportionately affect poorer communities, who are less able to cover repairs with their own funds. This may perpetuate inequities in access across wealth quintiles. CWSA promotes area-mechanics and trained pump operators, but the IRC data suggests that around half of WSMTs had spare parts available within three days, and 2/3rds being able to reach an area mechanic within three days (see Table 20).

Table 20. Summary of performance of WSMTs (Source: IRC) Brong Northe Upper Upper Western Central Theme Description Ahafo rn West East WSMT composed in line with guidelines 14% 14% 14% 5% 3% 1% and trained Govern Up to date financial and operational 18% 11% 21% 3% 16% 5% ance records No political interference in composition of 93% 97% 94% 98% 98% 99% the WSMT Spare parts available within three days 40% 62% 50% 47% 52% 61% Area mechanic available within three data 54% 77% 66% 62% 64% 73% Operati Breakdown repairs within three days 42% 61% 53% 56% 52% 54% ons At least annual routine maintenance 26% 39% 35% 56% 46% 38% Regular water quality testing by certified 8% 7% 6% 13% 4% 1% institute Positive revenue/expenditure balance 21% 16% 30% 6% 14% 11% Financi al Bank account and financial records 14% 12% 22% 4% 14% 5% manag Tariff set 34% 38% 42% 7% 7% 22% ement Facility management plan in place 22% 25% 40% 12% 15% 13% C.4.4 Demand fo sachet water

The widespread use of sachet water in Ghana (see Figure 24) doesn’t appear to be an equity risk, as consumption within poorer quintiles is minimal and overall it is drunk more as a refreshment than as the sole source of drinking water. Sachet water is almost exclusively consumed in urban/peri-urban areas with electricity, because in rural areas without power there are no fridges to keep the sachets cold, and no sachet distributors. Communities reported not drinking sachet water daily, but mainly “when we go into town” or “mainly in the dry season” when it is hotter.

Figure 24. Trends in usage of improved water sources, piped on premises, and bottle and sachet (DHS 2014) Urban Ghana Rural Ghana

100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% 0% Poorest Poor Middle Rich Richest Poorest Poor Middle Rich Richest

Unimproved Source Unimproved Source

Improved Source, excluding bottled and sachet Improved Source, excluding bottled and sachet water water Bottled and Sachet Water Bottled and Sachet Water

Text Box: Prices paid for sachet water

 A typical 500ml sachet costs 20 pesos (0.4 GHC/litre)

 If sachets are regularly consumed (e.g. during the dry season) they are bought in bulk in 15l bunches (costing GHC 3-4; i.e. 0.23 GHC/litre)

 The urban communities we spoke to estimated that they consumed between160-620 sachets per person per year (depending on whether it was an occasional or regular practice) – which would cost between GHC 37-140 per year (USD $8-35 per person per year).

Motivation for sachet water consumption appears to be largely around status, rather than lack of trust in the quality of GWCL water or borehole water. Sachet water was largely seen as a status symbol associated with Ghana’s lower-middle-income status. It was seen as more practical, when offering water to visitors (“we don’t want to offer tap water from a shared cup”). Sachet water was widely perceived as better quality – colloquially it is known as “pure water” – but when probed, preference was largely driven by the sachet water’s cooler temperature compared to tap water, given Ghana’s warm climate53. As many if not most sachet operators fill their sachets using GWCL water, it is reasonable to assume that they would be of similar quality. According to GWCL, some sachet water is of poorer quality than tap water due to contamination during packaging.

“It is all just a change in attitudes. 20 years ago we had women with water on their heads selling from cups shared. Then people started selling slender tied plastic bags filled with water. Then they said it gives cholera. So we saw the rise of sachet water. Now bottled water is replacing sachets. (GWCL Northern Region)

“Sachet sellers are the ones spreading the rumour that GW is poor quality – they do it so that they can gain business. It is not a true fact. GW is very clean – the only issue is sometimes there can be faecal intrusion of there are leaky pipes”. (GWCL Northern Region)

Overall, GWCL stressed that sachet water sellers are not seen as competitors, as almost all sachet operators buy water from GWCL to fill their sachets. Sachet operators were seen as good customers by GWCL.

53 In rural areas, drinking water from HBP was preferred to water from polytanks for the same reason; because it was cooler.

C.4.5 Accountability – knowing who to contact to gain service access

Given that water provision is largely demand-led, in response to community applications to the MMDA (see Section C.3.2.2), knowing who to contact to receive water provision is key. Some of the communities interviewed seemed not to be aware that GWCL or the MMDA can be contacted to provide water provision, reporting that they would contact their MP or an NGO to obtain water provision. While we could not ascertain how widespread such situations are, more remote and socially marginalised/less-connected communities are clearly less likely to know who to contact to receive water provision. This could have significant implications for perpetuating inequities in WASH access driven by socio-political factors. Women are also likely to have less of a voice than men in such demand-led processes but the research could not determine if women were less aware of service provision than men. C.5 Implementation of urban & rural sanitation and hygiene initiatives

C.5.1 Demand for improved sanitation

The level of demand for improved sanitation services differed strongly between urban and rural areas. In urban areas, there was clear demand for toilets and willingness to pay for public latrines54 (for occasional not daily use, see Section C.5.3) – however due to a number of constraints, this still led to limited construction of private household toilets (see Section C.5.4). (In)convenience of public latrine use was however also a key factor affecting demand – when a public latrine was far, dirty, expensive or if individuals did not want to go out at night, widespread open defecation was reported by interviewed communities:

“When it rains we either use the KVIP, or shit in a bag, and throw it in the rubbish/gutter once it stops raining”. (FGD in Kwabre East DA, Ashanti Region)

“At night we shit in plastic bags – we call it ‘shot put’ – or shit in the bathhouse… which then flows into the gutter”. (FGD in Ashaiman MA, Greater Accra Region)

“People think it is the responsibility of the government to provide toilets. People’s mentality that everything should be free especially if it is coming from the government. So they don’t see why they should pay for a DA managed public toilet”. (CWSA Great Accra Region)

In rural areas, demand for latrine facilities (not necessarily improved facilities) varied significantly depending on whether a CLTS approach had been implemented in the community or not. In short, the extent of CLTS adoption becomes one factor contributing to geographical inequities in sanitation access. In the four communities visited in CLTS areas, communities were clearly aware of health risks of open defecation, and were willing to invest their own labour and locally available resources to build a private household latrine55. These communities reported having seen clear health benefits for their children since open defecation practices have reduced. In contrast, in four rural non-CLTS areas, communities appeared reasonably comfortable to continue open defecation; in some cases because it was seen as a way to enrich their farm lands, or to feed their pigs. Mixed messages from previous approaches contributed to reducing interest in demand-led CLTS approaches: two communities (one of who had previously received toilet subsidies) clearly stated that they expected subsidies to be provided before being willing to dig a pit. The mobilisation approach chosen by districts clearly played a pivotal role in determining the extent of sanitation demand in rural areas (see Section C.5.5).

54 The research did not explore gender different in willingness to pay for public latrines or willingness to pay for investments in household toilets. 55 Rural communities were however less willing to pay-per-use for a public toilet (see Section C.5.3).

“Three years ago there were no toilets here. Then the DA came to explain, now we’ve seen the health benefits. We use the toilets daily; they don’t smell – we put ash”. (FGD in Nadowali DA, Upper West Region)

“We heard about toilets from neighbours so we wanted to also learn how to build them. We’ve seen the health benefits for children so wanted to build them too”. (FGD in Mion DA, Northern Region)

In addition to rural/urban differences, there were also differences in demand for sanitation facilities between women and men. Men generally felt more comfortable defecating in the open, whereas women would prefer to use a toilet (e.g. public latrine) or defecate in a plastic bag. Girls indicated that they preferred not using public toilets due to the health risk of infections and preferred to defecate in a plastic bag. These aspects could affect inequities in the usage of sanitation facilities by gender. C.5.2 Capacity to meet demand for sanitation services

Because sanitation interventions need to be carefully tailored to context (see Section C.5.4), capacity to meet demand for improved sanitation appears constrained by the ability of District sanitation extension staff to regularly travel to urban and rural communities. This could perpetuate geographical inequities in sanitation access: EHSU staff reported that lack of transport budget significantly limited their ability to visit communities regularly enough to explain health risks of open defecation, to do CLTS triggering if necessary, to advise households on latrine design types, to enforce building codes in urban areas, and to regularly follow up with communities once demand for improved sanitation had been created. In districts there were was no donor programme, EHSU staff reported that they did not have internal funds available to cover fuel costs and that often they also had no vehicle or motorbike available. This is partly a result of sanitation not being strongly prioritised within the District budget (see Section C.3.3.1), and worsened by the fact that REHSU officials don’t have operational funds to visit districts and advise on toilet design (see Section C.3.2.1).

In the longer term, the fact that sanitation value chains are still quite under-developed is likely to constrain the ability of Districts to meet sanitation demand. This could perpetuate geographical inequities in sanitation access. Training of masons was only done in a limited number of Districts which had a donor programme which focussed on this aspect. Latrine pit emptying services were also only present in some of the districts visited.

“SaniMarts are a waste of resources – people don’t come to look are the demonstration toilets. They don’t work for encouraging people to build their own toilets. It would be better use that money to train more artisans”. (CWSA Western Region) C.5.3 Attitude to public latrines

Public toilets are generally only found in densely-populated urban areas because toilet operators were only interested in operating in areas with sufficient demand so that they could make a profit – regardless if they were operating a district-constructed public toilet or a privately-built public toilet. Public latrine operators were unlikely to operate in less densely-populated areas, where people are much less willing to pay for visiting a public toilet56 because there are fewer space constraints on open-defecation.

56 In the 1950s, communally-dug ‘trench toilets’ were promoted at the edge of villages. These were unsuccessful. Because they were free, nobody maintained them and they became extremely dirty. Some of the communities we visited still had ‘trench toilets’ but these were rarely used.

Figure 25. Public toilet in Kumasi town

Of the five urban communities interviewed, all were of the opinion that public latrines in public spaces (lorry parks, markets) as well as in residential areas (“communal latrines”) were an important sanitation option for them. This was particularly important option because paying per visit at a public latrines was more affordable and feasible than constructing a private household toilet (see Section C.5.4). The public toilets widely used (if not daily) are a mix of MMDA-constructed (but franchised) and privately-constructed public toilets (these include private toilets inside households where the public can pay to enter).

“I’m a tenant. There is no toilet where I live. Using public toilets is the only option here”. (FGD in Ashaiman MA, Greater Accra Region)

“We need public toilets when we’re travelling for business and not near home”. (FGD in MA Asokore Mampong, Ashanti Region)

“The best way you can reach people [to change their behaviour] is through communal toilets because you cannot force people to build their own, but you can make a public toilet available and hope that they will take it up in the long term”. (FGD in Kwabre East DA, Ashanti Region )

“Because we don’t have enough public toilets, communities sometimes use the school KVIP toilet! Then it gets very dirty very quickly. [Demand exceeds supply]”. (FGD in Juaboso DA, Westen Region)

Text Box: Prices paid for public latrines  Based on the communities interviewed, public latrine prices varied slightly, with assembly-built ones being cheaper and privately-built WCs being more expensive:

Latrine type Price per visit (GHC) Assembly-built Free or GHC 0.20-0.40 Privately-built (KVIP) GHC 0.40-0.70 Privately-built (WC) GHC 1  The urban communities we spoke to estimated that they didn’t use public latrines daily – usually using them about 5-10x in a week. Assuming an average cost of GHC 0.5 per visit, this would cost each person around GHC 130-261 a year (USD $31-62 per year).

 This would amount to 2-3.5% of mean annual per capita income in urban areas (based on a comparison to the 2014 LSMS survey which reports urban incomes as GHC 7020 per person per year).

While communities saw public and communal toilets as an important sanitation option for them, districts and CWSA/REHSU had different views on their appropriateness. National sanitation policy only promotes public latrines in public spaces (lorry parks, markets) but not in residential areas (“communal latrines”). This was consistently the view of the REHSU. Some districts followed this view and no longer constructed public toilets in residential areas because these were felt to dis-incentivise private household toilet construction. However other districts saw them as a key sanitation option and either tolerated communal latrine construction by private operators, or still maintained franchised public toilets in communal areas.

“We discourage districts to refurbish old public toilets – they should be closed long-term. Public toilets disincentivise the construction of household toilets”. (REHSU Northern Region)

“Even if [public toilets] could be an interim solution, we don’t promote public toilets in CWSA projects because it is against the policy. And because it discourages private household construction”. (CWSA Western Region)

“Because the MMA cannot build public toilets in communal areas, we encourage private-built public toilets. Despite the law, we think public communal toilets are essential – they are an interim solution, where there is no space [for private household toilets]. But long-term we want household toilets”. (MA Sekondi-Takoradi)

“Public toilets will be ideal for highly congested places in Accra in an effort to bridge the equity gap. This should be a temporary solution. In this case, these public toilets should be privately owned and managed. Managers of such a facility have to be trained on how to maintain it so that it doesn’t pose any environmental concerns”. (REHSU Greater Accra Region)

“Public toilets can be a temporary measure for bridging the gap [in demand and supply]. The cleanliness of public toilets is however very critical”. (DA Juaboso)

Interviewed communities generally preferred public toilets built by private individuals to the ones built by the assembly. While the assembly had attempted to improve the management of public toilets by using a franchise mode, in many cases urban communities still reported that those public toilets built by private individuals were still cleaner and better managed. Communities were happy to pay a bit more to use these57 (see box above). It appears that they can be a relatively

57 The research did not explore gender different in willingness to pay for public latrines.

© Oxford Policy Management, March 2017 5 WASH Sector Equity Analysis for Ghana – Fieldwork report lucrative business for toilet operators, who can usually cover the cost of pit emptying with their earnings (see box below).

Overall, it is clear that private toilet operators play an important role in bridging the urban supply-demand gap where household toilets are still unaffordable or impractical.

Text Box: Impressions from a latrine operator (Sekondi Takoradi MA, Western Region)

We interviewed a public toilet operator of an Assembly Toilet (12 seater). She also managed the GWCL standpipe tap next to the toilet.

She used to earn GHC 400 in a month to give to the MMA to cover maintenance costs, but people broke the fence around the toilet and used the toilet for free using the back entrance. Now she only earns GHC 200 in a month and this amount is not enough to cover the cost of dislodging. The. MMA is trying to build a new fence. C.5.4 Affordability and practicalities of private household latrine construction

Communities and district assemblies were of the view that private latrine construction is unaffordable for poorer households in urban areas. The table below presents cost estimates for several improved latrine designs commonly promoted by the districts visited. Cost of construction varied between GHC 1728-3011 for a one-seater toilet (see Figure 26 for a summary and Figure 27 for a detailed breakdown of costs).

Figure 26. Average improved latrine construction costs (Source: TREND, 2016) Based on a material survey, the average latrine cost is GHC 2,944 (the maximum cost using the most expensive materials was 4,240 and the minimum was 1,688). The largest cost drivers were the sub-structure (38% of costs) and the superstructure (44% of costs). The rural variety made from cheaper local materials cost only GHC 867 – mainly because both the sub-structure and the super-structure were only 1/3rd of the price of the same element within the average urban toilet.

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

- Average price (urban) Maximum (urban) Minimum (urban) Rural

Sub-stucture Slab Seat Super-structure

Even though latrines are constructed at a household level (not an individual level) the high constriction cost represents a significant proportion of household income. Based on our interviews with communities, an average latrine of GHC 2,944 (including labour costs) would cost 13% of an urban poor household’s income and 38% of a rural poor household’s income. Compared to average rural and urban incomes as extrapolated from the LSMS survey, this would amount to 8% and 15%

© Oxford Policy Management, March 2017 5 WASH Sector Equity Analysis for Ghana – Fieldwork report respectively (see Table 21). Due to this substantial cost, several donor programmes are promoting a toilet subsidy approach (see Section C.5.5). However, communities reported that even with a 50% subsidy, some of the proposed toilet designs were still unaffordable.

Table 21. Latrine costs as a percentage of household income The table below displays both annual income estimates based on our limited interviews58 and LSMS data extrapolated from the 2014 survey. The LSMS data indicates that household incomes are on average 3.12x per capita incomes so we used the same assumption for our income data.

Mean annual income (GH₵) Latrine cost as %income

Per capita Per household Per capita Per household 2014 prices Urban (LSMS data) 7,020 20,930 Rural (LSMS data) 3,303 11,408 n/a All Ghana (LSMS data) 5,347 16,645 2017 prices* Urban (LSMS data) 9,343 27,858 25% 8% Urban poor (our data) 6,000 18,678 39% 13% Rural (LSMS data) 4,396 15,184 53% 15% Rural poor (our data) 2,000 6,226 117% 38% All Ghana (LSMS data) 7,117 22,154 33% 11% (*)2017 price estimates are based on an assumption of annual 10% inflation in incomes.

Construction costs were driven by several factors:  Labour was more expensive in urban areas than rural areas;  Digging the pit by hand took longer in urban areas, which often contained housing rubble.  More expensive materials were used (cement and concrete blocks) rather than local material (wood, mud bricks and thatched roofs). This was as a result both of the unavailability of local materials in urban settings, and a perception that more durable materials should be used (partly due to the associate status)  The superstructure was usually built of concrete blocks. To support their weight, this required pits to also be lined with concrete blocks, significantly driving costs.  As there is rarely space in urban areas to dig a new pit once it is full, latrines must be built in a way to make them easy to empty and built with durable enough materials so that they can be emptied and reused for many years (i.e. the pit needs to be lined)  In dense where pit emptying trucks could not enter, composting toilets were seen as the only option, even if these were more expensive to build.

Interviewed communities were not aware of other lower-cost options (such as replacing cement blocks with red bricks), and broadly followed the design recommended by the district.

“There are no cheaper options – the cheaper toilets cannot be emptied / or take many years to be safe to empty. This is not an option because have no space here to dig a new pit when full. Need expensive composting toilet models”. (MA Ashaiman)

58 The urban and peri-urban communities we spoke to estimated that they earn between GHC 400-600 per month, translating into around GHC 4900-7200 per year (average 6000/year). The rural farming communities we spoke to estimated that they have much less liquid cash available at their disposal, earning as little as GHC 1000 in their annual harvest, which might be supplemented by another GHC 1000 over the course of the rest of the year.

Figure 27. Breakdown of latrine construction costs (Source: TREND, 2016) Materials commonly used in urban areas are indicated in BLUE and materials commonly used in rural areas are indicated in GREEN.

Super-structure costs (itemised costs in GHC) Sub-structure costs (itemised costs in GHC)

KVIP with blocks (plastered) Single compartment block substructure VIP KVIP with blocks (not plastered) (1.2x2.1x2.0m) VIP with blocks (plastered) KVIP with mud bricks (not plastered) Single pit with stone pitching substructure VIP with blocks (not plastered) (1.2m depth) KVIP with mud bricks (plastered) Circular lined with blocks substructure (dia Hardwood board superstructure VIP… 1.2m, 1.5m depth) Plywood superstructure VIP 1.2x1.5m Aluminium sheet superstructure VIP… Single comp. With old barrel substructure Wooden slabs superstructure VIP… (1.2m depth) Bamboo superstructure VIP 1.2x1.5m Rectangular unlined substructure (1.5m Mud and wattle superstructure VIP… depth) Coconut palm fronds superstructure… - 400 800 1,200 1,600 0.00 200.00400.00600.00800.001,000.001,200.001,400.001,600.00

Seat costs (itemised costs in GHC) Slab costs (itemised costs in GHC)

Reinforced concrete rectangular slab with pour… Ceramic seat Reinforced concrete rectangular slab KVIP… Reinforced concrete rectangular slab VIP… Concrete seat Reinforced concrete circular slab VIP D 1.2m

Wooden seat Timber slab VIP 1.2x1.5m Mosambique slab VIP d 1.2m 0.00 50.00 100.00 150.00 200.00 250.00 300.00 Mud and wattle slab VIP 1.2x1.2m Sanplat 0.6x0.6m

0 100 200 300 400 500 600 700 800 900

Table 22. Descriptions of common ‘improved’ latrine types in Ghana

Two-seater KVIP One-seater VIP Mozambique Biofill (World Bank) SanPlat Pit lining with cement blocks; Pit lining with cement blocks; Used to be popular, now A decomposing toilet, Pit without lining & slab & cement slab; superstructure out cement slab; superstructure discouraged because the pit promoted for congested superstructure out of local materials. of cement blocks. out of cement blocks. is not lined. urban areas where cannot

de-sludge

In addition to these affordability challenges, communities and district assemblies in urban areas explained that space constraints made it impractical to retro-fit a toilet in a dense housing area. There was no space to add an extra toilet room to the side of the house as this would often jut out into the path. There was also resistance to converting an existing room in the house into a toilet, as it was needed as a bedroom.

Landlords in particular had no incentive to convert a tenant’s bedroom into a toilet room, as they would lose out in rent. The high proportion of tenants in urban areas means these users have no right to build a toilet in their house of residence, even if there was demand for it. This in part explains the high use of public toilets in urban areas.

While building codes require every house of residence to have a toilet, district assemblies reported that they are not able to enforce this law. District assemblies do not have the staff to inspect every house. One district assembly which attempted to take a large number of landlords to court, encountered political difficulties in following through with the fines.

In rural areas, construction costs were roughly GHC 300-850; i.e. substantially lower than costs in urban areas because cheaper local materials could be used. Table 23 below presents cost estimates for pit latrines, including the cost of labour, to make it comparable with urban construction costs. Note that labour was usually provided for free, sometimes with a compensation in-kind in the form of a meal. Local materials could often also be fetched for free59, but entailed considerable investments of time to cut and fetch timber, and fetch the water needed to make local mud bricks, for example. In the table below these inputs were costed, by asking communities “if the neighbouring community asked you to build a pit latrine for them, how much would you charge them?” The CLTS communities interviewed in the Upper West and Northern Region explained that if someone of the same communities asked them to build a pit latrine for them, this would be done for free due the solidarity felt with other community members. This solidarity was particularly strong in rural communities which had been triggered though the CLTS process.

If we had to put a price on it, [the pit latrine we dug] would be expensive, but we use our own strength. (FGD8 Upper West)

The biggest cost driver was the labour needed to dig the pit by hand. Communities explained that in rocky areas (e.g. near Kumasi) this was a long laborious exercise which would take five labourers over a week, as every rock needed to be broken by hand and removed. A simple traditional pit latrine was the most common design, sometimes with a lid to keep flies out. When the pit was full, a new latrine would be dug. Improved designs with slabs and vent pipes were rare in rural areas.

It is important to note that inability to dig a pit was not seen as a constraint – the four CLTS communities interviewed unanimously reported that if an elderly or disabled member of the community was not able to build a toilet, neighbours or relatives would build for them. In non-CLTS areas, elderly or disabled people without a toilet appeared free to use the toilet of a neighbour (see Section C.5.6 on sharing).

59 Even when toilets had an iron sheet roof, this was not perceived as a cost because households would only use an iron sheet if “left over” from those already bought to roof the main house. Iron sheets are usually purchased in packs of 12. The iron sheet cost in the table was estimated based on the proportion of the cost of a whole pack.

Table 23. Rural construction cost estimates (in GHC) for pit latrines (one-seater) It appears that our cost estimates are similar to the industry survey data – with the exception of the costs of the superstructure, which were cheaper because bricks making only included the costs of labour (as the mud and water was free).

Our data Industry FGD8 FGD9 survey Digging the pit GHC 150 (2-3 people) GHC 50-60 (takes 3days, 2m deep, GHC 354 soil is hard in the dry season) Carpenter GHC 20 GHC 50-60 to fetch wood & make floor GHC 86 Floor = Cutting & GHC 40-50 (its far) fetching timber Bricks for super- 100 bricks = GHC 40- GHC 200 for mud walls (1day is made GHC 427 structure 50 + dinner out of mud bricks, 3days if just adobe style which is more common) Roof thatch 2 or 3 iron sheets (GHC GHC 10 for thatch 60-90 ) TOTAL GHC 300 GHC GHC 300 GHC GHC 867 (included water & food for workers)

However there was a clear trade-off between using cheaper local materials and the life-span of the toilet. The four rural CLTS communities interviewed reported that the walls of pits collapsed after heavy rains and the floor of the latrine collapsed due to rotting wood beams or beams infested by termites. CLTS communities reported that they would be happy to rebuild their pit latrines – because they had seen the health benefits of latrine use – but this statement should be taken in the context that all of the interviewed CLTS communities had been triggered in the last 6 months, and still felt motivated to rebuild latrines. Frequent collapse is likely to dis-incentivise residents to rebuild in the longer term.

Interviewed communities in rural areas were not aware of how to build more durable pit latrines less prone to collapse, whilst still keeping costs down. In some areas, the districts and REHSU maintained that the only option in areas of sandy soils is to line the pit with cement blocks. This option was however unaffordable to most rural households, leading several communities and districts to insist that subsidised latrines are the best policy option (see Section C.5.5). In other areas, CWSA and REHSU maintained that a pit could be lined with bamboo, a woven mat, or cut sides of an old barrel – all significantly cheaper than concrete blocks. One CLTS facilitator explained that communities were taught different designs as part of the CLTS process, but that some may be easier to construct than others. Local innovations made in one region don’t appear to be shared with other regions. The lack of a transport budget for DEHOs to regularly visit communities (see Section C.5.2) is probably further constraining their ability to provide tailored advice on latrine design for different soil conditions.

Yes we taught the community [how to dig] the cone shaped pit [which doesn’t collapse so easily] but maybe they forgot [because none of the household toilets here have that shape]. Also it is more difficult to dig, maybe they don’t have the right tools. (DA Nadowli) C.5.5 CLTS or subsidised latrines?

The Environmental Sanitation Policy of 2010 gives the districts the responsibility to promote the construction and use of private household toilets. Even though NESSAP clearly discourages a subsidy approach, districts had widely differing views on whether such promotion could be best achieved through CLTS triggering, or through the provision of toilet subsidies. The

‘community spirit’ needed to make CLTS work was perceived to be fading, and to be particularly weak in rural areas. Due to the high cost of latrine construction, urban districts often followed several parallel approaches, namely (i) attempting to mobilise landlords with varying success; (ii) attempting to secure donor funds to provide subsidises latrines; and (iii) constructing public toilets to meet demand in the meantime. Subsidised toilets, or in-kind “support” for poorer households (in the form of free bags of cement, which are not viewed as a “subsidy” locally, even though de facto they are) were seen as essential to help with construction costs in urban areas. In rural areas, the additional cost of a small amount of cement could feasibly be covered by rotating savings groups.

“In the past we just persecuted those that open defecated but this did not help change behaviour. Now were are trying a new approach. We started urban-CLTS with UNICEF recently”. (MA Ashaiman)

“CLTS doesn’t work – the community spirit is gone. Also aiming for 80% ODF still actually carries a 20% cholera risk! This is like faecal man slaughter! The poor need latrine subsidies: we have latrines built with subsidies from 10 years ago and they are still used!” (CWSA Northern Region).

“Yes CLTS works! We still have community spirit here!” (DA Upper West)

“Subsidy is tricky: One should never give cash as it will just be used for other expenses. Providing materials is better, but then you have the challenge of having to choose the latrine design beforehand. And if the design is not accepted, people will never actually use the materials: if they wanted a WC they will not build a sanplat even if you provide slabs for free”. (REHSU Western Region)

“The best is to provide water or electricity as reward for ODF; this is the best incentive – it is better than providing slabs. Then neighbours will see what the other village has gotten, and will follow their example”. (MMA Mion)

“We used to be proud of cleaning up our environment. It was done every Saturday. But the National Sanitation Day Campaign that was launched 1-2 years ago, after the Accra cholera outbreak, has eroded community spirit because they started to fund MMDAs to clean up”. (REHSU Western Region)

Implementing a demand-led CLTS approach was seen as been easier in rural communities, which usually have a strong sense of solidarity. The communities visited had set up their own open-defecation watchdogs, which would report people to the chief if found open-defecating. In several communities they’d be made to pay a GHC 100-150 fine; which is a lot of money in a rural community (see Section C.5.4 on affordability).

“Still 60% of the community do OD here. We have set up community watch dogs. A spot fine of GHC100.00 to be paid if one is caught doing open defecation. So far, 3 people have been caught and 2 paid the fine. The last person ran away from the community. OD is done mainly by the youth and by community members who do not have household latrines and live far away from the only communal latrine available”. (FGD in Juaboso DA, Western Region)

Implementing a demand-led CLTS approach was seen as particularly challenging in urban areas. District staff explained that urban settlements rarely had a sense of cohesion and solidarity needed to make a demand-led approach work. The landlords – who would make the decision to build a toilet or not – often did not reside on site, and were therefore hard to ‘trigger’. Some districts attempted to convince landlords to use a part of their tenant’s rent to pre-finance toilets, with varying success. Lastly, public latrine operators openly opposed a push for private latrine construction because it would jeopardise their income stream:

“We have tried to implement CLTS in Kumasi town but we struggled – public latrine operators don’t want to lose their income!” (MA Asokore Mampong)

“When all tenants in a compound are friends or related, they can easily pool their rent and convince the landlord to build a toilet for them. But often it is not so, and then it is a challenge”. (REHSU Western Region)

In the past, many donor programmes had implemented a toilet subsidy approach which clearly made it more challenging to implement a demand-led CLTS approach in the same areas afterwards. Several donors still promoted a toilet subsidy approach currently, making it more challenging for districts to follow the NESSAP position dissuading toilet subsidies. However, communities reported that even with a 50% subsidy, proposed toilet designs were still unaffordable in urban areas, which has led SNV to roll out a micro-credit scheme where households can pay construction cost back in instalments, over the course of 12 months (see box below).

Text Box: Case studies of SNV Toilet Subsidy Programme with Fidelity Bank SNV is implementing a Toilet Subsidy Programme with Fidelity Bank. Its focus is primarily urban, in small towns – but it is aiming to cover the whole country. Fidelity Bank operates the programme through a network of micro-finance institutions (MFIs).

We interviewed one of their MFIs (Adom Boafo – which means “helping gracefully”). They have received a 10% loan from SNV – and give a 17% loan to households. Loans were first issued 18 months ago. Since then eight people have signed up for a toilet loan. Total amounts to repay depend on the toilet model chosen – but usually the total loan is GHC 1500-2000. Household are required to deposit 30% up front to get the loan (i.e. GHC 450-600), they can take this out at end if all have been paid back. From the on households pay in monthly instalments over 12 months – i.e. 150 per month.

There was however consensus among district and CWSA staff that if a toilet subsidy approach needed to be adopted due to the unaffordability of construction costs, such an initiative should be done hand in hand with demand-creation and raising awareness of the health risks of open defecation. Communities reported that where subsidised toilets had been distributed without demand creation and without long-term follow-up, subsidised materials ended up not being used for toilet construction.

“In rural areas like here, we should do demand-creation first and see who builds [their household toilet]. If anyone cannot afford two bags of cement, then we provide cement for free to the few households left over. In urban areas, we need a blend of CLTS and microfinance”. (Mion DA)

“We cannot build a toilet with a cement floor without subsidy. This is a poor area. We need several sacks of cement. An NGO did a subsidy approach here, but they only deposited materials (two sacks of cement and a vent pipe per family) but the cement was not enough. Mobilisation was poorly done, it didn’t involve DEHO and the NGO never came back to check on us. So hardly any households built their own toilet. The few that did complete it, had extra money to buy more materials”. (FGD in MA Tamale, Northern Region)

“An NGO did a subsidy approach here (60% subsidy) but they only contacted landlords. They did not do community-wide sensitisation on health risks. Very few Landlords came forward”. (FGD in Sekondi Takoradi MA, Westen Region)

“Subsidies should not be cash, they should only be materials. In the Volta Region, DANIDA successfully implemented this approach. For a KVIP they provided 8 bags of cement, a slab, vent pipe, and two iron sheets. DANIDA set up supply stores where households could send an application for materials. These are then delivered to the household, after which the store was paid by DANIDA. This worked well because mobilisation was done through community elders and focussed on their pride of the community and keeping their children staying safe”. (CWSA Western Region)

District and CWSA staff also felt that combining demand-creation with ‘support’ is key for moving up the ladder, and encouraging households to upgrade their basic pit latrines. Experience of several communities where UNICEF has implemented programmes suggests that setting up village savings & loan associations is an effective way of addressing the affordability of more durable construction materials needed to upgrade the toilet60.

Here we’re started village savings and loan associations in three communities with UNICEF. Funds are used for social funds, loans and sanitation. Sanitation funds are used to cover latrine construction costs through monthly repayment – this is a key way of upgrading basic toilets, if they only have a basic one. (MA Mion)

Overall, the overlapping mandates of REHSU and CWSA on rural sanitation is leading to implementation of slightly different sanitation approaches, and a lack of lesson sharing and data sharing. In part due to the history of both institutions, it was more common for REHSU to promote pit latrines under a CLTS approach, but for CWSA to promote VIP/KVIPs, usually through a subsidy approach. Some donor CLTS initiatives were coordinated by the REHSU while others were coordinated by CWSA – with no apparent lesson sharing between them. The sanitation coverage data compiled by REHSU using data from the DESSAP does not appear to be shared with CWSA.

“We are supposed to have a Regional WASH team to coordinate between REHSU and CWSA, but we don’t meet regularly. The previous coordinator was active but he retired. The new coordinator is not active. We hope the new ministry will help with REHSU-CWSA coordination. (REHSU Western region)

Some CWSA colleagues are defending the new Rural sanitation model launched by REHSU, but most of us are against it. We are promoting latrine subsidies. We need to promote KVIP which allow proper containment”. (CWSA Northern Region)

“We promote KVIPs. But actually a latrine with a wood floor and mud to plug holes can stop flies – but this stage is not recognised as part of Ghana sanitation ladder”. (CWSA Ashanti Region)

“We have been using NGOs and private consultants as CLTS facilitators but it is not working. They have no long term vested interest in the community. Now we are trying to do CLTS facilitation through the DEHOs [this is the standard REHSU approach] – these are really motivated. We hope this will work better. These just need a motorbike and fuel, and they will be even live in the community to be able to pass ODF messages every day. That is the most effective way”. (CWSA Western Region) C.5.6 Attitude to sharing

According to DHS 2014, 72% of rural households and 68% of urban household share their improved latrines with other people.

In rural areas, toilet sharing appears common largely because of a definitional issue: The four rural CLTS communities we interviewed explained that one toilet is built for each extended family. An extended family usually consists of 2-4 households living in close proximity or within a ‘compound’ surrounded by a low wall. As a result, a rural toilet is often shared with 12-20 people. In some communities this could dissuade toilet use, but this was less so the case in communities that had been triggered under CLTS. Several communities indicated that they hope to build a second toilet for their family in the future, but so far only one had been built because it requires a joint investment of labour and several weeks to build (see Section C.5.4).

60 The research did not explore gender different in willingness to save for latrine upgrades.

“Here 14-20 people share one toilet! That is the size of the extended family (2-3 households). Sometimes you need to wait a bit to go, but we don’t mind. If you really need to go, you go to the neighbour; you don’t open-defecate”. (FGD in Nadowali DA, Upper West Region)

“We share [our toilet] with too many people. I prefer to go to the bush, we are a big compound, people always come knocking when you are sitting on the toilet; there is no calm”. (FGD in Kwabre East DA, Ashanti Region)

“We share [our toilet] with our whole family. We try to leave the compound pit latrine for the elderly because they cannot walk far. The young people go to the bush”. (FGD in Kwabre East DA, Ashanti Region)

Occasional use of toilets by unrelated neighbours was also widely accepted areas because toilets were built through a communal effort under the CLTS process. Because most rural communities are small and neighbours know each other, there was also no barrier to using another family’s toilet “if in need”.

“Because we built all toilets together as a community (went round house to house), we have no problem sharing toilets. They belong to all of us”. (FGD in Mion DA, Northern Region)

The only taboo mentioned was toilet sharing between women having their periods, and other men of the household. In this case, some women would open-defecate instead.

“Toilet sharing is an issue when you have your periods. If you share the same toilet as a man then, your bleeding will never stop. He has put juju on you. So you either need to go to bathhouse to wash before going to toilet, or you go to the bush”. FGD in Mion DA, Northern Region)

In urban areas, the frequent use of shared public toilets, and the fact that many tenants live in tenement housing with shared facilities explains high ‘sharing’ figures in urban areas. The current MIS data is not able to distinguish between these different types of ‘sharing’. Analysis of the latest DHS data (see Figure 28) suggests though that sharing of public toilets is noticeably higher for the urban poor (72% of toilets) than for the urban rich (32%) – whereas for improved public toilets in rural areas the proportion remained around 57% regardless of wealth quintile61. This highlights the high dependence of poorer urban households on shared facilities. Occasional use of toilets by unrelated neighbours is however less common, as neighbours know each other less well.

“This toilet is for everyone living in this tenement block, but people from outside cannot come in and use” it. (FGD in Asokore Mampong MA, Ashanti Region)

61 The proportion of shared compound toilet remained roughly 20% of improved toilets, across both urban and rural locations regardless of wealth quintile. But it is important to note that in rural areas shared compound latrines are likely to be unimproved and do not feature in the above graph.

Figure 28. Sharing of compound latrines and public latrines (DHS data) “Sharing of a compound latrine” was defined as sharing with 2-6 households, and “sharing of a public latrine” as sharing with more than 6 households.

Rural improved latrines (n = 2887) Urban improved latrines (n = 5161) 1000 1400 1200 800 1000 600 800 400 600 400 200 200 0 0 Poorest Poor Middle Richer Richest Poorest Poor Middle Richer Richest

Private Private Shared compound toilet Shared compound toilet Shared public latrine Shared public latrine C.5.7 Disability-friendly toilets

Wider awareness of the needs of disabled people was seen as a relatively need development by district staff. Institutional toilets (schools, office buildings) are generally constructed in a disability friendly manner, with access ramp, rails and doors wide enough for wheel-chairs. The same held for public toilets recently constructed by the district assembly. However, already existing public toilets were only sometimes upgraded, if the district had funds available.

Privately-built public toilets rarely had ramps or rails, but often include at least one stall with a seat which was intended for elderly and disabled people who had difficulties squatting. Private household toilets were rarely disability friendly, as that depended on whether a household had a disabled family member or not.

Annex D List of people interviewed

D.1 KIIs at national level

ORGANISATION NAME POSITION CONTACT EMAIL Government bodies MWRWH (Water Fred Addae Director, Water 0243673132 [email protected] Directorate) Senior Tony EHSD Environmental 0203311201 [email protected] Tsekpetse Health Technologist Head, Fiscal MoF Joseph Antwi 0242537894 - Decentralization Unit Theodora Extension Services Adomako- Coordinator CWSA Adjei 0244819042 [email protected]

IT specialist Esinu Abbey Johnathan NDPC Deputy Director 0244763067 [email protected] Azasoo GWCL Richard Otoo Chief Manager 0244336173 [email protected] Office of the Ransford Administrator of Director, Operations 0277427876 [email protected] Ayensu the DACF Public Utilities Director, Regulatory Simons Y. Regulatory Economics and 0541828989 [email protected] Akorli Commission Research NGOs Jesse Coffie Senior Advisor, SNV 0207092558 [email protected] Danku WASH WASH Technical World Vision Attah Arhin 0244713332 [email protected] Coordinator Head of Sustainable Yaw Sarkodie Service Programme [email protected]

Water Aid Matilda Akua Planning, Monitoring Afriyie and Evaluation [email protected] Officer WSUP Ibrahim Musa Country manager 0243713406 [email protected] Veronica Ayi- IRC Programme lead 0277451705 [email protected] Bonte Donor organisations Janet Dufie Policy Officer Dutch Embassy 0501567218 [email protected] Arthur GNWP Emmanuel Water and Sanitation World Bank 0244790263 [email protected] Nkrumah specialist

D.2 KIIs with MMDA

Name Designation ASHAIMAN MUNICIPAL ASSEMBLY Patrick Tsigbey Municipal Environmental Health Officer Awagah Nicholas K. Municipal Engineer Michael Agyemang Municipal Planning Officer Kwame Grundow Assistant Development Planning Officer Sitsofe Adzah Social Development Officer KWABERE EAST DISTRICT ASSEMBLY Owusu-Ansah Collins Technician Engineer Matilda Fati Bukari District Water and Sanitation Team- Community Mobilizer Agnes Nangwello District Finance Officer Osei Ababio Victor District Environmental Officer Darko Richard Assistant Development Planning Officer Daniel Fofie District Planning Officer Alhaji J. M. Hardi District Coordinating Director Evans Dankyira District Head of Works ASOKORE MAMPONG MUNICIPAL ASSEMBLY Charles Baaye Municipal Budget Officer Adam Mohammed Baba Municipal Coordinating Director Collins Ohene Gyan Municipal Planning Officer Isaac Biya Newton Department of Social Welfare and Community Development Ebenezer Yeboah Municipal Environmental Health Officer Richard Omari- Safo Head of Works Department Mary Serwaa Adjei Department of Social Welfare and Community Development Sali U. N. Municipal Finance Office NADOWLI/KALEO DISTRICT ASSEMBLY Justice Amoah District Coordinating Director Isidore Benlu District Finance Officer Prosper Kpamkyaano Social Welfare Officer Bilattey Bimi Assistant Development Planning Officer Donatus D. Tay-Worgbale Engineer Samuel Nuamah Eshun Community Development Officer Mohammed Ibrahim District Environmental Health Officer Ali Tamimu T. B. Community Development Officer MION DISTRICT ASSEMBLY Abubakari F. Zafordir Assistant Budget Analyst Mohammed Zaa-idatu Assistant Director Lucy Elkang District Finance Officer Abdulai Abubakari District Environmental Health Officer Nyame Boateng District Works Engineer Ibrah A. Gombila District Planning Officer Stephen A. Amponsah District Works Engineer TAMALE METROPOLITAN ASSEMBLY Joyce Yeri Social Welfare Officer Samuel Salam Laar Metro Environmental Health Officer Martin Ahorlu Head, Waste Management Tahiw Hikmatu Social Welfare & Community Development Officer Gaspard K. Dery Municipal Coordinating Director A. S. Rumaith Assistant Director

Felicia Borgkur Assistant Development Planning Officer Issah Salifu Musah Public Relations Officer James Q. A. Nunoo Metro Works Engineer Akati Mahama Salamatu Senior Accountant Alhaji Inusah Abubakari Planning Officer Abdul-Rahaman B. Ahmid Deputy Director Imoro Andani Metro Budget Officer Adam Wahabu Head of WASH team SEKONDI-TAKORADI METROPOLITAN ASSEMBLY S. Yirenkyi Appiah Assistant Director I Nicolina K. Ayirewogye Assistant Social Development Officer Ahmed Sulley Metro Environmental Health Officer Rhoda Kankam Danquah Assistant Budget Analyst James Amoasi Revenue Mobilisation Officer Rexford Arthur Assistant Development Planning Officer Mahama A. Abu Senior Development Planning Officer JUABOSO DISTRICT ASSEMBLY Francis Nkrumah Antiedu District Coordinating Director

Andrews Tawiah-Boadi District Finance Officer Fianu Raphael Brown Assistant Works Engineer Barnabas A. Akanlise Assistant Planning Officer Philip Lutterodt District Budget Officer Sarfo B. Adamu Kra District Water and Sanitation Team Oduro Akese Head of Social Welfare and Community Development Ernest Addai District Planning Officer Christian Ababio Head of Business Advisory Center Daniel Asase District Environment and Sanitation Officer

D.3 KIIs with Regional offices of GWCL

Name Designation GHANA WATER COMPANY LIMITED- NORTHERN REGION Nicholas H. Okyere Regional Water Quality Assurance Manager Nii-Abbey Nicholas Communications Officer GHANA WATER COMPANY LIMITED- UPPER WEST REGION Daniel Konadu Regional Operations Manager Edward Agyekum Regional Project/Distribution Manager GHANA WATER COMPANY LIMITED- WESTERN REGION Evans Akot-Adzei Regional Water Quality Assurance Manager Ing. Mark Teiko Codjoe Regional Chief Manager GHANA WATER COMPANY LIMITED- GREATER ACCRA REGION (Accra East) Ing. Jacob Yendor Regional Chief Manager GHANA WATER COMPANY LIMITED- ASHANTI REGION Kwesi AWORTWI Head of production – for Ashanti East

D.4 KIIs with Regional offices of CWSA

Name Designation COMMUNITY WATER AND SANITATION AGENCY-ASHANTI REGION Seth Nii Duodu Amoo IT Specialist Edward Kofi Ackon Engineer Ernest Agudetse Extension Services Specialist Jennifer Quagraine Administrative Manager

Francis K. Enu Regional Director COMMUNITY WATER AND SANITATION AGENCY-NORTHERN REGION Ofori Maccarthy Regional Director Joseph Jonah WASH Engineer COMMUNITY WATER AND SANITATION AGENCY-UPPER WEST REGION Jatoe Matilda Secretary Japheth Kansaanah Assistant Accountant Suubil Naamtii Information Technology Specialist Stephen Asugre Jnr. Engineer Emmanuel Oppong Accountant Melvin Tagoe Engineer B. B. Charles Extension Services Specialist COMMUNITY WATER AND SANITATION AGENCY-WESTERN REGION Henry Ampah Johnson Engineer Kuupuolo Gaeten Timothy Bright Jones Obeng Hydrogeologist Evelyn Fiawornie Extension Service Specialist Mohammed Kpegla Adama IT Specialist COMMUNITY WATER AND SANITATION AGENCY-GREATER ACCRA REGION Dodji Attiogbe IT Specialist Safuratu Muhammed Andani Regional Director

D.5 KIIs with Regional offices of EHSD

Name Designation REGIONAL ENVIRONMENTAL HEALTH AND SANITATION- UPPER WEST REGION Henry Bagah Naatu Freda REGIONAL ENVIRONMENTAL HEALTH AND SANITATION- NORTHERN REGION Zakari Budali Regional Environmental Health Officer Dawuda Y. Shaibu Regional CLTS Coordinator Alabira Osuman M&E focal person Rex Jakpa Mumin Regional Director REGIONAL ENVIRONMENTAL HEALTH AND SANITATION- WESTERN REGION Douglas Tagoe Assistant Regional Environmental Health and Sanitation Officer REGIONAL ENVIRONMENTAL HEALTH AND SANITATION- ASHANTI REGION Paul AKANABA Regional Environmental Health and Sanitation Officer REGIONAL ENVIRONMENTAL HEALTH AND SANITATION- GREATER ACCRA REGION Charles Sintim Regional Environmental Health Officer Michael Dogbe Assistant Regional Environmental Health Officer Samuel Nortey Environmental Health Officer Charrlotte Adjei Regional Focal Person for CLTS

E.1 Comparison of government policies (water)

GWCL Corporate CWSA Corporate Water Sector Strategic National Community Water and National Water Policy (NWP) Plan Plan Development Plan (WSSDP) Sanitation Strategy (NCWSS)

GWCL Corporate CWSA Corporate Water Sector Strategic National Community Water and National Water Policy (NWP) Plan Plan Development Plan (WSSDP) Sanitation Strategy (NCWSS) The policy identifies the challenges The NCWSS recommends three with use of ground water including options/ strategies to tackle saline intrusions along the coastal The plan proposes Investment difficult hydro-geological areas zones, low yield from boreholes in the development of options in - Explore the use of other ground parts of Northern, Upper East and multi village hydro water siting techniques. Upper West etc. There are however no None schemes to serve None geologically - Expand the distance of provisions in the policy that focuses on communities with challenging exploration for ground water. If strategies to be adopted for the hydro-geological areas any is successful, develop and provision of water to hydro-geologically difficulties. supply. challenged areas and areas with - Explore surface water options. unacceptable water quality. Recognition that the needs of the Provisions for physically challenged should be the elderly/ Recommendation to develop ‘protected’, and that some None None None physically disability friendly technology options communities are less able to pay for challenged spare parts Recognition that improved water services enhances women’s dignity, Recommendation to increase Recognition of school attendance of girls, reduces participation of women in WSMT and gender health risks for women and girls. None None intensify efforts of ‘mainstreaming None aspects Recommends increased participation gender issues’ in WASH services of women in WSMT and ‘gender delivery. sensitive’ policy delivery by GWCL

National Environmental National Environmental Sanitation Policy Rural Sanitation Model and National Community Water and Sanitation Strategy and (NESP) Strategy (RSMS) Sanitation Strategy (NCWSS) Action Plan (NESSAP) Recognition of appropriate technology to meet the needs of the poor and vulnerable, Recognises the different The strategy proposes the and that the poor use more public/communal abilities/needs of the extremely development of cheaper cost latrine Pro-poor toilets because they have fewer private poor Aim of gradual improvement of technology options that meet the targeting on household latrines. However how policy it is service, while making provision demand and needs of people. This is sanitation implemented is left at the discretion of the Recommends micro-credit for the needs of the vulnerable to be achieved through the use of provision MMDA. Recommendation of a study to schemes to support the poor with local materials for the construction of assess demand for different sanitation latrine construction costs latrines. options.

Type of water initiatives Type of sanitation initiatives Focus on other equity Degree of pro-poor approach Geographic focus funded funded aspects Donors Support districts to develop strategic sanitation plans Construction of potable Central, Northern and water supply Construction of institutional Agence Française Brong Ahafo infrastructure i.e. hand- toilets de Développement n/a n/a Focus on rural, small dug wells, boreholes, (AFD) towns and peri-urban extension and Information, education and areas construction of networks communication activities targeted on hygiene and sanitation. Expansion and rehabilitation of GWCL Community-Led Total Sanitation Five urban Embassy of the networks (CLTS) Recognition that access to water Water Resources municipalities in Kingdom of the and sanitation is a challenge Management Accra, Elmina and Netherlands (EKN) Micro finance for household particularly in poorer urban areas Promotion of private Cape-Coast. latrine construction sector involvement / local entrepreneurship Recognition that there are regional disparities between the CLTS north and the south, Focus on women, Global Affairs Small Town Water children (new-born), The Northern Canada (GAC) Systems, Boreholes Construction of disaster resilient Support Ghana's efforts to youth and vulnerable Regions WASH facilities address the multiple challenges communities affecting the north and other deprived areas’. Small Town Water CLTS in rural areas Systems, Household latrine construction in Upper East, Upper Boreholes fitted with the Greater Accra Metropolitan Provision of 50% subsidy for West, Northern, Faecal sludge World Bank pumps, Area (GAMA) households in low income urban Brong Ahafo, Central management communities in GAMA Western, Greater Extension and Accra rehabilitation of GWCL Construction of institutional water systems latrines and BCC Campaigns

Type of water initiatives Type of sanitation initiatives Focus on other equity Degree of pro-poor approach Geographic focus funded funded aspects CLTS in rural areas, sanitation CLTS in Northern, marketing, hygiene and Upper West, Upper behaviour change campaigns UNICEF mainstreams East, Volta and gender in the Central Regions Supporting the Government of Focus on increasing access to implementation of their Ghana to pilot Community-Led improved sanitation and water programmes and UNICEF community-based IWRM Urban Environmental Sanitation services to disadvantaged projects. Urban Sanitation Pilot (CLUES) in Ashaiman, communities’. Project in Ho Community Development for Focus on women, Municipal, Tamale Health (CDH) in Ho and Urban children and youth Metro and Ashaiman CLTS in Tamale. Municipal

Type of water initiatives Type of sanitation initiatives Focus on other equity Degree of pro-poor approach Geographic focus funded funded aspects

CLTS/ sanitation marketing; Village Savings and Loans Schemes; ‘Safi Latrine’ - low cost Addressing issues that technology Aims to increase access to and rural communities in relate to the reliability of use of sustainable, equitable and the Northern, Upper water supply, the Partnership with Fidelity Bank to affordable water, sanitation and provide loans for i) pipe Focus on women and East, Upper West,, SNV sustainability of water hygiene services for improved connection to households ii) Upper East, Central, systems, the affordability health, livelihoods and economic persons with disability construction of Septic Tank iii) Volta and Greater of services, and equitable well-being in rural, peri-urban Accra Regions access to water for all. construction of household toilet areas and schools in Ghana iii) household hand washing facility iv) faecal desludging v) borehole construction and mechanisation vi) household water retooling/ spare parts. Strong focus on Equity and Inclusion, District Wide Approach (DWA)62, Endogenous Increase sustainable and Increased focus on sanitation: in Development (ED)63, Boreholes fitted with iron equitable WASH for all in targeted schools, clinics and public Human Rights Based Five regions; Upper removal plants Local Government Authorities by spaces. Approach (HRBA)64 East, Upper West, (new/rehabilitation) 2021. and Learning & Greater Accra, Water Aid developing innovative Knowledge Pipe borne connections The strategy document Eastern and Western approaches and technologies Management. Equity recognises that ‘most of the Regions. and Inclusion is central Water kiosks unserved/underserved live in CLTS approach to WaterAid’s projects, rural areas and urban slums’. which therefore target the most hard to reach and underserved communities.

62 DWA- ‘is a programmatic approach that shifts from service delivery to sector strengthening and collaborating with more and differentiated strategic partnerships. It takes the district as the central geo-political location and critical nexus space for change towards universal access to WASH’. 63 ED- working with districts/communities to develop context specific solutions (harnessing local resources) to hygiene and sanitation challenges that can inform sustainable behaviour change policies and practice. 64 HRBA- A rights-based approach is a transformational development process in which people are the drivers and subjects of their own development.

Type of water initiatives Type of sanitation initiatives Focus on other equity Degree of pro-poor approach Geographic focus funded funded aspects Aim is that ‘all children especially Construction of the most vulnerable and their demonstration latrines families have improved WASH for persons with water treatment for consumption, production and disability, the aged or technique to remove processing CLTS approach (no subsidies) female headed excess fluoride and All the ten regions of households. World Vision arsenic Provision of water in ‘hard to Ghana and mainly in and the construction of reach’, marginalised and rural areas. institutional latrines solar powered water unserved communities. WV aims Developed disability systems to provide water to communities friendly toilet designs which others have abandoned under their WASH and due to difficulties of getting Disability Project. ground water through boreholes