Development of Sustainable

Sanitation for Promotion of Public

Health & Environment:
Cambodian Scenario & Indian Lessons

Prof. K.J. Nath

Chairman, Science & Technology, Sulabh International Social Service Organization;
President, Institute of Public Health Engineers, India;
Chairman, Arsenic Task Force, Govt. of West Bengal, India;
Member, National Ganga River Basin Authority, GOI,
Member, Scientific Advisory Board & SEA Regional
Coordinator, International Forum on Home Hygiene, IFH, UK
Former Director, All India Institute of Hygiene & Public Health, Govt. of India (GOI)

GMS Phnom Penh Plan for Development Management, Leaders

Networking for Knowledge (LINK) Alumni Lecture Series
Phnom Penh, Cambodia, 21 February 2011 1

Implication of Sanitation on MDGs

„ Goal 1: Eradicate Extreme Poverty and Hunger
… Sanitation provides economic benefits that reduce extreme poverty.
poverty

„ Goal 2: Achieve Universal Primary Education

… Improved sanitation promotes school attendance

„ Goal 3: Promote Gender Equality and Empower Women

… Safe sanitation facilitates gender sensitive hygiene facilities at school
and work; promote the attendance of menstruating girls and women.

„ Goal 4: Reduce Child Mortality

… In addition to reducing child mortality from diarrhea related malnutrition,
improved sanitation can help to reduce morbidity for millions of other
children.

Excerpts from Sanitation as a Key to Global Health: Voices from the Field - UN University – Institute of Water,
Environment & Health

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Implication of Sanitation on MDGs
„ Goal 5: Improve Maternal Health
… Maternal health, child survival and access to sanitation are intricately
linked.

„ Goal 6: Combat HIV/AIDS, Malaria and Other Diseases

… Improved sanitation and hygiene reduces risk of waterborne diseases
like malaria, cholera.

„ Goal 7: Ensure Environmental Sustainability

… Improved water and sanitation benefits the connection between
environment and health.

„ Goal 8: Develop a Global Partnership for Development

… The sanitation sector is currently fragmented, with stakeholders playing
diverse roles in different regions and time periods.

Excerpts from Sanitation as a Key to Global Health: Voices from the Field - UN University – Institute of Water,
Environment & Health

Cambodian Scenario
„ In Cambodia, a country of 14 million people,
85% of which lives in rural areas, the access to
sanitation in rural areas increased from 9% in
1998 to 23.3% in 2008.
„ Millennium Development Goal (MDG) for 2015
has been set at 30% coverage. 35% of the
population
p p are reported
p to be below p
poverty
y line.
„ More than ½ of those without improved
sanitation facilities are non-poor households.

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Cambodian Scenario (cont’d)
„ An epidemiological assessment of the health outcomes of
sanitation remains uncertain, however, diarrheal disease and
mal-nutrition are mutually complementary and forms a vicious
cycle with lack of sanitation in poor households.

„ In Cambodia, the risk of diarrheal disease is 3 to 4 times

higher among severely under-weight children.

„ Optimal health outcomes are unlikely unless sanitation

improvement strategy effectively address the sanitation
problems of the poor.

Rural Sanitation Improvement

Programme in Cambodia
„ Much of the current achievements for promoting rural
sanitation are attributable to the efforts made by the
Ministry of rural development especially the Dept. of
Rural Health Care in collaboration with all provincial
partners of Rural Development and various development
partners, NGOs and the International donors.
… ADB Tonle Sap RWSS Project (TS-RWSSP) and Second RWSS
Project (RWSSP2)
… Plan Cambodia CLTS Programme
… IDE Sanitation marketing project
… WTO & Lien Aid Sanitation marketing project

3
Rural Sanitation Improvement
Programme in Cambodia
„ In Cambodia, it appears
pp that the various p
programme
g p
partners
who are promoting sanitation, have been able to achieve
significant behaviour change and sanitation demand generation
in pockets, but nationwide, access to sanitation remain
extremely low and the MDG target set by the National Govt. is
rather modest.
… Lack of strategic approach for nation wide scaling up of a
sustainable Rural sanitation Programme.
… Lack of integrated
g rural development
p p
programme
g at the commune
level incorporating and prioritizing sanitation.
… Due to various reasons public finance of sanitation in most
programmes in Cambodia is not effectively addressing rural poor.
… Lack of regulatory & institutional framework for rural
housing/sanitation programme.

Impact of CLTS/Sanitation
Marketing
„ In Cambodia CLTS and sanitation marketing g concept
p
have made significant impact in promoting the behaviour
change in the community and developing demand for
sanitation.
„ Unfortunately, the CLTS approach adopted Sanitation
technologies which, worked only in dry seasons and its
cost-effectiveness is questionable when one considers
the critical issue of sustainability.
„ Such technologies are neither sustainable nor
upgradable and promotion of the same in the short term
would be counter-productive in the long term context.

4
Impact of CLTS/Sanitation
Marketing
„ In Sanitation marketing
g which is basically,
y, a market
based approach, currently being promoted by frontline
NGOs like Lien Aid, IDE, WTO, etc, are putting more
emphasis on training of entrepreneurs on affordable and
sustainable technology options and developing a
delivery mechanism based on demand promotion and
development of supply chain.
„ However, this is pertinent to note, that given the current
l
levell off rurall poverty iin C
Cambodia,
b di this
hi approach
h too
cannot effectively promote sanitation across all sections
of the rural community, particularly the rural poor.

Appropriate Technology Options

„ The issue of affordability vis-à-vis
vis à vis sustainability
needs closer examination in deciding about the
appropriate technology options for sanitation.
„ Presently dry pit toilets as well as direct single
pit and offset single pit pour flush toilets are
being promoted under various programmes.
„ Unlined pit latrines which fail due to flooding
flooding,
soil collapse, infestations are neither sustainable
nor upgradable.

5
Appropriate Technology Options
„ It has been observed that even among the economically well-off
section
ti who h can afford
ff d better
b tt quality
lit ttoilets
il t and
d are spending
di more
than US$ 200 for super structure, two pit pour flush/Ecosan design
are not being promoted.
„ The issues of eco-friendliness and pollution of ground water should
also receive adequate attention.
„ Present design makes it difficult to recycle the bio-mass from latrine
pits.
„ Rural consumers should g get multiple
p choices depending
p g on
affordability and sustainability.
„ SISSO has developed eco-friendly technically appropriate, socio-
culturally acceptable and economically affordable designs of
sanitary toilets in India, cost of which varies from US$30 to US$ 300.

Appropriate Technology Options

„ In trying to address the affordability we
should not compromise sustainability and
the sector managers must not forget that
sustainable sanitation development would
be the key to promotion of public health
andd environmental
i lh
health
l h iin rurall
Cambodia.

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The Issue of Subsidy:
Affordability/Sustainability
„ Divergent opinion is noted in Cambodia for and against subsidy in
rurall sanitation
it ti programme.
„ In Cambodia the Sanitation sector which is vitally linked with Public
Health & Environment of the Community and closely associated with
the poverty of the people cannot be 100% addressed by the Private
Sector / Market. However, approximately 60% of the non-poor
section of the population could be served by the market.
„ The Consultant strongly feels that CLTS/sanitation marketing and
Govt. subsidized pprogrammes
g need not be mutuallyy exclusive,,
rather future sanitation programme should draw upon the strengths
of CLTS/sanitation marketing and integrate them into a scaled up
nationwide programme supported by the Govt. and promoted by
sector partners, with provisions of minimal subsidies required by the
poor for having access to sustainable sanitation.

The Issue of Subsidy:

Affordability/Sustainability
„ In the Cambodian context,
context in majority of
the rural households, economic decision
might not be in favour of investment on
sanitation and as such market alone
cannot be the key to promotion of
sanitation
i i and d element
l off subsidy,
b id as
such, cannot be avoided altogether.

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Feasibility of Toilet linked Bio-Gas
Technology
„ 30% of rural families have the potential (enough dung to justify) to
h
have d
domestic
ti Bi
Bio-gas plants.
l t
„ 96% of rural Cambodia use firewood for cooking.
„ There has been impressive growth in the construction of domestic
Bio-gas plants in the country rising from 296 in 2006 to 10,500 by
2010,10% of which are connected to toilets.
„ Experience in India, China, Vietnam, etc, indicates the potential of
the technology.
„ There appear to be significant prospect of connecting rural toilets to
the existing Bio-gas plants.
„ Lack of effective coordination between MRD & the Dept. of
Agriculture.

Feasibility of Toilet linked Bio-Gas

Technology
„ It is globally accepted that domestic bio-digester
bio digester
programme is likely to have very positive impact
on the ecology and environment in terms of
energy saving, carbon credit, sanitation, health
and rural employment.
„ It has been reported that in Nepal, 80% of the
g plants are connected to the toilets.
bio-gas
„ In India, SISSO is successfully running bio-gas
plants connected to the community toilets
complexes in many places.
On the strength of the statistics & arguments provided by The National Bio-Digester Program, there appear to be huge
prospects of Bio-Gas linked Toilets in the rural areas.

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 Flow Chart for Rural Bio-Gas System
in Cambodia
Energy

Livestock &
B
Poultry Gas
Y
P
R Input Bio- Output
Farm Agriculture O Digester
Family D
U
I C
N Crops & T Slurry
P Vegetables S
U
T

(Food & Fertilizer)

Construction of Bio-Gas Linked Toilet

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Lessons from India
„ Supply driven,
driven subsidized Govt
Govt. programme did
not succeed during 80s/90s, primary because:
… Lack of Enabling Environment
… Lack of Capacity Development at the Community
level
… Lack of IEC Support & Awareness among the
consumers
… Sanitation was not a perceived need of the
community

Lessons from India

„ TSC created the enabling Environment, but without Govt.
h d
hardware/Technology
/T h l ((subsidy)
b id ) support,
t iimprovementt was nott
sustainable and Nation wide scaling up was rather modest.
„ Many “Nirmal Grams” (ODF) reversed to O.D. villages.
„ Beyond 2005, National Sanitation Programme gathered significant
momentum with the launching of integrated Rural Development
Project with support for BPL families, (2/3 Centre + 1/3 State) US$
50 per family combined with IEC support and sustainable
technology promotion (Role of SISSO & other NGOs).
„ India is on the threshold of Achieving MDG

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Lessons from India
„ Integrating
g g Sanitation into Comprehensive
p Rural
Development Programme of Govt. of India (Bharat
Nirman – Build India)
… Rural Health Mission
… Rural Sanitation
… Rural Water Supply & Water Quality Management
… Rural Employment Generation
… Rural Education / Mid Day Meal
… Rural Roads / Telecommunication
„ Nodal Dept: Ministry of Rural Development/PRI
… Key to success: Capacity building in the Panchayetiraj
Organizations at the District/Block & Village Level.

Lessons from India

„ Appropriate
pp p & Sustainable Sanitation Technology
gy
… In trying to address affordability, we should not compromise on
sustainability.
… Upgradable Technology has minimal environmental &
Hydrogeological requirements. Unless those are met, reversal of
Behavior, rather than upgradation, will result.
… Govt. subsidy for the poor should ensure basic designs &
components of a sanitary toilet – which could be upgraded with
socio-economic development.
… Non poor sections should be provided with multiple choices for
Non-poor
technology selection by the NGOs/Market.

„ Sulabh Experience of Technical Innovation & Social

Mobilization, and large scale scaling up of the same.

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Two Pit Pour Flush Toilet

Multiple Choice
Sulabh has 46 models ranging from US$ 20 to more than US$ 200

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Community Toilet Complex linked to Bio-Gas Plants

Community Toilet Complex linked to Bio-Gas Plants

26

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Lessons from India
A track change - by demand or just willingness to pay?

Physical
y Achievement under TSC For
IHHL (Individual Household Latrine)
7000000
6000000
5000000
4000000
3000000
IHHL BPL
2000000
IHHL APL
1000000
0

Source : Total Sanitation Campaign

Lessons from India

Economics of the IEC

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Lessons from India
Beneficiary contribution?
Expenditure
p under TSC across years
y
16000
14000
12000
Expenditure in Rs. (in millions)

10000
8000
6000
4000
2000
0

Centre State Beneficiary

Lessons from India

Cost of Inaction
„ In India, according to a World bank report, the total costs in terms of
h lth and
health d productivity
d ti it iimpactt off llack
k off safe
f water
t and
d sanitation
it ti
and environmental degradation, add up to a total of US$ 9.7 billion
per year i.e 4.5% of the GDP of the country at 1992 values.
„ The health impact of water and air pollution and lack of sanitation
account for 73% of the total damage.
„ Unfortunately, the health sector, which bears the burden of the
activities of sectors like urban & rural development, industry etc,
q
does not have adequate institutional capacity,
p y infrastructure for
monitoring the environmental health impact of the same.
„ As such, it can do little advocacy for protecting and promoting
environmental health.

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Epilogue
„ Investment in Sanitation makes economic
sense. It is possibly the most prudent and
cost effective investment for the promotion
of Health, Environment and productivity of
a nation.

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