Level: Country, subnational and community

T4 UNICEF-SLRA2013-0528-Asselin



Sanitation and equity

Sanitation improvements have been concentrated in the richer segments of the population. In Africa, the poorest quintile is 20 times more likely to practice open defecation than the richest quintile.


Figure: Wealth quintile distribution of sanitation improvements in Africa

15 toolkit figure

Source: Patkar, Archana and Louisa Gosling, ’Equity and Inclusion in Sanitation and Hygiene in Africa. A Regional Synthesis Paper’, Water Supply and Sanitation Collaborative Council and WaterAid, July 2011, p. 3


Inadequate sanitation and hygiene affects poorest households most, and young children in particular are more exposed and susceptible to sanitation-related health risks.

In addition to poverty in terms of income and assets, a range of groups are socially excluded, such as women and girls, disabled people, the elderly, those living in informal settlements or urban slums and those living in distant, hard-to-reach areas.

For women and girls, exclusion may mean being left out of decision making about constructing latrines or handwashing stations, being denied access to safe toilets even where they exist or a lack of access to menstrual hygiene management measures. For disabled people, exclusion may mean an inability to physically access toilets or reach handwashing facilities.

‘Equity involves recognizing that people are different and require specific support and measures to overcome the specific impediments that stand in the way of their being able to access and use services sustainably, in this case safe sanitation and hygiene practices’ (source: http://www.wsscc.org/sites/default/files/publications/equity_and_inclusion_synthesis_africa_working_paper_for_africasan_final.pdf).

Equity means correcting inequalities.

To correct inequalities, ‘equity will need to be woven into the fabric of every investment, every supervision mission, every reward and every audit’ (see www.wsscc.org/sites/default/files/publications/equity_and_inclusion_synthesis_africa_working_paper_for_africasan_final.pdf).

Monitoring equity in sanitation and hygiene is needed at all levels.

  • Equity is monitored at the local level by identifying excluded groups and assessing the barriers they face in accessing and using hygienic toilets and practicing hygienic behaviours.
  • Equity is monitored at provincial, state (Note: state refers to organs of state and national to actual populations, they are different for monitoring purposes) and national levels by developing systems with disaggregated data (by poverty quintile, by gender, by age, etc.) to target those who are hardest to reach and have the highest need (with targeted financing and with appropriate rewards and sanctions) and to track changes at all levels.

The Working Group on Equity and Non-Discrimination (of the UNICEF-WHO Joint Monitoring Programme Process For Drinking Water and Sanitation on Post-2015 Global Monitoring of Water, Sanitation and Hygiene) has produced a useful checklist for evaluating proposed WASH targets and indicators, aimed at allowing decision-makers to determine whether issues of equity, equality and non-discrimination are adequately addressed given the demands and limits of global monitoring.


Equality Checklist

When examined as a whole, do the goals, targets, and indicators:

  • prioritize basic access and focus on progressive realization toward safe and sustainable water, sanitation and hygiene for all, while reducing inequalities?
  • address spatial inequalities, such as those experienced by communities in remote and inaccessible rural areas and slum-dwellers in (peri-)urban areas?
  • focus on inequities, shining the light on the poorest of the poor?
  • address group-related inequalities that vary across countries, such as those based on ethnicity, race, nationality, language, religion, and caste?
  • attend to the impacts of individual-related inequalities that are relevant in every country of the globe, such as those based on sex/gender, age, disability, and health conditions imposing access constraints—as they are experienced both inside and beyond the household?
  • Do they address menstrual hygiene management?

‘Eliminating open defecation is an important pillar of our equity agenda as it largely affects the poorest and most vulnerable groups of people. The impacts for children would be significant in terms of morbidity and mortality reductions, and improved educational achievements. Elimination of open defecation would also ensure that basic human rights are met including intangible, but nevertheless very important benefits such as privacy and dignity, especially for women and girls’ (See MoRES Toolkit: Indicator Selection Guidance – WASH, UNICEF, 2012:1).


What is MoRES?

The UNICEF-led Monitoring Results for Equity Systems (MoRES) is a conceptual framework to improve equitable planning, programming, implementation, monitoring and management based on data collection and analysis of bottlenecks (constraints) as well as taking appropriate corrective action.

It confirms UNICEF’s commitment to use data to improve outcomes for the most disadvantaged.

MoRES is based on a determinant framework that recognizes that there are enabling and constraining factors (or bottlenecks) that affect the achievement of desired results.

A bottleneck is defined as a factor constraining progress in the delivery of goods or services to a target population, and in the sustained consumption of that service. A bottleneck can be the absence of an enabler or the presence of a disabler.

Determinant analysis is a systematic approach to identifying priority bottlenecks to achieving the 10 determinants and to unpacking the reasons why specific bottlenecks and barriers exist in order to identify strategies to address them. See MoRES Bottlenecks and Strategies to address them.

Ten determinants of equity are identified within four main domains. Country-specific indicators need to be identified for each of these determinants.


Table: Determinant analysis to identify priority bottlenecks

Categories of determinants (domains)
Enabling environment
–       Social norms
–       Policy and legislation
–       Budget and expenditure
–       Management and coordination
Service delivery (broadly corresponds to supply)
–       Essential commodities and inputs
–       Access to information
Behaviour change (broadly corresponds to demand)
–       Financial access
–       Social and cultural practices
–       Continuous use
–       Sustainability of services


Equity bottlenecks and indicators

Critical indictors are:

  • the proportion of a country’s population using an improved sanitation facility (disaggregated by residence and wealth quintile);
  • the proportion of a country’s population that practices open defecation (disaggregated by residence and wealth quintile);
  • the number of countries globally having a national policy or legislation on elimination of open defecation.


Table: Guidance for the selection of level 3 (WASH-related) country-specific indicators based on frequently found bottlenecks

Examples of bottlenecks
Ideas for country-specific indicators
Links with monitoring tools
Social norms
Provision of sanitation (through construction programmes, subsidies) does not change social norms (i.e. does not result in increased use of facilities/reduction in OD)

Girls are pursuing education in environments that lack adequate facilities, supplies, and gender sensitivity
Percentage of population ODF/living in ODF communities

Percentage of schools with adequate sanitation facilities

National legislation on sanitation with specific reference to the elimination of OD
Elimination of ODF Protocol
Weak political will and leadership
Lead institution identified
National Sanitation policy and strategy available

Sectoral review of eThekwini commitments (or equivalent)
CSO completed or reviewed
Standardization of sanitation technology restricts communities to a limited menu of technologies

No comprehensive sanitation policy, with clear accountabilities
Policies of various ministries with sanitation components overlap, contain inconsistencies in approaches
Lead institution identified
National Sanitation policy and strategy available

Sectoral review of eThekwini commitments (or equivalent)
CSO completed or reviewed
The eThekwini Declaration and AfricaSan Action Plan 2008
Budget/ expenditure
National budget allocated to sanitation in general and to ODF initiatives in particular remains very low – only a very few NGOs are piloting ODF approaches

Low budget allocations for sanitation and lack of accountability – as a result, sanitation programmes tend to rely on donor supported projects. Where funds are available, they are often used for infrastructure rather than sanitation promotion
Percentage of national budget allocated to sanitation and hygiene
Availability of budget for sanitation promotion at subnational level
Agreed percentage of national WASH budgets allocated to sanitation promotion
Sectoral review of eThekwini commitments (or equivalent)
CSO completed or reviewed
The eThekwini Declaration and AfricaSan Action Plan 2008
SWA high-level commitments see here
Management / Coordination
Lack of adequate cross-ministry coordination group on sanitation
Difficulties creating cross-ministerial consensus, particularly if a ministry is not willing to let go of its mandate, but also not willing to lead on improving the sector
Lack of accountability
Lack of data/monitoring system
Lead institution identified
Sectoral review of eThekwini commitments (or equivalent)
National plan with targets, strategies, resources and accountabilities
National monitoring and information system in place
Regional reports on sanitation
Existence of WASH consultative group on sanitation
The eThekwini Declaration and AfricaSan Action Plan 2008
Availability of essential materials / inputs
Availability of construction materials and skills at community level is a challenge in some areas. In most areas bricks are locally produced but in some districts, brick moulding is a challenge due to loose soils. River sand and pit sand are not available in some areas while cement is rarely available in most remote rural areas
Predetermined technologies and supply driven programmes do not meet needs and are often too expensive to be replicated/maintained
Supply chain – supplies dispersed (no ‘one-stop shop’, inconsistent quality and availability, insufficient variety of technology options)
Project approach does not create sustainable latrine component supply chains
Lack of technological options for adverse hydro-geological conditions or topographical terrain
Percentage of communities with at least one entrepreneur stocking WASH commodities
Percentage of latrines constructed from locally available materials
Sanitation Marketing strategy in place
Access to adequately staffed services, facilities and information
Too few public and environmental health personnel
Too few public and environmental health personnel trained on CATS or other ODF approaches
Insufficient good quality facilitators to support CATS
Lack of services to support households once pit latrine is full

Proportion of wards with access to at least one Environmental Health Technician (or equivalent) per ward

Number of certified CATS facilitators

Availability of pit emptying services

Proportion of households with access to information on sanitation through various channels including health facilities, Community Health Worker or equivalent, media

Number of trained CATS facilitators per 100 communities

Assessing service levels
Financial access
The ‘culture’ of asking for subsidies (donor syndrome) still militates against self-reliance (even where people can afford to provide themselves with a toilet)
Perceived and real high costs
Few technically appropriate, attractive, low-cost options available in local markets
Difficulty saving up money and a lack of financing options
Percentage of communities with at least one household with a self-initiated latrine
Number of micro-credit schemes
Sanitation marketing strategy
Existence and selection of low-cost appropriate technology options
Monitoring Sanitation Marketing
UNICEF Guidance note 9
Sanitation marketing guidelines (Ethiopia)
Costing criteria (CATS and SanMark) See here and here
Socio-cultural practices and beliefs
Social/cultural beliefs/practices are resistant to change
Time lag between triggering and action to achieve ODF status
Percentage of population ODF
Community members report socio-cultural barriers to using toilets/latrines (e.g. sharing with in-laws, hole over hole, etc.)
Elimination of ODF Protocol
Continuity of use
Slippage: individuals/households returning to OD and/or not consistently using sanitation facilities
Percentage use of latrines
Percentage of population ODF
Proportion of communities sustaining ODF after one year
Proportion of communities that are ODF after one year and practicing handwashing with soap following defecation
Proportion of communities that have upgraded their latrines

Assessing service levels

Elimination of ODF Protocol
Quality of facilitation for community-level triggering
Lack of follow-up (post-triggering)
Lack of timely OD certification and monitoring
Sanitation facilities built by households do not meet
JMP standards of ‘improved sanitation’
Percentage of population ODF
Post triggering follow up statistics
Number of communities where verification process has taken place
Number of communities where slippages rates are less than 5%
Assessing service levels
Elimination of ODF Protocol

Note that data collected through the tools to assess the enabling environment (including WASH-BATS, marketing and service performance) can be used to monitor equity using the MoRES approach. MoRES hones in specifically on bottlenecks to equitable services delivery and enables a more detailed analysis of equity-related constraints and involves an analysis of the quality of services at subnational level.


Figure: Seven steps to be followed for WASH-related equity monitoring  

16 toolkit figure

Source: See Athens_MoRES_in_Early_Learning_6_June_2012.pdf


Many countries, including Bangladesh, the Democratic Republic of the Congo, Ghana, Mozambique, Nepal, Zambia and Zimbabwe, have completed bottleneck analyses.


Lessons learnt so far

  • The MoRES determinants framework has proved useful in developing a structured analysis of problems and weaknesses in the service delivery pathway.
  • The outcomes of bottleneck analyses have been used as the basis for developing funding proposals.
  • The flexibility to develop country-specific indicators and build on existing monitoring systems and adapt MoRES determinants is fundamentally important.


Country examples