Unlike India, Ethiopia has recognised sanitation as a health problem and focused on behavioural change over toilet construction
In Ethiopia, seven in every 10 people use toilets instead of defecating in the open. While this may not sound like much of an achievement, to grasp the true import of the statistics one has to consider that some 25 years ago, less than one in every 10 Ethiopians used toilets. The African country, in fact globally, registered the maximum reduction in the proportion of the population defecating in the open between 1990 and 2015, as per the Joint Monitoring report of 2015 by the World Health Organization (WHO) and Unicef.
The extent of the achievement becomes even clearer when one compares the figures with India, whose per-capita gdp is four times that of Ethiopia. In 1990, less than three in every 10 people in India used toilets. Despite several nationwide campaigns and celebrity endorsements to create awareness about sanitation, only six in every 10 Indians use toilets.
So how did Ethiopia, one of the poorest countries in the world, achieve the results? Ethiopia’s success lies in the fact that it recognises sanitation as a health problem. Unlike in India where sanitation and drinking water are under one ministry, Ethiopia has put sanitation under the health ministry. In fact, the Ethiopian government’s Health Extension Program, started in 2003, is responsible for rolling out key sanitation interventions in rural areas, where 85 per cent of the country resides. Of the 16 broad services offered under the scheme, seven cover hygiene and environmental sanitation, such as excreta disposal, solid and liquid waste disposal, water quality control and personal hygiene. Under it, two women health workers are employed in every kebele (the smallest administrative unit of Ethiopia, similar to a ward in India) to sensitise families about sanitation and to encourage them to build toilets.
Its Trachoma Prevention Program is another example of how integrating sanitation under health programme helps. Rolled out in 2002, the scheme promoted construction of toilets because poor sanitation and lack of personal hygiene are important triggers for the infectious disease that can leave people blind. In just a year, the access to toilets in some rural areas increased from six to over 50 per cent, says Kamal Kar, whose Kolkata-based non-profit clts Foundation works on sanitation issues in the Amhara region of Ethiopia. A follow-up after three years showed that the communities continue to use the toilets, he adds.
In 2013, the government took the concept of integration a step forward by rolling out the One wash (water, sanitation and hygiene) National Program to synth-esise sanitation works carried out by six ministries—water, irrigation, electricity, education, finance and economic develop-ment—with the health ministry.
Ethiopia has ensured that sanitation prog-rammes do not just focus on the con-struction of toilets but also promote the idea of using them. "Unlike India, Ethiopia does not subsidise toilets. It instead focuses on behavioural changes. This is where it scores over India," says Andrés Hueso of WaterAid, the UK. This has been done through a cross-sector approach where the government has roped in communities, and advocacy agencies such as Unicef, who and WaterAid.
"Today, local communities and political leaders together discuss the types of sanitation services required, reflect on the tariff, and monitor performance," says Kebede Worku, Ethiopia’s health minister. This principle of participation is visible in all the sanitation programmes. In the Health Extension Program, for example, the services provided at the kebele level are customised to meet the needs, demands and expectations of the people.
The Community-Led Total Sanitation and Hygiene Program (cltsh), another important sanitation programme that was started in 2009, is implemented by school health clubs and water committees at the kebele level. Community participation has not only given a boost to the construction of toilets, but also ensured the long-term sustainability of the practice.
The country also has open defecation-free verification and certification guidelines and has committees, set up at every administrative level, from kebele to the national, to verify that the guidelines are being followed. "After a kebele is declared open defecation-free, monitoring is done by trained leaders from the community. We also have a system where kebeles are coded according to their open defecation-free status," says Worku.
A recent report by WaterAid says that all of this has been possible because the Ethiopian government has "strong development priorities". It also attributes the political stability of the current government, which has been in power for two decades, for the success. Worku says the country is already reaping the benefits. "Between 2000 and 2016, open defecation reduced from 82 to almost 32 per cent. In the same period, under-five mortality reduced from 166 per 1,000 live births to 67," he says. The minister adds that toilets in public places have allowed girls in rural areas to attend the school even during menstruation. "Additionally, it preserves the dignity of disabled people and saves the environment," he says.
Despite Ethiopia’s remarkable success, the change has not been consistently effective throughout the country. Some rural areas still lag behind (see ‘Inconsistent performance’) and according to a 2013 World Bank survey, poor sanitation costs Ethiopia 13.5 billion Birr (US $570 million) each year, which is 2.1 per cent of the national gdp. Another concern is that a number of the toilets set up are not sanitary. Jane Bevan, rural wash manager, Ethiopia Unicef, says that under cltsh, several toilets are constructed in the traditional way with sticks and mud, and the drop holes are rarely covered. “Such toilets are not effective in preventing diseases.” But this does not reduce the extent of the achievement.
The Indian government, which aims to make the country open defecation-free by October 2, 2019, can learn a lot from the Ethiopian journey.
(Read exclusive interview of the Ethiopian health minister)
This story was published in the April 1-15, 2017 issue of Down To Earth magazine under the headline "Ethiopia pushes hygiene".
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