WATER AND SANITATION PROGRAMME

African Conference on Sanitation and Hygiene AfricaSan +5

Towards Meeting National and MDG Sanitation Targets: A Review of Sanitation Status in Tanzania

Prepared by: Deo Binamungu ACHRID Limited P.O. Box 72446, Sam Nujoma Road, Plot No. 698, Block A Sinza Area (Opposite Mlimani City) Dar Es Salaam Tanzania

December 2007

TABLE OF CONTENTS
1 INTRODUCTION ................................................................................................................... 3 1.1 Background................................................................................................................................ 3 1.2 Scope of Sanitation .................................................................................................................... 4 1.3 Review Objective ...................................................................................................................... 5 1.4 Scope ......................................................................................................................................... 6 1.5 Expected Output ........................................................................................................................ 6 1.6 Methodology and Report Structure ........................................................................................... 6 2 TANZANIAS SANITATION STATUS AND TRENDS .................................................... 7 2.1 Prospects of Achieving MDG/National Targets........................................................................ 7 2.1.1 Sanitation Coverage: Excreta Disposal ..................................................................................... 7 2.1.2 Access to Sewerage Services................................................................................................... 10 2.1.3 Solid Waste Management ........................................................................................................ 11 2.1.4 Garbage Disposal..................................................................................................................... 12 2.1.5 Hygiene Education and Promotion .......................................................................................... 13 2.1.6 Inequities in Access to and Use of Quality Sanitation Services .............................................. 14 2.1.7 Main Critical Aspects for Achieving MDG Sanitation Targets ................................................ 1 2.2 Policies, Strategies, Institutional and Legal Frameworks.......................................................... 2 2.2.1 Policies and Strategies ............................................................................................................... 2 2.2.2 Legal and Regulatory Framework ............................................................................................. 6 2.4 Institutional Framework ............................................................................................................ 8 2.4.1 Excreta Disposal, Septic Sludge Management and Domestic Wastewater Treatment .............. 8 2.4.2 Collection, treatment and sanitary disposal of solid waste ...................................................... 10 2.4.3 Coordination Platforms ........................................................................................................... 10 2.5 Hygiene Promotion and Education .......................................................................................... 13 2.5.1 Hygiene promotion using PHAST approach .......................................................................... 13 2.5.2 Health Education ..................................................................................................................... 14 2.5.3 School WASH Programmes ................................................................................................... 14 2.6 Financing ................................................................................................................................. 15 2.7 Monitoring and Evaluation ...................................................................................................... 17 2.7.1 National Sanitation monitoring indicators............................................................................... 17 2.7.2 Existing Information System for Sanitation ............................................................................ 17 2.7.3 Sanitation linkage with improvements in health, mitigation of environmental pollution and poverty reduction .............................................................................................. 18 2.8 Capacities ................................................................................................................................ 19 3 SUCCESFUL EXPERIENCES, LESSONS LEARNED AND RECOMMENDATIONS..... 21 3.1 Successful experience and lessons learned .............................................................................. 21 3.1.1 Latrinization Programme ......................................................................................................... 21 3.1.2 School Health Programmes ..................................................................................................... 21 3.1.3 PHAST Approach.................................................................................................................... 22 3.1.4 Health and Cleaniliness Competition ...................................................................................... 22 3.1.5 Healthy Villages Programme ................................................................................................... 23 3.1.6 Emerging Coordination Mechanisms ...................................................................................... 24 3.2 Recommended Actions............................................................................................................ 24 3.2.1 Policies and Strategies ............................................................................................................. 24 3.2.2 Legal Framework..................................................................................................................... 24 3.2.3 Institutional Framework .......................................................................................................... 25

3.3 Financing ................................................................................................................................. 25 3.4 Monitoring and Evaluation ...................................................................................................... 25 3.5 Capacities ................................................................................................................................ 26 ACRONYMS ....................................................................................................................................... 27 REFERENCES .................................................................................................................................... 28 ACKNOWLEDGEMENTS ................................................................................................................. 29

LIST OF TABLES Table 1: Linkages between Sanitation and All MDGs .......................................................................... 3 Table 2: Different Reported Sanitation Coverage in Tanzania .............................................................. 8 Table 3: National Coverage of Excreta Disposal Facilities in Tanzania ............................................... 9 Table 4: Distribution of Households by Garbage Disposal, Tanzania mainland 2000/01 ................... 12 Table 5: Sanitation Coverage and Health and Human Development Indicators ................................... 1 Table 6: Policies and Strategies Adopted by Institutions Responsible for Sanitation in Tanzania ....... 3 Table 7: Focus of Sanitation Related Policies ....................................................................................... 5 Table 8: Sanitation-related Legislations and Regulations in Tanzania ................................................. 7 Table 9: Division of Primary Functions in the Sanitation Sector .......................................................... 8 Table 10: Division of Primary Functions among Institutions Involved in Sanitation ........................... 9 Table 11: Objectives, Functions and Compositions............................................................................. 11 Table 12: Information Available on Investments for MDG/national Targets (Rounded off figures to the nearest 100,000) ............................................................................................................. 16
LIST OF FIGURES Fig. 1: Percentage Population Connected to Water Supply and Area Connected to Sewerage in UWSAs in Tanzania mainland. ................................................................................................. 10 Fig. 2: Waste Generated and Amount Collected for Disposal in Cities and Municipalities in 2005... 11 Fig. 3: Common Methods in Use for Solid Waste Disposal in Tanzanian Urban Areas ..................... 12 Fig.4: Tanzania Cholera Trends from 1998-2006 ................................................................................ 13 Fig.5: Morbidity and Mortality due to Cholera, 1998-2006 ................................................................ 14

INTRODUCTION

1.1 Background The review of the Tanzanian sanitation status is a reflection on how Tanzania is fairing to keep its promise in meeting the UN Millennium Development Goals (MDG) and its own national targets. On one hand, under Goal 7 (Environmental Sustainability), the MDG target calls upon each member country to reduce by half the proportion of people without sustainable access to safe water and basic sanitation by 2015. There are however, some relationships between sanitation and the rest of the MDGs as illustrated in Table 11.
Table 1: Linkages between Sanitation and All MDGs Goal Relationship with Sanitation SaSan is Sanitation is critical for productive lives Goal 1: Eradicate Poverty Sanitation is better for quality education, enrolment and retention (especially girls) Goal 3: Empower Women and Sanitation enhances women dignity Gender Quality Sanitation empowers women to seek better economic opportunities Goal 4: Reduce Child Mortality Poor sanitation and hygiene claim the lives of 1.5 million children under five years per year Sanitation reduces morbidity and mortality Sanitation reduces pre and post natal risks Goal 5: Improve Maternal Health Goal 6: Combat Diseases Malaria, diarrhoea, intestinal worms are manor diseases killing people Bladder and kidney infections are common among women Sanitation prevents water related diseases Goal 2: Achieve Primary Education Goal 7: Ensure Environmental Sanitation prevents environmental damage Sustainability Sanitation improves urban dwellers lives Sanitation calls for public-private partnership Goal 8: Develop Global Partnerships

On the other hand, Cluster 2 of the Tanzanian National Strategy for Growth and Reduction of Poverty (MKUKUTA), on Improvement of quality of life and social well being sets out to achieve by 2010 the following sanitation related targets: Increased proportion of rural population with access to clean and safe water from 53% in 2003 to 80% in 2009/10 and less time spent on collection of water; Increased proportion of urban population with access to clean and safe water from 73% in 2003 to 90% in 2009/10; Increased access to improved sewerage facilities from 17% in 2003 to 30% in 2010 in urban areas; 100% of schools to have adequate sanitary facilities by 2010; Increased proportion 95% of people to have access to basic sanitation by 2010; Cholera outbreaks cut by half by 2010; Reduced water related environmental pollution levels from 20% in 2003 to 10% in 2010; 1 on Reduction in harmful industrial and agricultural effluents; Paper Link Development Cooperation and sanitation Technology by Dr. Chang Hyank-sik, Seoul, Korea 3

In principle the above targets are embedded in the Tanzanian Development Vision12 which emphasizes on improved human health as a critical ingredient for economic growth and elimination of poverty in Tanzania. The vision aims at achieving an absence of abject poverty by 2025. 1.2 Scope of Sanitation Sanitation has been considered differently among the stakeholders in the country. While others refer sanitation to safe disposal of human excreta others go beyond disposal of human feaces to even include wastewater as well as solid waste disposal. This has created ambiguity such that even the data given by different stakeholders concerning sanitation differ considerably in terms of coverage and scope. Ironically, there are divergences in the way the water and health sectors in Tanzania define sanitation. Whereas the former defines sanitation as the practice that separates people from excreta and protects transmission of faecal contaminant and is easily accessible in all seasons 3 the latter sees it as the state of cleanliness of the environment which prevents the occurrence of diseases due to poor environment and hygiene.4 It is evident that the above definitions differ in scope as the water sector definition reflects only the options of human excreta disposal (in this case latrine) while that of the health sector is broader in scope as it includes latrines and liquid and solid waste management. All in all WHO defines the term sanitation as the provision of facilities and services for the safe disposal of human urine and faeces. The word Sanitation also refers to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal. (WHO health topics, www.who.int/topics/sanitation/ent) The Guidance Manual on Water and Sanitation by DFID explains sanitation as the safe management of human excreta which also includes both the hardware (e.g. latrine and sewers) and the software (regulations, hygiene promotion) needed to reduce faecal oral diseases transmission. It encompasses too the re-use and ultimate disposal of human excreta. The manual further explains that in developing countries sanitation includes drainage, solid waste management and the control of vector and vermin. By and large both the WHO and DFID definitions signify that sanitation is a very important aspect of public health of which its inadequacy has been a major cause of diseases world-wide, hence improvement of the same can have significant benefit on health both in households and across communities. However, for the purpose of this report sanitation has been taken to encompass the following aspects: 1) Hygiene, meaning, habits related to the safe management of human excreta.

2 3

URT, (1999), Development Vision 2025 for Tanzania, Dare s Salaam Annual Water Sector Report 2006/2007, October 2007,pg 25 4 The National Environmental Health and Sanitation Policy Guidelines, April 2004 pg 98

2) Safe excreta disposal, which includes access to improved sanitation to avoid contact with excreta, which encompasses the following improved sanitation facilities5 and their proper use and maintenance: a. b. c. d. Pit latrine with slab Ventilated improved pit (VIP) latrine Composting toilet Flush or pour-flush to i. pit latrine ii. septic tank iii. piped sewer system

3) Municipal wastewater treatment, 4) Septic sludge management (collection, treatment and sanitary disposal), including the emptying of septic tanks (and other similar facilities in place), transportation to designated treatment sites or final disposal, and technically, socially, financially and economically appropriate methods for the production of biosolids for reuse as fertilizers or soil improvers; 5) Municipal solid waste management collection, treatment and sanitary disposal. , through technically, socially, financially and economically appropriate methods to prevent health risks and environmental pollution. The safe excreta disposal options listed under item 2 above concur with the acceptable MDG basic sanitation monitoring indicators. The rest of the aspects imply sanitation in its totality instead of a narrow perspective which considers sanitation only as ways of safe disposal of human excreta (latrines).

1.3 Review Objective The second African Conference on Sanitation and Hygiene AFRICANSAN + 5, is scheduled to be held in Durban, South Africa from February 18 to 20, 2008. The overall objective of the conference is to promote sanitation and hygiene improvement programs in Africa and to assist key stakeholders identify actions to accelerate achievement of national targets and the Millennium Development Goals (MDGs) for sanitation.
At this conference participants will have an opportunity to review actions taken by different countries in their efforts to improve the state of sanitation and hygiene since the last AfricanSan + 5 conference of 2002. On its part, Tanzania through WSP-AF and its partners have launched the preparatory phase of the conference which includes holding sector stakeholder meetings in order to pull together relevant information and also identify best practices and experiences within the country which can be shared during the conference. In that respect, WSP-AF has commissioned a private consultant Mr. Deo Binamungu to prepare a comprehensive report on the status of sanitation in the country as part of the Tanzanian specific input to the conference. The assignment will be undertaken in close partnership with the African Development Ban (AfDB), UNICEF and World Health Organisation (WHO).
5

Source: Meeting the MDG drinking water and sanitation target: the urban and rural challenge of the decade WHO & UNICEF, 2006

1.4 Scope The main activities under this assignment are:

1. Preparing the review of the sector status in Tanzania; 2. Create a data base of main experiences and interventions in the sanitation and hygiene sector; and 3. Support the regional coordinator in the preparation of the consolidated synthesis

1.5 Expected Output The expected outputs of this undertaking include:

1. A documented knowledge of the status of the sanitation sector in Tanzania based on the guidelines provided by the Client; and 2. A detailed inventory of key documents and reports and the sources of information on sanitation and hygiene in the country.

1.6 Methodology and Report Structure The Consultant has prepared this report by using the following methods outlined in the Terms of Reference (ToR) the task through:
1. Desk review of the sector including analysis of the available official data and information published by national and international agencies 2. Interviews with key stakeholders involved in the sanitation and hygiene sector The structure of the report is based on the guidelines provided by WSP-AF.

TANZANIAS SANITATION STATUS AND TRENDS

This chapter examines the status and trends in Tanzania as it forges to achieve the MDG/national targets in as far as access to improved sanitation of its population is concerned. It highlights the status of infrastructure coverage of sanitation and hygiene education and promotion in the country and the critical aspects towards achievement of MDG and national targets.

2.1 Prospects of Achieving MDG/National Targets Tanzania reaffirmed its commitment to the MDGs when it formally subscribed to the Millennium Declaration at the United Nations (UN) General Assembly of 6-8 September 2000.6 Since then all subsequent national development strategies have focused on eradicating poverty. Access of improved water supply and sanitation services has been singled out in the NSGRP as well as in the Tanzanias Development Vision 2025 as one of the main development concerns in the country.
As far as sanitation is concerned Tanzania has so far recorded a mixed progress in attaining MDGs and national targets. According to the MDG Progress Report7 the status of progress for sanitation is on track. The report cites increased budget allocation for water supply and sanitation since 2005/06/07 and increased water and sanitation projects in the urban areas as the main factors towards achieving MDG targets. Also, it confirms that the water sector has effective sanitation and water policies which are in line with the demands of the MDGs. Another key factor which might contribute towards achieving MDG and national targets is the supportive environment through the collaborative approach among the key stakeholders to develop a common understanding of the current sanitation situation in the country and identification of shortfalls and needs. Many of these stakeholders have of late been seeking to adopt and include in their planning systems the countrys sanitation and hygiene targets. However, this encouraging trend as cited in this report pose some critical questions as analysed in the following sub-sections.

2.1.1 Sanitation Coverage: Excreta Disposal Information on sanitation coverage in Tanzania is provided by different field surveys as shown in Table 1. Whereas the HBS indicates that the overall sanitation level for Tanzania was 93% in 2000/01, the DHS puts it at 87% in 2004/05. Other field surveys include the National Census in 2002 (91.5%) and the Annual Health Statistical Abstract by the MoHSW 2006 (64.8%).
Regardless of the timing for each survey, the overall percentage coverage gives an impression that sanitation coverage in Tanzania in terms of access to latrines at household level is relatively high.

6 7

UN General Assembly (2000) UN Millennium Declaration, A/RES/55/2 MDG Progress Report, 2005, Tanzania (Draft August 2006)

Table 2: Different Reported Sanitation Coverage in Tanzania

S/N 1 Source of Information Household Budget Survey (HBS) 2000/01 Demographic Health (DHS) 2004/05 National Census 2002 Survey Sanitation Coverage Overall -93% Rural 91.8% Urban 97.7% Overall 87% Rural 83.3% Urban 97.6% Overall 91.5% Rural 89.0% Urban 98.6% Permanent toilets 47% Temporary toilets 53% Overall coverage 64.8% Overall 47% Rural 43% Urban 53% Criteria Use of sanitation facility Indicator The proportion of people using sanitation facility The proportion of people using sanitation facility, urban and rural The proportion of people using sanitation facility, urban and rural The proportion of people using permanent/temporary toilets The proportion of people using appropriate sanitary latrines The proportion of population with access to improved sanitation, in urban and rural areas

Use of sanitation facility

Use of sanitation facility

Sector Study MoHSW 2005

Use permanent/temporary toilet

of

Annual Health Statistical Abstract MoHSW 2006

Use of appropriate sanitary latrines

WHO/UNICEF Joint Monitoring Program (JMP)

Access to improved sanitation facilities in Urban and Rural Areas

Source: Annual Water Sector Status Report: 2006/2007

However, a study by WATERAID8 contends that the statistics employed in assessing progress towards the MDG target suffer from two basic limitations namely; The governments coverage figures tend to be exaggerated due to flawed da ta collection techniques; and Most of these statistics give no impression of sanitation adequacy in terms of the accepted MDG definitions It concludes that the coverage figures for basic sanitation tend to be over -stated and the scale of the sanitation challenge nationally has, until recently, been under-acknowledged by the government of Tanzania (GoT). The GoT has on many occasions used the figures in Table 2 to indicate progress towards achievement of both MGD and national targets in sanitation. But as seen in these statistics the term latrine is too broad since it covers both adequate and inadequate sanitation. Moreover, it is doubtful that these surveys made any physical check of the existence of the sanitation facilities in surveyed households. Hence, these data do not necessarily refer to latrine ownership but use even if the interviewed households share sanitation facilities or use public toilets. Based on the MDG definitions outlined in preceding chapter, the latest Joint Monitoring Programme (JMP) undertaken by WHO/UNICEF9 which is the official monitoring mechanism of

8 9

Promoting Better Hygiene and Sanitation: A Review of WaterAids Experiences and Lessons Learned, Sept. 2007 www.wssinfo.org, WHO/UNICEF JMP, 2004

Table 3: National Coverage of Excreta Disposal Facilities in Tanzania

Type of facility Urban Pit-Latrines 92.6 Traditional Pit-latrines 89.3 Ventilated Improved Pit-Latrine (VIP) 3.3 Septic Tanks and Soakage pits 3.6 Sewerage 1.4 Others (type not indicated) 0.7 Without access to any excreta disposal 1.7 facility Source: DHS 2004

National Coverage (%) Rural Total 82.3 84.6 81.9 83.5 0.4 1.1 0.5 1.2 0.3 0.5 0.9 0.8 16 12.8

the MDG commitments, has revealed a declining trend in sanitation coverage in the rural areas from 45 per cent in 1990 to 43% in 2002. The report shows a slight increase of sanitation coverage in the urban areas from 52% in 1990 to 53%. Overall, the average access level to basic sanitation is about 47%. Though these figures may seem to depict a favourable situation relative to other developing countries and specifically so in Sub-Saharan Africa, it remains a fact that Tanzania still lags behind in sanitation coverage and the situation is hardly changing. There are also notable geographical variations in terms of sanitation coverage. In nomadic communities the coverage is as low as 12%. 10 The PHDR (2005) indicates that in some rural districts more than 50 per cent of households were found to have no toilet facilities. For example, the report found out that 57 per cent of the households in Ngorongoro district had no toilet facilities whereas in Kiteto and Simanjiro districts the figure was slightly higher at 58 and 61 per cent respectively. The situation in Monduli district was worse with 79 per cent of the households without toilet facilities. In all these districts majority of inhabitants are pastoralists. The MDG Progress Report (2005) by GoT notes also another shortfall regarding these data that they do not reflect the actual use of the facilities or other hygienic practices that would help reduce prevalence of water and sanitation related diseases. The data regarding school sanitation is on the other hand, difficult to obtain from the National Census and demographic surveys. Therefore, the status of coverage indicator in schools relies on data provided by MoEVT. According to MoEVT statistics out of 333,899 permanent toilets required for government and non-government primary schools only 129,944 are available reflecting a shortage of 203,955. Hence, the coverage is about 39 per cent11. However, it is important to note that, this data does not describe the adequacy of facilities as it is common to find schools with a high concentration of boys and girls using only one or two stances. This trend of ambiguity in definitions and inadequate data and information makes it difficult to precisely figure out the magnitude of the adverse effects of poor sanitation and hygiene in Tanzania. However, few available data indicate that there still a long way to go to achieve the so called
10 11

Annual Water Sector Status Report, 2006-2007 MoEVT Basic Education Statistics in Tanzania (BEST), Regional data, December 2006

Improved Sanitation. The direct result of stagnant changes in sanitation coverage is the ever unabated incidences in sanitation related diseases such as diarrhoea, especially among the under 5, dysentery and cholera. Figures 4 and 5 show the trends in cholera prevalence as well as morbidly and mortality rates related to cholera between 1998 and 2006 in Tanzania .

2.1.2 Access to Sewerage Services Very few urban areas in Tanzania are provided with sewerage systems. For instance, out of 18 cities/municipalities/towns only ten have sewerage systems. Urban authorities with sewerage systems include Dar es Salaam, Tanga, Morogoro, Dodoma, Arusha, Mwanza, Mbeya, Tabora, Iringa and Moshi. According to UWSSAs Report (2005/2006), the total number of sewerage connections is 13,055 indicating coverage of 10 per cent in terms of area and 14 per cent in terms of population12. The NWSDS however, indicates that sewerage coverage is 17%13. These figures indeed show that aggregately access to sewerage services in Tanzanian cities or municipalities is limited.
In most municipalities, the collected sewage is treated in waste stabilization ponds (WSP) before being discharged into water courses such rivers, lakes or ocean. However, most of the ponds are not working properly which creates a risk of discharging partially treated waste water to the surface and groundwater resources. For example, about 15% of Dar es Salaam residents are connected to the city sewer network that was built in the late 1950s. The city has eight waste stabilisation ponds, of which only four are in operation.
Fig. 1: Percentage Population Connected to Water Supply and Area Connected to Sewerage in UWSAs in Tanzania mainland.

120% 100% 80% 60% 40% 20% 0%

Ar us ha

Do do m

% Population connected to water supply

Area connected to sewerage

Source: (Modified from Ministry of Water Annual Reports for Urban Water Supply and Sewerage Authorities for Financial year 2004/2005 and DAWASCO in October, 2006.)
12 13

URT, MoW, Annual Report, UWSSAs FY 2005/2006 NWSDS 2005-2025 pg 49

10

Ta bo ra

wa nz a

Ta ng a

ng a

be ya

or o M

DS M

Iri

os hi

2.1.3 Solid Waste Management Availability of solid waste services in many urban areas of Tanzania is also still poor. It is estimated that only 25% of generated solid waste is being collected. About 5-10% of the urban population receives regular solid waste collection services in most cases confined to few areas, usually the urban centers and high-income neighbourhoods14. Poor people in unplanned urban areas and those who live in rural areas have no access to solid waste collection.
Fig. 2: Waste Generated and Amount Collected for Disposal in Cities and Municipalities in 2005

Tanga

Tabora

Moshi

Morogoro

Municipal

Iringa

Temeke

Kinondoni

Ilala

Dodoma

200

400

600

800

1000

1200

Waste generated (tones/day)

Waste collected (tones/day)

Source: Blinker et al., 2006 The disposal options are limited to open crude dumping, semi controlled and land filling. In recent years, the Ilala municipality in Dar es Salaam has designed a sanitary disposal system where solid
14

(Mato, R.A.M. (2002), Groundwater Pollution in Urban Dar es Salaam, Tanzania Assessing Vulnerability and Protection Priorities. Ph.D Dissertation. Eindhoven University of Technology, The Netherlands.

11

waste is land filled properly. In addition there is no ground water contamination because leachate is not allowed to escape to the environment. The sanitary disposal system forms 5 percent of all the disposal systems employed in cities and municipalities in Tanzania.
Fig. 3: Common Methods in Use for Solid Waste Disposal in Tanzanian Urban Areas
percent

5%

32% 49%

14%

Open crude dumping

Semi controlled

Land filling

Sanitary Land fill

Source: Cleanliness Competition Draft Report, MOHSW, 2007

2.1.4 Garbage Disposal Another common solid waste management method is through garbage collection. Hence, disposal of household garbage is one of environmental health indicator especially in urban areas where most land is occupied for dwelling and commercial activities. Table 3 represents the data collected by HBS. The table depicts the distribution of households by means of garbage disposal as reported by National Bureau of Statistics (NBS).
Table 4: Distribution of Households by Garbage Disposal, Tanzania mainland 2000/01

Type garbage Mainland Rural Other Urban disposed Tanzania (%) (%) (%) Rubbish pit in 23.1 23.5 24.7 compound Rubbish pit 30.5 27.1 44.9 outside compound Rubbish bin 3.1 0.5 8.8 Thrown inside the 19.3 22.8 8.9 compound Thrown outside 22.0 24.5 11.8 the compound Others 2.0 1.6 0.9 Number of HH 6,453,755 5,046,213 981,563 Source: NBS, 2005, Environmental Statistics, Tanzania Mainland

Dar es salaam (%) 14.6 38.4 20.3 1.2 16.2 9.3 425,979

12

2.1.5 Hygiene Education and Promotion The sanitation situation on the ground validates that hygiene practices are also very low. For instance, MoHSW study revealed that only 31.3 per cent of latrines had hand washing facilities, while 50% of families wash hands in shared containers and 15.1% of the households had children feaces around their compounds.15 The horror is justified by recurrences of cholera outbreaks in almost all regions including Dar es Salaam which hosted the disease for the whole year of 2006. Epidemiological data for 2004-2005 indicate that, there were 12,923 reported cases of cholera with 350 deaths, 154,551 cases of dysentery with 170 deaths and 863,488 cases of typhoid with 1,167 deaths. The situation worsened in 2006 where a total of 14,297 cases and 254 deaths occurred due to cholera alone.16 Figs 4 and 5 below indicate the trend of cholera disease in the country between 1998 and 2006.
In conclusion the MDG Progress Report by GoT notes that demand for improved personal hygiene was not well linked with sanitation and availability of water in the MDG 7 as there is no monitoring indicator for hygiene practices in the MDG target. However, NSGPR/MKUKUTA has identified cholera outbreak within a given period as a monitoring indicator for improved hygienic practices.
Fig.4: Tanzania Cholera Trends from 1998-2006

TANZANIA CHOLERA TRENDS FROM 1998-2006

NUMBER OF CASES AND DEATHS
16000 14000 12000 10000 8000 6000 4000 2000 0
1998 1999 2000 2001 2002 2003 2004 2005 2006

Cases Deaths

YEARS

Furthermore, sanitation is usually promoted on the basis of health benefits only and reasons which could help change the peoples behaviours such as convenience, privacy and status are neglected.

15 16

Assessment of Household Sanitation and Hygiene Practices, MOHSW;2004 Ministry of Health and Social Welfare, Epidemiology Annual Reports 1998-2006

13

Fig.5: Morbidity and Mortality due to Cholera, 1998-2006

Morbidity and Mortality due to Cholera, 1998 - 2006

10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Months
Cases Deaths

May

Jun

Despite the high burden of water related or water borne diseases, recently there have been some notable social and economical improvements in the country. The education and health sectors are doing relatively well, as is the countrys economic performance. One result has bee n a decline in child mortality from 1999 to 2005, infant mortality fell from 99 deaths per 1000 live births to 68 per 1000 live births, while U5 mortality rate from 147 per 1000 live births to 112 per 1000 live births17. However; one cannot plainly link this improvement in health indicators with sectoral progress on sanitation and hygiene due to existence of other programmes like immunization and nutrition which to some extent do much better than sanitation. This requires a more scientific approach to quantify the impact of improved sanitation and hygiene practices to health and wellbeing. The best way is perhaps to conduct an impact evaluation to quantitatively show how much sanitation and hygiene contribute to these achievements.

2.1.6 Inequities in Access to and Use of Quality Sanitation Services The National Health Policy 1990 (now under review) aims at implementing both national and international commitments. The vision is to have a healthy community that can contribute effectively to individual development and the country as a whole. Hence, the ministrys mission is to facilitate the provision of basic health services which are proportional, equitable, of high quality, affordable, sustainable and gender sensitive.
Though the policy stresses on equity and quality delivery of services, in reality the implementation of sanitation and hygiene have not received sufficient attention. Urban areas are more advantaged compared to rural areas. For instance, the sewerage services in urban areas are exclusively a government responsibility except that the users pay little tariffs. On the other hand, on-site sanitation which is very common in rural areas is the responsibility of the household. Thus, sewerage is highly subsidized by the government as opposed to on-site sanitation which is used by majority of the urban and rural poor. Furthermore, planning of sanitation services especially in urban areas favours sections
17

NBS and ORS Macro 2005

14

of the communities that are easiest to reach and ignore households living in slums or the unplanned urban areas. This is especially so when the charges associated with these services are too high. Hence, access to adequate basic sanitation such as sewerage networks are connected only to areas where affluent sections of the population reside. The sanitation and hygiene component is as important for health as water supply. Adequate sanitation and improved hygiene practices can only be easily attained when go hand in hand with access to clean and safe water supply. However, currently access to clean and safe water is unevenly distributed in favour of the urban areas to rural areas. Similarly, the urban water supply networks do not reach the unplanned areas. In so doing most of population lacks clean and safe water supply to facilitate hygiene practices within their communities. Household sanitation is also faced with the non-active participation of women in the decision making process. Women who have the most to gain from sanitation and generally more receptive to its benefits than men has not been adequately addressed by agencies promoting sanitation. For example, there is a general dependency of majority of women on men to finance latrines and dig pit latrines. As discussed earlier, sanitation in schools is in the worst shape of all, only 36.7% school with adequate sanitary accommodation (Poverty and Human Development Report 2005).Toilets are smelly and dark; children naturally do not want to use them. In addition lack of washing facilities, privacy especially during menstrual period contributes to drop out of school girls altogether. Finally, it is important to note that the MoW which under the WSDP has invested a significant amount in sanitation has not been able to establish any equity monitoring indicators to ensure that even the poorest and most vulnerable groups access basic water supply and sanitation services.

15

Table 5: Sanitation Coverage and Health and Human Development Indicators

Domestic wastewater treatment 2007 N.G. Solid waste Sanitary Collection disposal(*) 2007 N.G. 2007 N.G. Health indicators Chronic Child malnutrition(2) mortality(3) Year(2004-5)** 2004** Poverty indicators Extreme HDI(4) poverty(5) Year 2003***

Population 20071 20151

Excreta disposal 20072 MDG / N.G.

ADD(1) Year

Urban 97.6% 26% Rural 83.3% 41% Total 39,446,061 49,861,768 87% 95% 38% N.G. National goal (1) Incidence of acute diarrhoeal diseases in children under 5 (2) In terms of stunted growth in children under 5 (3) among children under 5 (4) Human Development Index (5) According to national criteria (*) Specify final disposal method

112/1000

30%

Sources and comments: 1NBS and ORC Macro-2005; 2 Tanzania Demographic Health Survey Report 2004/5; Tanzania Poverty and Human Development Report 2005;

2.1.7 Main Critical Aspects for Achieving MDG Sanitation Targets (a) Reforms

Different sectors involved in sanitation in Tanzania have since the 1990s adopted a number of policies and strategies to embrace the public sector and local government reforms. Both the Local Government Reform Policy and the Local Government Act (1982) amended in 2000, devolves the responsibilities of provision and facilitation of water and sanitation services to the LGAs. The policy and legal reforms provide a good opportunity for central government to support LGAs to generate more revenues, reduce costs, and operate water and sanitation services more effectively. In other words, they empower the communities through their LGAs to prioritise areas of interventions, plan and implement their sanitation and hygiene promotion activities. However, in reality this devolution of responsibility and authority ahs been progressing at a low pace as there have been some perceived resistance from the central government ministries that were used to providing such services directly to the communities. Although the roles and responsibilities of government institutions for the implementation of development projects/activities are diagrammed on paper, LGAs, wards, communities have yet to sufficiently assume their assigned roles. Thus, it is common to observe disconnects in community and ward level planning, absence of monitoring, absence of general district support to communities, lack of district initiative to address local issues18

(b) Financing Another critical aspect is the financing of sanitation and hygiene promotion activities. Traditionally, the national financing for sanitation and hygiene promotion activities both from the Government of Tanzania and the donors has been all along meagre relative to sector investments in water supply. Neither the MoHSW nor MoW has indicated a clear priority to invest in this sub-sector. Despite the fact that the former has the legal mandate to nationally drive the sanitation and hygiene agenda, it does not have a viable strategy to solicit adequate funding to invest in the sub-sector.
For over two decades sanitation and hygiene have been combined with water supply in the manner which has worked to the sidelining of the former thus, leaving a bulk of resources and attention with the latter. More often than not, sanitation development has been planned to move at the same pace as water supply with a specific time frame regardless that the promotion of the former requires more time to enable people change their hygiene behaviour and sanitation practices. Where resources have been available a greater proportion is usually spent on constructing water infrastructure and not enough on promotion, planning and support of sanitation initiatives. In addition, technocrats do not have capacity to convince policy makers and or politicians to take action on ensuring that there is enough funding for sanitation. The capacity required here is to convince the decision makers at all levels to value the relationship between water supply and sanitation.

18

Water and Sanitation in Tanzania: An update based on the 2002 Population and Housing Census: WaterAid, 2005

Most of the decision makers in the MoHSW are medical professionals who by nature of their professional inclination focus more on curative related financing than prevention. And when preventative issues are discussed for financing there is a tendency to dwell more on immunization, HIV/AIDS, Trachoma, Malaria, and the like than on improved environmental sanitation. Most of these interventions are donor driven investments. This is in spite of the emphasis in the NHP, that prevention is better than cure. Moreover, the existing policies do not allow any subsidy to household sanitation, and that the commonly promoted improved sanitation technologies for households are too cost ly for the majority of the people especially the poorest.

(c) Capacities Sanitation requires capacity in terms of technical, human resources and working tools. Technical capacity refers to assisting communities to adopt sanitation options or systems that are affordable. In most areas especially in rural areas communities have been exposed to costly technologies and often a single technology. Likewise the health sector at LGA level and especially at ward or community level is faced with acute shortage of personnel. While in urban areas one ward is allocated at least with about two health assistants or inspectors, the situation in rural Tanzania where a ward may consist between three and five villages, only one health person is allocated. Moreover, rural sanitation personnel are hardly equipped with working tools such as transport.
At district level training is usually adversely affected by limited financial resources. Hence, LGAs have limited skills and experience in delivering sanitation and hygiene services. In addition there is no proper guidance provided by MoHSW and/or MoW on how LGAs should plan and implement sanitation and hygiene activities.

2.2

Policies, Strategies, Institutional and Legal Frameworks

2.2.1 Policies and Strategies Sanitation is embedded in a number of policies and strategies as shown in Table 5. This indicates the cross cutting and multidisciplinary nature of the sector and the importance it commands in contributing to the well being of the population. However, there is no single policy on sanitation to spearhead a common vision and guidance to all the sectors involved in sanitation. The main sectors are health, water, education and environment. Hence, each sector has developed its own policy and strategies to address its immediate and long term needs. At present MoHSW is preparing a consultative process to develop a National Sanitation Policy so as to rectify this situation.

Table 6: Policies and Strategies Adopted by Institutions Responsible for Sanitation in Tanzania S/N 1 Institution/Agency Policy/Strategies MoHSW National Health Policy (1990) under review Areas of Emphasis Need for adequate water supply and basic sanitation to minimise water borne and water related diseases which are the major problems in the country; Recognition of health of individuals, households and community at large as dependent on the availability of safe water supply, basic sanitation and improved hygiene practices National Environmental Health Raising public awareness and demand for improved environmental health and and Sanitation Policy Guidelines sanitation services for good quality of life (2004) Draft National Environmental Setting out how MoHSW and stakeholders will implement the National Health Health, Hygiene and Sanitation Policy to achieve NDV (2025), MDGs (2015) and NSGRP (2010) targets Strategy (2006-2015) - NEHHASS Draft Sanitation Options Manual (2006) 2 MoW Provision of basic designs for sanitation hardware and facilities

National water Policy (2002) - Integration of water supply and sanitation and hygiene education NAWAPO Urban sewerage services National Water Sector Development Strategy (Draft) Setting out the strategy for NAWAPO implementation and a guiding document for implementation of WSDP. Guidelines to support realignment of the water related aspects of other key sectoral policies with the NAWAPO Clarifies institutional arrangement that defines roles and responsibilities of various actors Addresses the need to include sanitation as part of water supply interventions Improvement of service delivery by making local authorities more democratic and autonomous within the framework established by the central government Provision and facilitation of water and sanitation services as an important responsibility of local government authorities

PMO-RALG/LGAs

WSDP Local Government Reform Policy

VPO-Division Environment

of National (1997)

Environment

Policy

Ministry of Lands National Land Policy (1995) and Human Settlements National Human Settlements Recognizes the existence of unplanned settlements in most urban areas in development Policy (2002) Tanzania, which call for social services infrastructure upgrading such as roads, water supply and sanitation. MoEVT Education and Training Policy (1995) Statements on provision of adequate sanitation facilities and hygiene education in all education sector institutions. The policy recognizes the need for inclusion of Environmental Health, Hygiene and Sanitation in education curricula and programmes. Setting standards for school sanitation Provides framework for participation of women and men in development including matters related to water, environmental health, and hygiene and sanitation activities. Stresses on the interests of women in proper storage of water at home, privacy, and specific gender needs of toilets.

Promotion of technology for efficient and safe water use, particularly for water and waste water treatment, and recycling Provision of community needs for environmental infrastructure, such as safe and efficient water supplies, treatment and waste disposal services Promotion of other health related programmes such as food hygiene, separation of toxic/hazardous waste and pollution control at the household level Development of environmentally sound waste management systems especially for urban areas A review of laws, rules and regulations governing hazardous wastes and other wastes Provides a framework for enforcement of sanitation and housing standards in the country.

MCDGC

Gender Policy

The above policies and strategies indicate how important the country gives to the development of the sanitation sector. As the shown in Table above the existing sector policies and strategies relate to the following key issues on sanitation and hygiene promotion: Hygiene promotion and health education Excreta disposal Collection, treatment and sanitary disposal of septic sludge Wastewater treatment Collection, treatment and sanitary disposal of solid waste yes yes yes yes yes

Each of the sector policies has a special focus on poverty reduction, environment protection or economic development as illustrated in Table 7 below:
Table 7: Focus of Sanitation Related Policies SN Focus Sector Policies 1 Policies which form part of poverty reduction National Health Policy strategies National Water Policy National Education Policy National Community Development Policy National Land Policy and National Human Settlements Development Policy Rural Development Policy and Strategy 2 Environmental protection policies 3 Economic Development Policies National Environment Policy National water policy National Land policy National Human Settlement Development Policy Industrial policy Industrial policy National Water Policy National Environment Policy

Two critical aspects of sanitation policies and strategies: 1. There is yet no clear national advocacy strategy for sanitation and hygiene development among the key stakeholders though some of them such as international NGOs and other multilateral agencies like WATERAID, WSP and UNICEF have recently started to move towards formulation of a shared advocacy vision. 2. There is no one clear policy that focuses solely on sanitation; all the existing policies simply show a good will for the improvement of the sub-sector. This calls for the urgent need to develop Legal Framework an independent policy to take care of sanitation and hygiene in the country.

2.2.2 Legal and Regulatory Framework There are several sector- specific legislations which guide implementation of various aspects of environmental health in Tanzania including that for sanitation, hygiene, drainage, infectious diseases control, occupational safety and health and industrial and chemical exposure. Table provides references of such laws and regulations related to specific sanitation issues. Overall, the provision of water supply and sanitation services in Tanzania resides primarily in Cap. 281 of the Laws of Tanganyika 1947-1950 and subsequent amendments, regulations and ordinances. Hence, existing legislations have been developed over time through various amendments to this original primary law. This fact has led to a number of flaws in the current legislative provisions as highlighted in the textbox below.

Table 8: Sanitation-related Legislations and Regulations in Tanzania S/ SANITATION ISSUES YES/N REFERENCE N O 1 Hygiene promotion and health education YES Cap. 281 of the Laws of Tanganyika 1947-1950 and subsequent amendments, regulations and ordinances 2 Excreta disposal YES Environmental Management Act, 2004; The Local Government( District Authorities) Act, 1982 as amended to 30th June 2000; The Local Authorities (Urban authorities) Act, 1982 as amended to 30th December, 2000. 3 Collection, treatment and sanitary disposal of YES Public Health (Sewerage and Drainage) Act, 2002 septic sludge R.E The Local Government (District Authorities) Act, 1982 as amended to 30th June 2000; The Local Authorities (Urban authorities) Act, 1982 as amended to 30th December, 2000. 4 Wastewater treatment YES Public Health (Sewerage and Drainage) Act, 2002 R.E Environmental Management Act, 2004; The . Local Government( District Authorities) Act, 1982 as amended to 30th June 2000; The Local Authorities (Urban authorities) Act, 1982 as amended to 30th December, 2000. Collection, treatment and sanitary disposal of Environmental Management Act, 2004; solid waste The Local Government( District Authorities) Act, 1982 as amended to 30th June 2000; The Local Authorities (Urban authorities) Act, 1982 as amended to 30th December, 2000 5 Control of pollution in hydro-graphic basins YES Environmental Management Act, 2004
6 Reuse of human excreta Reuse of Septic sludge Reuse of Municipal wastewater YES YES YES Environmental Management Act, 2004 Environmental Management Act, 2004 Reuse of solid waste YES Public Health (Sewerage and Drainage) Act, 2002 R.E Environmental Management Act, 2004; The Local Authorities (Urban authorities) Act, 1982 as amended to 30th December, 2000. Environmental Management Act, 2004; Public Health (Drainage and Sewerage) Act, 2002 R.E; The Local Government( District Authorities) Act, 1982 as amended to 30th June 2000; The Local Authorities (Urban authorities) Act, 1982 as amended to 30th December, 2000.

Two critical aspects of the legal framework: 1. Lack of a single comprehensive Public Health Act to regulate issues related to public health and well being. In other words, there is lack of harmonisation of sanitation related legal issues and in some cases contradictions in intent. 2. Inadequate enforcement of the existing legislations and some of the legislations are out dated offering very light punishments.

2.4 Institutional Framework The MoHSW is legally mandated as a lead ministry for coordination and setting of standards for sanitation in the country as well as supporting LGAs to deliver sanitation and hygiene services. Other agencies which claim to be key sub-sector stakeholders are the Ministry of Education and Vocational Training (MoEVT), which is involved in school sanitation, the Ministry of Water (MoW), which in addition to sanitation in rural areas is responsible for sewerage services in the urban areas. The Prime Ministers Office Regional Administration and Local Government (PMO -RALG), which is directly responsible for the LGAs has to ensure that the latter implement their statutory duties which include promotion of sanitation and hygiene. The environment sector, on the other hand has the responsibility of providing legal and institutional framework for sustainable management of the environment and natural resources as prescribed in the national Environmental Policy. 2.4.1 Excreta Disposal, Septic Sludge Management and Domestic Wastewater Treatment In general the institutional framework with regard to excreta disposal, septic sludge and domestic waste water treatment in the country is as described in Table

Table 9: Division of Primary Functions in the Sanitation Sector

SN 1 Institution/Agency MoHSW

MoW

PMO-RALG

MoEVT

Key Responsibilities Formulation of policy guidelines and strategies Prepare Acts and Regulations Protecting public health (setting standards, regulating processes) Provide technical assistance to LGAs Supervision and Monitoring the performance of LGAs, service providers for compliance Formulation and coordination of NAWAPO, WSDP Setting standards Quality monitoring, evaluation and assurance Coordination of water sector development activities Urban sewerage Coordinate planning of Water Supply and Sanitation projects from LGAs Coordinate LGA budgets Coordinate capacity building for LGAs Formulate standards for school sanitation

LGAs

UWSSAs

Oversee implementation of school sanitation Coordination of physical planning of sewerage/ sanitation Provide sanitation services to the population in their areas Formulate by-laws concerning sanitation Primary school latrine provision Own, manage and develop water supply and sewerage assets Prepare business plans to provide water supply and sewerage services, including capital investment plans Secure finance for capital investment and relevant subsdies Contract and manage service providers Formulate by-laws for srvice provision

Table 10: Division of Primary Functions among Institutions Involved in Sanitation

National Government
MOHSW MOW MoEVT NEMC

Regional Level
UWSSAs Institution 2 LGAs

Private sector

NGOs

User committees

Users

Development of policies and strategies Regulation Implementation of projects O&M management Oversight

Responsible

Involved

Not involved

Two critical aspects of the institutional framework 1. Coordination and collaboration between different institutions and agencies working on the same issues of sanitation and hygiene at national level is weak leading to poor sharing of available information and unclear sanitation implementation guidelines at lower level - LGAs . 2. The existing policies and strategies do not precisely indicate the institutional home for sanitation, for instance; the MOHSW is responsible for policy and standards for software development, MOW for hardware(sewerage and treatment plants), MoEVT is responsible for school sanitation; PMO-RALG/LGAs for implementation of the decisions made by the sector ministries. In the absence of a formal sanitation policy it is even difficult to come up with viable strategy or guidelines.
2.

2.4.2 Collection, treatment and sanitary disposal of solid waste The management of solid waste in Tanzanias urban and rural areas has become an ever increasing problem. In urban centres, the problem is much greater because of the many sources of waste generation, which include households, industries, commercial entities, institutions, agriculture and hospitals. A large part of the waste especially solid waste are buried or burnt on-site, disposed haphazardly by road sides, on open spaces, or in valleys and storm water drains.
In addition, the municipal solid waste management units are involved in crude dumping, normally in natural depressions, on open land and in abandoned quarry sites. Wastes containing hazardous components and hospital waste are also disposed of in the same dumpsites. Plastic waste on the other hand have been a major threat to the environment though the government has taken some initiatives to prohibit industrial manufacturing of fine polythrene bags measuring <30 microns. Plastic wastes are non-biodegradable and emit hazardous gases in the environment when burned haphazardly. Sometimes, the plastic waste materials are misused as flying toilets in places where there are no toilet facilities.

2.4.3 Coordination Platforms As cited earlier, sanitation and hygiene sub-sector in the country has over the years suffered from weak or inexistence coordination amongst the actors. This has resulted into duplication of work and hence wastage of scarce resources around this field. It is until recently when partners have realized a need to formulate working committees and/or teams at central and local government levels to coordinate sanitation and hygiene activities. Key coordination platforms include the National Steering Committee for Sanitation and Hygiene initiated by MoHSW, the Sanitation and Hygiene Thematic Working Group (SHTWG) formed under the Joint Water Sector Review (JWSR) of the WSDP, and the Regional and District Water and Sanitation Teams. There is also an Environmental Working Group (EWG) under the division of environment in the Vice Presidents Office (VPO).
These objectives, functions and compositions are as described in Table 11

10

Table 11: Objectives, Functions and Compositions

SN 1 Committee/ Group National Steering Committee of Sanitation and Hygiene Objectives To strengthen coordination within the sector and with other ministries, NGOs, private sectors, community based organizations and External Support Agencies (ESAs). Composition MoHSW, MCDGC, MoEVT, PMO-RALG, VPO, MoID, MoLUD, MoW, and DPs e.g. WSP, UNICEF, WHO, WATERAID etc, research institutions Functions Provide guidance to all actors on Sanitation and Hygiene for sustainable development. Facilitate identification of support needed for implementation of sector programmes Improve information availability and dissemination for decision making and priority setting by responsible sectors. Finance committee undertakings

Thematic Working Group On Sanitation and Hygiene (TWGSH)

MoW, MoHSW, WA, WSP, KfW, UNICEF,

Analyse the current situation in sanitation sub sector with regard to coverage, definition, indicators and institutional arrangement including role and responsibility. Analyse performance of sanitation sub sectors against set targets and plan Valuate lessons learnt and seek consensus on appropriate approaches and models Facilitating cross cutting dialogue and co-ordination with regard to on site sanitation, hygiene promotion and HIV/AIDS Analyse hygiene practice and health impact and suggest ways to improve data collection and monitoring measure Analyse and review the impact of HIV/AIDS on water sector development Promote HIV/AIDS mainstreaming strategies and plans Prepare documentation for the water sector working group and the joint water sector review and suggest actions/undertaking for the future. To shape and rehearse the environmental aspects of the MKUKUTA To improve consensus amongst environmental

Environmental Working Group (EWG)

To promote environmental integration in development of policy and plans within the context of pro-poor growth.

Government sectors including representation of Local Government Authorities,

11

SN

Committee/ Group

Objectives

Composition CBOs, NGOs, private sector and donors

DWST To plan, manage, coordinate, monitor ans supervise water and sanitation activities in LGAs DED/MD, DPLO, DWE, DCDO, DHO,

Functions stakeholders who had not been fully organised before at national level; and To coordinate with many donors who were increasingly expressing varied interests on environmental issues. To find common ground, explore new ideas, and develop a unified voice on the environment throughout the MKUKUTA process.19 Coordinate and liase with MoW, donors, NGOs, external agencies Prepare DWS plans Plan, coordinate and manage financing of W&S implementation projects Supervise and monitor W&S activities Provide continuous backup support to communities

19

.Assey et al. 2007. Environment at the heart of Tanzanias development. Lessons from Tanzanias National Strategy for Growth and Reduction of Poverty(MKUKUTA). Natural resources issues. Series No. 6. International Institute for Environment and Development. London, UK)

12

Critical aspects of the institutional framework: for solid waste management 1. Currently there is no national policy and legislation on recycling of solid wastes and as such this is done in a haphazardly manner and according to the needs of the market. 2. Migre budget allocation for solid waste management hampers effective collection and disposal of SW. 3. With exception of one municipality in Dar es Salaam (Ilala), the rest of municipal councils in Tanzania do not have sanitary land fills for disposal of solid waste

2.5 Hygiene Promotion and Education Regarding hygiene, a study carried out by the Ministry of Health and UNICEF in 1999, in seven councils in Tanzania mainland indicate that, between 62% and 68% of population do not wash hands before eating. Only 33% washed hands after visiting toilets, 6% washed hands after attending a child who had defecated and 17% washed hands before preparing food. In addition, only 50% of primary schools have sanitary toilets20. 2.5.1 Hygiene promotion using PHAST approach The Participatory Hygiene and Sanitation Transformation (PHAST) approach was launched in 1993 by WHO, UNDP and the World Bank. It was developed because conventional health messages were largely known and understood, but were having minimal impact on sustainable hygiene and sanitation behavioural change and practice. It was intended to improve upon existing behaviourchange methodologies like SARAR and PROWWESS. PHAST reached Tanzania in 1997, since then it has been introduced in more than 70 districts. Over 7,000 Tanzanians have been exposed to formal PHAST training, including 3,600 community owned resource persons (CORPs) who extend PHAST into the community.
PHAST has been carried out in Tanzania for over 8 years and different reviews and evaluations have revealed that it is effective at conveying key health messages but not so effective at bringing important improved hygiene behaviour change. The recent review confirms this finding and reveals that the elaborate set of steps takes communities to the point where behaviour transformation might be possible and then abruptly stops. Regarding the impact of this intervention, the recent evaluation, just like the previous one revealed that, although the PHAST process is effective at spreading a multitude of health and hygiene messages, it has not been instrumental enough at bringing the intended improved and sustained hygiene behaviours. It has not proven any difference from the more traditional, top-down, didactic methods it was meant to replace. In addition, PHAST was observed to be very expensive as such it relies exclusively donors and NGOs i.e. not replicable by government especially at LGAs.

20

Assessment Study on Sanitation Status and Hygiene Practices at the :Household Level in 7 Councils in Tanzania mainland; 2005

13

2.5.2 Health Education Health Education is a fundamental element in promoting health of the individual, family and community at large. The importance of health education is that individuals and communities are in position to change their behaviour to improve their surrounding environment provided that they shall be motivated and involved in the decision making, planning, implementation, monitoring and evaluation.
In Tanzania Health Education has long been provided through various channels and approaches. At national level, there is a unit responsible for coordination of health education services in the country. The unit is located within the Ministry of Health and Social Welfare framework. At community level, health education is usually provided in health facilities to people who go to seek medical care. This approach is not very effective since it targets people who are inflicted (already have problems), in this case the messages directed to them have very small room in their mind compared to the health problems they face at that time. Community meeting have also been utilized to sensitize people on the need of observing hygienic practices; this is very common when there is outbreak of diseases like cholera. On the hand in case of schools, curricula have been developed which encompasses health education. It covers hygiene measures, sanitation and reproductive health.

2.5.3 School WASH Programmes A number of programmes have been targeting school children for hygiene behavioural changes on assumptions that (i) they were of a right age to adopt good hygiene practices, (ii) they could transfer these behaviours to their home environment and (iii) such behaviours could help in alleviating water and sanitation related diseases which are very common among children. The main actors who have spearheaded these efforts include WA, UNICEF, HESAWA21 and the Netherlands Government-support RWSSP in Shinyanga region.

Mention two critical aspects in hygiene promotion and health education: 1. PHAST has been a dominant tool for promoting hygiene-related behaviour changes for almost a decade, but has not been effective in bringing about such change. A successor to PHAST is required that focuses on a smaller range of behaviours, is easier and simpler to introduce, and contributes in a more integrated way to a multi-channel approach to behaviour change promotion with message reinforcement from diverse sources. Change promotion with message reinforcement from diverse sources. 2. The mass media used to deliver health education is not the best way since it relies on the assumption that people have access to radio and Television. In addition these channels exclude women since they have very little time if any to listen on radios and TVs. 3. The school WASH programme has not sufficiently succeeded to link water, sanitation and hygiene properly, as most schools do have some type of sanitation facilities but without reliable water supply and hand washing facilities.

21

SIDA funded programme in Lake zone regions (Mwanza, Mara and Kagera) between 1985-2002

14

2.6 Financing As discussed earlier, sanitation and hygiene promotion are not among the priority areas as they usually receive little attention in funding as compared to Malaria, HIV/AIDS and immunisation despite of high rate of diarrhoeal diseases and cholera outbreaks occurring in different parts of Tanzania. Currently, the largest funding for the sector is through WSDP which has allocated US $2.5 million per year to be distributed to all LGA budgets for sanitation activities. The total allocation for each LGA US$ 20,000 per year and is linked to the schedule for disbursements of funds through the GoT.22 Thus, the largest funding for sanitation and hygiene is currently available through the MoW which prioritizes water supply actions over sanitation and hygiene promotion.
Despite that sanitation has been currently reflected in the WSDP budget, the allocated amount is proportionally low to what has been allocated for water supply or for that matter sewerage services in the urban areas. This amount however, does not include any financial allocations by other sector ministries such as MoHSW, PMO-RALG and MoEVT through any other funding sources, which is not easily accessible. There are however, other bilateral and multilateral funds which do not appear in the WSDP-SWAP basket. For instance, WSP-AF has allocated US $ 3 million for a period of three years23. The following financing model has been developed to facilitate the funding of sanitation and hygiene in order to achieve sanitation goals. 1. Enabling Environment includes the cost of programming, monitoring and evaluation, regulation, technical oversight, organizational change, training, co-ordination with other sector, and public advocacy. 2. Promoting Hygiene Behaviours under which funding is required for assessing the current situation, development of materials, training programmes, staff costs, transport and office overhead along with the ongoing costs of operating in communities and supporting a dynamic change process at local level. 3. Improving access to hardware including sanitation marketing cost include for staff, transport, office overhead, preparation of materials, cost of media, placement, training, construction of demonstration facilities and other pilot investments and enabling operational and maintenance. 4. Subsidies for Sanitation relying on household investments for the hardware intervention can be problematic due to high level of Poverty so subsides is necessary for the hard ware intervention.24

22

(Scott,.T Assessment of Tanzanian Sanitation Enabling Environmental conducted as a Baseline for the water and sanitation program Tanzania 2007
23 24

Annual Water Sector Status Report 2006/2007

Sanitation and Hygiene Promotion Guidance 2005)

15

Table 12: Information Available on Investments for MDG/national Targets (Rounded off figures to the nearest 100,000) Investments required to Estimated investments Category meet over the next 5 years (US$) MDG / national goals (US$) (Hygiene promotion and health education)* urban 5,000,000 rural urban rural Septic sludge management (Municipal wastewater treatment)** Municipal solid waste management urban rural urban 28,700,000 rural urban NA NA 28,700,000 NA NA 10,800,000 10,800,000 5,000,000

(Excreta disposal)***

rural

Sources and comments: *Water Sector Development Programme 2006-2025, November 2006; taken as total investment for Hygiene and Hand washing Promotion+ Hygiene/Hand washing promotion/School sanitation from 2005-2010. **National Urban Water Supply and Sewerage Strategic Programme, Vol. 1, September, 2005;Taken as Capital investment requirements for 13 UWSAs from 2005-2010 *** Water Sector Development Programme 2006-2025, November 2006; taken as total investment for Sanitation Marketing (School/HH latrine retrofitting from 2005-2010) NA-Not Available

Critical aspects of financing sanitation 1. Despite the fact that water supply and sanitation are interlinked, policy and decision makers do not put much interest in the latter as it is on the former. Hence, more investments are allocated to water supply than it is for sanitation 2. Unlike other related services such as water supply sanitation services lack a well established unit cost per capita thus hindering effective planning and allocation of resources.

16

2.7

Monitoring and Evaluation

2.7.1 National Sanitation monitoring indicators As previously discussed sanitation covers a wide range of issues; it includes excreta disposal, septic sludge, waste water disposal and solid waste management. The national indicators for monitoring sanitation performance are:
Number of households with access to sanitation facilities Amount of solid waste generated Amount of solid waste collected Number of garbage pits (for rural areas) Number of households with connections to sewerage Number of sanitation facilities built in school Number of cholera attack rate

Nevertheless, the lack of common definitions of indicators and lack of accurate data still are the main constraints in sanitation performance monitoring.

2.7.2 Existing Information System for Sanitation Various institutions are involved in surveys related to sanitation. Though the existing databases are yet to be harmonised it suffices to conclude that these are the only reliable sources so far for sanitation data in Tanzania. The following institutions are said to be relatively reliable sources of data for sanitation and hence potential for sanitation performance monitoring.
a) National Bureau of Statistics (NBS) The NBS conducts a number of surveys, which can provide useful information for monitoring some of the outcome indicators. There are on going efforts by ministry of water to ensure sanitation indicators are dully included in the questionnaires. b) Ministry of Health Database The Ministry of Health and Social Welfare uses the Health Management Information System (HMIS) to collect data and monitor performance of sanitation especially on latrine coverage in the community. Currently efforts are underway to incorporate additional sanitation indicators as shown above. c) Ministry of Education Database The Education Management Information System (EMIS) database does not include any other sanitation indicator related to school sanitation except the number of drop hole. d) Local Government Monitoring Database At PMO-RALG there is a Local Government Monitoring Database (LGMB) containing indicators for water supply but not sanitation. However, PMO-RALG has accepted to incorporate some indicators on sanitation.25

25

Annual Water Sector Status Report 2006/2007

17

e) Ministry of Water The Performance Monitoring Thematic Working Group (PMTWG) under the JWSR is responsible to put in place mechanisms to ensure agreed output and outcome indicators in the performance monitoring framework so that they can be regularly measured including establishing baseline information. Specific tasks assigned to this thematic working group include:

Review currently applied performance indicators Review and define the system of input, output, outcome and impact indicators Suggest improvements to current data monitoring and evaluation system Develop and/or improve performance assessment framework Assess sector performance on regular basis Prepare documentation for the WSWG and JWSR Assist in the benchmarking system for sector performance

The ministry is currently developing a management and information systems (MIS) 26 primarily intended for the Rural Water Supply and Sanitation Programme (RWSSP).

2.7.3

Sanitation linkage with improvements in health, mitigation of environmental pollution and poverty reduction

As of current it is difficult to relate specifically the contribution of sanitation to health improvement, poverty reduction or mitigation of environmental pollution. This is mainly because there has been no impact evaluation in the country to establish such relationships. However, globally, it has been found that improvement in sanitation (safe excreta disposal) can reduce diarrhoea incidences by 33%27. Likewise, it is known that the use of pit latrines without water tight lining causes ground water pollution due to seepages of sewage. Given the fact that about 84% of latrines in Tanzania are traditional pit latrines the emphasis has been to construct their latrines within a minimum distance of 30 metres upstream so as to avoid risks of contamination of shallow wells which are common in the country. Infant Mortality Rate (IMR) and Under Five Mortality Rate (UMR) s are some of the many indicators for poverty reduction. Improvement of sanitation plays a significant contribution in reducing IMR as well as UMR and as such improvement of sanitation contributes to poverty reduction In all the above mentioned cases there are no studies which have been undertaken to establish the impact of sanitation improvement on poverty reduction, improvement of health and mitigation of environmental pollution variables.

26 27

MIS not yet operational Curtis and Cairncross, 2003

18

Two critical aspects of sanitation monitoring and evaluation 1. There is no adequate information regarding baseline data on coverage, quality and quantity of sanitation services in the country. This is mainly because of inadequate coordination and networking among the sector stakeholders as well as comprehensive M&E action plans and framework. 2. Lack of common definitions of indicators and lack of accurate data are main constraints in carrying out effective performance monitoring 2.8 Capacities One of the critical factors contributing to poor environmental health in Tanzania is the inadequacy of environmental workforce specifically environmental health officers in both rural and urban areas. Inventory shows that, Tanzania does not have adequate numbers of environmental health workers. It is estimated that, of the 2200 environmental health workers currently available in the country, only 40% are working in rural areas. Majority of the 10,000 villages rely on services of ward environmental health officers28. These also are unable to serve all villages, because most of the Tanzanias villages are highly dispersed and cannot be easily accessed due to poor infrastructure. In addition, the number of ward health officers available, is small compared to the number of wards. As such environmental health workers are available in only few wards with majority of them concentrated in urban area.
There exists a number of training centres in Tanzania which focus on environmental health for middle and higher level cadres. However, it is difficult to tell how effectively the graduates from these training institutions are being utilised especially by the health and water sectors. For example, since 1982 a good number of environmental engineers have graduated at UCLAS29 but can hardly be found effectively utilised in any of the water and health sectors at all levels. In addition, there is generally low capacity among environmental health workforce in designing innovative approaches to environmental health management. The problem of low capacity has been compounded by inadequate opportunities for carrier development because of a few numbers of institutions providing specialised training courses for Environmental Health, Hygiene Services (EHHS). The problem is also caused by high attrition rate caused by different factors including HIV/AIDS. Another critical issue on the capacity of environmental health delivery system relates to inadequate funding of environmental health activities in the country. Funds allocated for environmental health activities at the MoHSW headquarters, are less than 0.5% of the overall budget of the Department of Preventive Health Services. A similar situation is experienced by LGAs, where the services are not efficiently implemented mainly because of inadequate or lack of resources. The problem of inadequate funding is compounded by weaknesses in the planning at the LGA level. Despite the fact that factors in the environmental health are major causes of top ten diseases in many of the LGAs, few of them have incorporated environmental health in their district development plans. The bulk of environmental health activities at the LGA are carried out either as
28 29

Draft National Environmental Health, Hygiene and Sanitation Strategy, 2007 Now Ardhi University located in Dar Es Salaam ,

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projects supported by development partners or special government campaigns. This has contributed into environmental health not being allocated adequate resources by LGAs. Related to issues of quality of environmental workforce, is the problem of capacity utilization and retention in regard to environmental health workforce. Generally the existing remunerative and incentive structures for environmental health workers are not sufficient enough. This is largely contributing to the sectors inability to recruit and retain good staff. This weak incentive structure, coupled with poor accountability systems has bred ground for corruption within the service. The problems of capacity have affected the performance of environmental health management in Tanzania especially the capacity of the service to respond to the negative consequences including diseases caused by contaminated water, air and land such as malaria, anaemia among children infested with worms etc.

Two critical aspects of capacities in the sector: 1. Capacities at all levels are inadequate but so much pronounced at LGA level where there is limited experience and expertise in delivering sanitation and hygiene services. The situation in exacerbated by the fact that there are no clear guidelines and approaches to LGAs on how they can effectively plan and implement sanitation and hygiene promotion.

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SUCCESFUL EXPERIENCES, LESSONS LEARNED AND RECOMMENDATIONS

The preceding discussions can in no way make one to conclude that Tanzania has not made any significant strides towards achieving its national as well as MDG targets. There are notable successful experiences and lessons learned in this sector as discussed in this chapter.

3.1

Successful experience and lessons learned

3.1.1 Latrinization Programme

Since her independence over 46 years ago, Tanzania has been struggling to address the issue of sanitation. The Mtu ni Afya30 national campaign in the early 1970s aimed at ensuring that every household owns and uses a latrine. At that time in point the coverage of household latrines was significantly low and hence the inception of the latrinazation programme throughout the country . Specifically, this campaign involved leaders at all levels to ensure that households acquired latrines in their own premises. The main approaches used were a combination of advocacy and sensitization through national media and public meetings as well as coercion and enforcement through village by laws. The results of this campaign were immediate that many households constructed latrines. The campaign was given added momentum following a cholera outbreak in 1977. Latrine coverage increased from below 5% to 20-50% between 1973 and 1980, reaching 85% in the 1988.31
Lesson Learned 1: Emphasis of the Mtu ni Afya campaign was on construction but no follow up on the use of latrines. As such many latrines were constructed because the government directive required so but often not used. The commonly saying Vyoo vya Bwana Afya(literary referring to Latrines belonging to Health Officer) emerged. Moreover, the quality of the constructed latrines was not necessarily up to the required standard to improve the health of the people. Hence, the campaign focused more on infrastructure and overlooked behaviour change. Lesson Learned 2: Another lesson learned was that top down and coercive mechanisms to promoting sanitation and hygiene behaviour change without gradual persuasive and encouragement for people to adopt innovations might be counteractive.

3.1.2 School Health Programmes As mentioned earlier, a number of WSS programmes have been targeting school children for hygiene behavioural changes. The HESAWA programme was among the pioneers of this approach in the 1990s under what was widely known as the School Health Package (SHP). The SHP consisted of three basic concepts:

30

You are Your Health, in Human Development Report 2005: International Cooperation at a Crossroads: Aid, Trade and Security in an Unequal World, UNDP
31

Poverty and Human Development Report 2005, pg 49 a footnote

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1. Community participation characterised by a bottom up planning approach; 2. Problem based learning as an approach for adult (parent education; and 3. Inter-sectoral collaboration between the key departments at LGA level. The SHP initial intervention was through screening of pupils for common diseases after which the results were presented to parents meetings with the aim of developing a community/school action plans including formation of school health clubs, training of school teachers on methods of hygiene education and promotion and construction of institutional latrines at schools. As a result many latrines were built at schools and active school health clubs formed.
Lessons Learned: 1. Since the plans focused on the improvement of sanitation at schools no community plans to improve sanitation were put in place. Hence, while children used good sanitation facilities at school the situation at home was very poor. As such, there was very little evidence that children acted as agents of behavioural change at home. 2. SHP focused on constructing latrines and overlooked the importance of water supply improvement at schools, which is very critical in hygienic behaviour hand washing.

3.1.3 PHAST Approach The PHAST approach has to some extent been used by many WSS programmes in Tanzania to identify in participatory manner hygiene problems in communities and developing local solutions. The approach had been found out to be effective in at conveying key health messages especially in places like Shinyanga were smaller groups of people Water User Groups (WUGs) were stimulated in a dialogue to identify, analyse their health problems and look for joint or individual solutions.
However, the key lessons learned in using this method, include: 1. The knowledge of key health messages has not corresponded with the level of communities adopting better sanitation and hygienic behaviours. Hence, the community action plans (CAPs) developed during the PHAST sessions were not usually implemented. 2. PHAST is considered to focus more on health benefits than other factors such as increased social status, convenience and privacy that can entice families to construct their own latrines. 3. PHAST undertakings have always been funded by donors and as such not mainstreamed within the normal LGA activities. 4. In addition PHAST is considered to be costly since it focuses on a limited number of people.

3.1.4 Health and Cleaniliness Competition The MoHSW initiated Health and Cleaniliness Competition in the late 1980s. The competition is done annually. It is carried out in four groups i.e. Cities, Municipalities, Town and district councils. The objectives of introducing this competition were as follows:

To reduce communicable diseases and other risks associated with dirty environment; increase awareness to the community on the importances of cleans and healthy environment;

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To broaden community involvement on issues related to environmental health; enable the community change behaviour related to environmental health and stress the importances of living in healthy environment; and To increase accoutability both to leaders and other stakeholders in the councils concerning healthy environment.

These competitions have succeeded in improving the status of environmental health and therefore cleaniliness in cities, municipalities, towns and district councils. For example, Mwanza City was among the dirtiest city in Tanzania some years back, but as a result of the cleanliness competition it is now the cleanliest city in the country. In addition the city is considered a model in East Africa. The competition will expand its scope to include institutions like schools, hospitals, hotels and prisons.

3.1.5 Healthy Villages Programme Healthy villages refer to the settings (Rural or Urban) in which Health Promotion and Disease Prevention activities are optimally done. Community members have access to basic services that meet their needs and its people live in harmony. It is a multi-faceted approach which entangles several public health interventions such as provision of safe and clean water; improve levels of sanitation, hygiene and status of the dwelling houses. It also puts emphasis on improving social services namely, markets, burial grounds, waste disposal and sanitation in public areas.
The programme started in 2006 in five pilot villages namely, Kitunda (Dar es Salaam Region), Chumwi (Mara Region), Namalenga (Mtwara Region), Kitisi (Iringa Region) and Mkowe (Rukwa Region). Currently the villagers are implementing the plans developed by themselves which address the community felt needs. The approach is community based in which case the community takes a leading role on the implementation and evaluation of the performances. It capitalizes on the use of locally available resources and expertise although other affordable technologies from outside are used whenever need arises. So far more than 75 community facilitators have been trained on PHAST approach. The facilitators are responsible for training other villagers on issues pertaining to health promotion interventions which include hygiene, sanitation, and other disease prevention measures. Another group of 75 artisans have been trained on how to fabricate concrete slabs and different types of latrine options. This enables the community to have a wide range of choices particularly on different types of technologies used for excreta disposal. Artisans are also trained in making interlocking bricks/blocks and roofing tiles as well as oriented to practise building houses using these bricks. The technology is simple to use and affordable. Within one year of implementation remarkable ground work has been observed in some of these villages. Mkowe village in Ruka region has been outstanding of all. There has been tremendous increase of sanitation facilities which include latrines, pits for rubbish and dish racks. In an effort to scale up the coverage of the VHP to other regions, the MoHSW has selected twelve new districts which will implement the concept in twelve pilot villages one in each district. It is anticipated that, the program will help to raise awareness and involvement of the community in undertaking environmental health interventions. In addition the programme is expected to help strengthen collaboration between health and other sectors.

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3.1.6 Emerging Coordination Mechanisms The emerging thinking in Tanzania among key sector stakeholders of forging broad partnership in tackling sanitation issues is timely and highly called for. Apart from the Sanitation and Hygiene Thematic Working Group under WSDP, there are other efforts currently spearheading partnership among the CSOs like WA, SNV, PLAN International, TWESA, and EEPCO regarding sanitation development in Tanzania. Other initiatives are being initiated by the multilateral agencies such as UNICEF and WSP-AF and sector related mministries.
It is expected that, by initiating the establishment of the NSCSH the MoHSW is prepared to create a stronger and effective inter-ministerial working arrangement, which will also bring in other sector partners such as WA, WSP, UNICEF, SNV, to create a shared vision of how sanitation and hygiene promotion should be planned and implemented.

3.2

Recommended Actions

3.2.1 Policies and Strategies

1. In consideration of the poverty and knowledge levels of the majority of the sanitation technology users, there should policy guidelines which focus on the most appropriate technologies for sanitation. Guidelines are necessary for adequate funding of continuous research on appropriate technologies. 2. A purposeful strategy to create awareness among policy and decision makers should be put in place so as to seek for political commitment and support in matters related to sanitation.

3.2.2 Legal Framework

Given the fact that laws governing public health in Tanzania are fragmented and sometimes overlapping, there is an urgent need to review these legislations with the purpose of having one comprehensive Public Health Act.

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3.2.3 Institutional Framework

3.2.3.1 Hygiene promotion, excreta disposal, septic sludge management and wastewater treatment 1. There is a need for overall institutional reforms at all levels focusing on establishing and effective implementation of sanitation including utilisation of resources. 2. There should be clear sanitation implementation guidelines and MoHSW should take a lead in ensuring that all stakeholders re involved. These guidelines will help LGAs to implement the sanitation component of WSDP. 3. The current MDG basic sanitation definition should be reviewed so as to include other acceptable safe excreta disposal options which are more feasible and affordable to the majority of the population. 4. Tanzania should adopt a total sanitation concept instead of the present practice of focusing on individual household sanitation. Community total sanitation should be promoted so that people see sanitation as a community issue.

3.2.3.2 Solid waste management

1. Efforts should be focused on strengthening public-private partnership in the management of solid waste especially in urban areas. 2. Public awareness on the importance of management of solid waste at household level should be seen as one of the sector priority commitments.

3.3

Financing
1. Launch policies for internal mobilisation of resources and identify resources to meet the existing resource gaps. Through this process develop a national investment plan for sanitation in its totalisty similar to WSDP. 2. Identify and implement quick and innovative financing/subsidy mechanism for household sanitation. 3. Strengthen and scale up the sanitation marketing model.

3.4

Monitoring and Evaluation

1. M&E survey should be regular instead of depending on National census, BHS and DHS which usually are conducted after a long interval. 2. Develop a set of commonly agreed output, outcome and impact sanitation and hygiene indicators including equity indicators. In connection to this, MoHSW should initiate a national impact evaluation of sanitation vis a vis on health improvement, poverty reduction and mitigation towards environmental pollution. 25

3.5

Capacities
1. There should be a comprehensive institutional and capacity review for sanitation at all levels. 2. Capacity building should focus on grassroots level where sanitation programmes are implemented. For instance, training should be focused on ordinary villagers as artisans rather than on government staff.

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ACRONYMS
AfDB CAP DFID DHS EMIS ESA EWG GoT HBS HESAWA IMR JMP JWSR LGAs LGMB MCDGC MDG MKUKUTA MoEVT MoHSW MoW NAWAPO NBS NDV NEHHASS NHP NSGRP PHAST PHDR PMO-RALG RWSSP SHP SHTWG TOR UN UNDP UNICEF UWSSA VPO WA WHO WSDP WSP-AF WSS WUG African Development Bank Community Action Plan UK-Development Cooperation Agency Demographic Health Survey Education Management Information System External Support Agencies Environmental Working Group Government of Tanzania Government Household Budget Survey Health through Sanitation and Water (Programme) Infant Mortality Rate Joint Monitoring Program Joint Water Sector Review Local Government Authority Local Government Monitoring Database Ministry of Community Development, Gender and Children Affairs Millennium Development Goals Tanzania National Strategy for Reduction of Poverty Ministry of Education and Vocational Training Ministry of Health and Social Welfare Ministry of Water National Water Policy National Bureau of Statistics National Health Policy National Environmental Health, Hygiene and Sanitation National Health National Strategy for Growth and Reduction of Poverty Participatory Hygiene and Sanitation Transformation Poverty Human Development Report Prime Ministers OfficeRegional Administration and Local Rural Water Supply and Sanitation Programme School Health Package Sanitation and Hygiene Thematic Working Group Strategy Terms of Reference United Nations United Nations Development Programme United Nations Childrens Fund Urban Water Supply and Sewerage Authorities Vice Presidents Office WaterAid World Health Organisation Water Sector development Programme Water and Sanitation Programme Africa Water Supply Services Water User Groups

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REFERENCES
1. Annual Reports for Urban Water Supply and Sewerage Authorities for Financial year 2004/2005 and DAWASCO MoW, October, 2006 2. Annual Water Sector Status Report 2006/2007 3. Annual Water Sector Status Report, 2006-2007 4. Assessment of Household Sanitation and Hygiene Practices, MOHSW;2004 5. Assessment of Tanzanian Sanitation Enabling Environmental conducted as a 6. Assessment of the Tanzanian Sanitation Enabling Environment Conducted as a Baseline for the Water and Sanitation Program Tanzania 2005 7. Assessment Study in Sanitation Status and Hygiene Practices at the Household Level in Seven Councils in Tanzania Mainland, MoHSW/UNICEF, January 2005 8. Assey et al. 2007. Environment at the Heart of Tanzanias Development; Lessons from Baseline for the Water and Sanitation Program Tanzania, Total Sanitation Sanitation Marketing Project; Scott,.T, 2007 9. Building on What Works: Lessons Learned from the Shinyanga Water Supply and Sanitation Programme, 2002-2006, Shinyanga, November 2006 10. Demographic Health Survey 2004 11. District Operatinal Manual, MoW, March 2006 12. Environmental Management Act, 2004 13. Epidemiology Annual Reports 1998-2006, MoHSW 14. Ex-Post (Retrospective) Evaluation Study, HESAWA, Tanzania, Final Draft Report, July 2006 15. Jasson Cardos; Paper on Hand Washing with Soap; Millenium Towers, Dar es Salaam December, 2006. 16. Mato, R.A.M. (2002), Groundwater Pollution in Urban Dar es Salaam, Tanzania Assessing Vulnerability and Protection Priorities. Ph.D. Dissertation. Eindhoven University of Technology, The Netherlands. 17. Meeting the MDG Drinking Water and Sanitation Target: The Urban and Rural Challenge of the Decade WHO & UNICEF, 2006 18. Millennium Development Goals: Progress Report, 2005, Tanzania 19. National Bureau of Statistics and ORS Macro, 2005 20. National Health Policy 1990 21. National Rural water Supply and Sanitation Programme (NRWSSP): Main Report MoW, March 2006 22. National Urban Water Supply and Sewerage Strategic Programme, Vol 1, September, 2005; 23. National Urban water Supply and Sewerage Strategic Programme, Vol. 1: Main Report, Mott Macdonald in Association with ULG Northumbrian La Consulting, MoW, September 2005 24. National Water Sector Development Strategy 2005 25. NBS, Environmental Statistics, Tanzania Mainland, 2005 26. Poverty and Human Development Report 2005, Research and Analysis Working Group of the Poverty Monitoring System 27. Programme Implementation Manual for WSDP, MoW, September 2006 28. Promoting Better Hygiene and Sanitation in Tanzania, A Review of WaterAids Experiences and Lessons Learned, Owen, M, September, 2007 29. Sanitation and Hygiene Promotion Guidance; 2005 30. Tanzania Demographic Health Survey Report; 2004/5 31. Tanzania Poverty and Human Development Report; 2005

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32. Tanzanias National Strategy for Growth and Reduction of Poverty(MKUKUTA). Natural resources issues. Series No. 6. International Institute for Environment and Development. London, UK) 33. The Draft National Environmental Health, Hygiene and Sanitation Strategy; 2006-2015 34. The Local Authorities (Urban authorities) Act, 1982 as amended to 30th December, 2000. 35. The Local Government (District Authorities) Act, 1982 as amended to 30th June 2000; 36. The National Environmental Health and Sanitation Policy Guidelines, 2004 37. The Public Health (Sewerage and Drainage) Act,2002 R.E; 38. United Republic of Tanzania, National Bureau of Statistics, Household Budget Survey, 2000/01 39. Unpublished report on PHAST Review; 2007 40. UWSSAs Annual Report for 2005/2006, MoW, February 2007 41. Water Sector Development Programme , 2006-2025, MoW, November 2006 42. WHO/UNICEF Joint Monitoring Programme for Water and Sanitation 43. WHO/UNICEF Study on Sanitation Coverage Targets for MDGs Worldwide 2004

ACKNOWLEDGEMENTS

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