Académique Documents
Professionnel Documents
Culture Documents
2010 - 2011
MSc Public Health
ACKNOWLEDGEMENTS................................................................................................................................3
EXCUTIVE SUMMARY....................................................................................................................................4
1. INTRODUCTION .........................................................................................................................................6
3.
BACKGROUND ............................................................................................................................................8
3.1
THE
SLUM
CONTEXT .....................................................................................................................................8
3.2
GOVERNMENT
APPROACHCES
TO
SLUMS
AND
ITS
IMPACT
ON
SANITATION ............................................8
3.3
COMMUNAL
LATRINE
PROVISION
IN
AFRICAN
SLUMS ................................................................................9
3.4
GOOD
PRACTICES
IN
THE
COMMUNITY
MANAGEMENT
OF
COMMUNAL
LATRINES ................................. 10
7.
RESULTS .................................................................................................................................................... 19
7.1
NUMBER
OF
PAYING
USERS ....................................................................................................................... 19
7.2
PHYSICAL
CONDITIONS
AND
OPERATING
CHARACTERISTICS
OF
FACILITIES .......................................... 20
7.3
SOCIAL
AND
ECONOMIC
CHARACTERISTICS
OF
COMMUNAL
LATRINE
USERS .......................................... 21
7.4
HOUSEHOLD
LATRINE
OWNERSHIP .......................................................................................................... 22
7.5HOUSEHOLD
RESSOURCES ......................................................................................................................... 21
7.6
PATTERNS
OF
USE
REPORTED
BY
COMMUNAL
LATRINE
USERS
........................................................... 21
7.7
CHILDREN
AND
COMMUNAL
LATRINE
USE .............................................................................................. 21
7.8
PAYMENT
AND
WILLINGNESS-TO-PAY ..................................................................................................... 24
7.9
SANITATION
ACCESS
AND
PLANS
FOR
FUTURE
USE
OF
COMMUNAL
LATRINES ....................................... 25
7.9.1
COMMUNAL
LATRINE
USERS
SATISFACTION
WITH
THE
FACILITIES .................................................... 26
8. DISCUSSION...26
9. CONCLUSION ............................................................................................................................................ 32
2
ACRONYMS
3
ACKNOWLEDGEMENTS
Project development: The idea for this project was shaped after several discussions with
LSHTM professors in the Department of Disease Control. The focus was sharpened after
meeting my supervisor who suggested that I concentrate on aspects of the community
management of communal latrines and its impact on use. Professor Claire Snowden also
helped refine my qualitative research tools.
Contact, input and support: I met with my supervisor three times to develop the research
protocol and to discuss issues regarding ethical approval in a post-conflict country. We had
further email exchanges to develop and refine my household survey and other research
tools. I proposed the project to several INGOs and Yael Velleman (WaterAid UK) forwarded
my proposal to Oxfam GB in Liberia, which is the lead agency of the Liberia WASH
Consortium. The Consortium believed the research would prove useful to the WASH sector
and agreed to host the research. In Monrovia I was based in the office of Concern
Worldwide Liberia, which provided practical advice, administrative and logistical support. I
intermittently contacted my supervisor by email to discuss issues in the field, initial findings
and the first draft of the report. Financial support for the fieldwork was obtained from the
School Trust Funds, Bob Holt (The Mears Group), Prasad Gollakota (UBS), Thomas Lilo
Joycutty (HSBC), and Dr. Nelda Frater (The Frater Clinic). Unpublished documents and
information was provided by Jenny Lamb and Andy Bastable (Oxfam GB), Yael Velleman
(WaterAid UK), Madeleen Wegelin (IRC), David Kuria (Ikotoilet) and Aytor Naranjo.
Encouragement and emotional support was provided by my dear friend and colleague Dr.
Thomas Burke (Partners HealthCare).
Main research work: I identified all references through my own desk review. In Liberia, I
supervised the data collection of six-community based enumerators. I carried out key
informant/group interviews, latrine observations and transect walks.
Writing-up: My supervisor read notes from my field research and made comments and
inquiries. He also read my first full draft of which no major revisions were required.
4
Executive Summary
Communal latrines are an inadequate policy response to the sanitation crisis of sub-Saharan
Africas urban poor. It is estimated that 180 million African urbanites have no access to
sanitation and if current demographic trends persist, a majority of the African population will
reside in urban areas by 2015. This will result in slum densification and increase the urban
need for sanitation by 50 per cent. Humanitarian organisations have responded by providing
community-managed communal latrines in urban slums.
The overall aim of this policy report is to investigate communal latrine provision as a policy
response to inadequate sanitation and endemic cholera in urban slums in the West African
country of Liberia. It examined communal latrine provision in the Billimah, New Kru Town
and Zinc Kamp slums of Monrovia where each community has two communal latrine blocks
built by Concern Worldwide Liberia as part of its cholera response. The facilities have six
pour-flush toilets that are connected to a septic tank. The toilets function independent of
water, electricity and sewerage, and a community-based WASH Committee undertakes
operation and maintenance (O&M) of the facilities. A household survey in which 79
respondents were interviewed was conducted to ascertain user satisfaction and to explore
communal latrine usage rates, characteristics of users and non-users, and evidence for any
groups being systematically excluded. Multiple methods of inquiry were used to triangulate
the findings and strengthen the scientific argument for validity.
The study sought to answer whether communal latrines significantly reduced open
defecation in Liberian slums. While adult respondents have benefitted from the provision of
communal latrines, young children have been largely excluded because of cost and societal
acceptance of open defecation amongst children. Although usage rates amongst the adult
population were reportedly high, there was an even larger portion of the target population not
using the latrine. The findings suggest that the manner and scale that communal latrines
have been provided in Monrovian slums is not sufficient to stop open defecation.
The study also questioned whether the community management of communal latrines was
sustainable. The findings suggest that the technical design has made it difficult for
community-based WASH Committees to maintain the latrines as communities reported too
small, overburdened septic tanks that leak raw sewage into the roads. The WASH
5
Committees cannot mitigate this environmental and public health risk without substantial
external assistance. Furthermore, the current design is not environmentally sustainable
because the sewerage network does not function properly and vacuum tanks are obliged to
empty septic tank contents untreated into the sea.
These management challenges are handled by the WASH Committees alone each having
varying levels of skill and motivation. The inability of the New Kru Town WASH Committee to
resolve a conflict resulted in the community being locked out of the communal latrines for
nearly five months. The Zinc Kamp WASH Committee was unable to find a caretaker for four
months and the facilities sat unused while the target population continued promiscuous
defecation. Each community reported that the user fees were not enough to empty the septic
tank when it first fills. These findings imply that the current management structure gives the
community too much responsibility in the O&M of the toilets without sufficiently building local
capacity to solve problems. This adversely affects use and threatens the sustainability of the
latrines.
6
1. Introduction
Globally 2.6 billion people lack access to improved sanitation about three quarters of who
reside in sub-Saharan Africa (hereafter Africa).1 A lack of access to the safe disposal of
human excreta has traditionally been worse in rural areas but a majority of the African
population is expected to reside in urban areas by 2015, increasing the urban need for
sanitation by 50 per cent.2 In Africa, urbanisation is synonymous with slum densification as
the region has an annual slum growth rate more than double the global average (4.53% per
annum). Currently about 80% of urban dwellers in poorer African countries reside in slums
and Africa is expected to have the highest number of slums by 2020.3
Challenges to providing sanitation in African slums are broad. Sanitation has been severely
underfinanced; there has been little investment into the research and development of cheap
sanitation innovations; it is expensive to import northern technologies; and national
sanitation policies fragment responsibilities across institutions. The aforementioned factors
result in a weak foundation for national sanitation provision in both urban and rural areas.
Urban sanitation has been further challenged by rapid urbanisation that has outpaced the
provision of water and sewerage pipes, poor governance, a lack of political will, a failure to
recognise and provide service to informal settlements and decentralisation with insufficient
capacity building at the local level.
State and non-state providers have responded to the sanitation crisis through the provision
of communal or shared latrines. This policy report will focus on communal latrine provision
as an international non-governmental organisation (INGO) response to inadequate sanitation
in African slums. While communal latrines do not meet the World Health Organization/United
Nations Childrens Fund Joint Monitoring Programme (WHO/UNICEF JMP) definition of
improved sanitation* it is the most common means by which humanitarian agencies aim to
reduce open defecation and the unsafe disposal of human excreta in the slums.
*
JMP: An improved sanitation facility is one (private or shared with a reasonable number of people) that
hygienically separates human excreta from human contact. Communal latrines are not considered improved
sanitation.
7
2. Aims and objectives
2.1 Aim
The overall aim of this policy report is to investigate communal latrine provision as a policy
response to improve sanitation amongst urban slum dwellers in Liberia.
2.2 Objectives
The objectives were to:
1. Summarise existing knowledge regarding communal latrines and other low cost
technologies with a focus on how management and fee structures impact
sustainability.
2. Carry out a case study of a select communal latrine in a cholera-endemic Monrovia
slum to explore usage rates, characteristics of users and non-users, and evidence of
any groups being systematically excluded.
3. Highlight good practices in communal latrine provision in select African slums
including latrine design/user fees/ cleanliness/ maintenance/ distance/ opening
times/gender sensitivity/child friendliness and how these features impact use.
4. Critically review the policy of (communal) sanitation provision in Monrovia slums in
light of the desk and field research, and make recommendations relating to urban
slum sanitation policy.
5. Make policy recommendations to the Liberia WASH Consortium and the Liberia
Water and Sewer Corporation based on evidence from field research and selected
good practices on sanitation provisions in the slums.
3. Background
8
household latrines.5 A lack of sanitation coupled with other environmental factors is
associated with the high levels of ill health found by Rhaman et al (1980)6 in the Dhaka
slums; and Gulis et al (2003)7 in the Nairobi slums.
Research has found that communal latrines are often just receptacles for excreta11 that are
inaccessible and unresponsive to the needs of the target population because of issues
related to cost, access, security and overuse.12 In Harare, Zimbabwe 1,300 people are
supposed to share six seats. In Kibera, Nairobi, 190 shared facilities serve a population of
250,000 (1:1300 users).13 In Nairobi slums women have reportedly been raped en route to
Health problems found included intestinal problems, measles, fever, skin diseases, chronic respiratory
infections.
9
the communal latrine.14 Researchers have found that mothers sometime worry that children
will catch diseases from adult faeces on toilet slabs and fear that small children will fall into
poorly designed toilets.15 These aforementioned factors discourage use and open defecation
is still prevalent in communities where communal latrines are provided.
Community processes to build and operate the bio-centres were found to promote
democracy and inclusiveness through the engagement of already-established community
groups that select sites of the bio-centres and manage services. The community groups
directly profit through a community-shareholding scheme in which 60% of the fees are
allocated to members as dividends; 30% pays for the O&M of the facility; and 10% is
deposited in a sanitation development fund.17 The technology of the bio-centres is equally
important as communities do not have to spend money to empty pits/septic tanks as the
toilets are connected to a bio-digester in which biogas is produced. Collectively the bio-
centres service about 12,000 users per day.
Another example of a good practice is the Greater Mumbai Slum Sanitation Programme
(SSP), which focuses on building strategic partnerships for the successful community
management of communal latrines.18 Under the SSP, NGOs lead a community-wide
consultative process, which results in the formation and registration of CBOs in sanitation-
stressed areas. Families must express demand through the contribution of a small
membership fee.** CBO members provide assistance and oversight of the latrine
construction throughout the building process. The integrated contracts feature of the SSP
formally links all actors in the provision of communal latrines in the slums. Unifying the
fragmenting service delivery of communal latrine provision in the slums, generating demand
10
for sanitation at the household level, and introducing mechanisms for the accountability and
regulation of the structures, provides the necessary conditions for the management of
communal latrines in the slums.19
11
COMMUNITY VILLAGE POP BUILT HOURS MANAGEMENT ACTIVITIES
Logan Town Zinc Kamp 2,362 2010 24 hours WASH HH survey
(pay-per-use) Committee Transect walk
Kinc Kamp 2,871 6.00-22.00 WASH Individual/group
(Shared) Committee interview
Latrine
observation
Freeport New Kru 3,783 2009 LOCKED WASH HH survey
Town Committee Transect walk
(Beach) Individual
New Kru LOCKED WASH interview
Town Committee
Bushrod Billimah I 3,520 2010 6.00-22.00 WASH HH survey pilot
Island Committee Latrine
Billimah II 6.00-22.00 WASH observation
Committee
12
(LD $5) by the sum of fees collected at the Zinc Kamp pay-per-use facility. On 7 July, the
day of the household survey, 20 users paid to use the Zinc Kamp facility. The monthly toilet
at Zinc Kamp has an average of 18 rooms (mean household size of 7.8), which means an
average of 140 have access to the pay-monthly facility. No information on the gender and
age of users was ascertainable from these data, and all rooms and users reportedly paid the
same established fees. No user count for New Kru Town was possible because the facilities
have been locked for nearly five months in a community political spat.
LD $5 equals US $0.07.
13
The enumerators were trained on 4-5 July and the survey was piloted in Billimah on 6 July.
Systematic data cleaning took place on 9 -10 July to eliminate errors that took place during
collection or data entry. [See Appendix 11.2]
On 6 July a transect walk took place with the Zinc Kamp chairman. The walk started at the
pay-monthly facility and ended at the front of the settlement. He pointed out areas where
households were squatting on unpaved government roads and explained how this
prevented any potential sanitation upgrades for large portions of the community because no
tankers could access pits or septic tanks for emptying. The poorest households lived in this
14
area. He also pointed out the section where many people owned homes, and stated that
although some homeowners could afford to build household toilets, the tradition was often
that people built the house first and thought about the toilet later. He also pointed out
abandoned latrines and non-functioning tap stands due to poor design and people stealing
the metal taps to pawn for money. He cited access to water and sanitation as one of the
biggest issues in the community.
5.3 Sampling
15
arrange the meeting with the women of the association.
6.1 Introduction
Liberia is a West African country on the North Atlantic coast of Africa. It is bordered by
Guinea to the north, Cte d'Ivoire to the east, Sierra Leone to the northwest, and the Atlantic
Ocean to the south and southwest. The population is estimated at 3.6 million, about 48% of
which are urban inhabitants. Liberia was entrenched in two brutal civil wars over a 14-year
period from 1989 to 2003 (1989-1996 and 1999-2003). The conflict destroyed the nations
infrastructure, institutions and systems of governance; uprooted families and killed an
estimated 250,000 Liberians. A direct result of the war is high levels of poverty in the
country, with at least twothirds of the population surviving on less than US $1 per day.
About 99% of Liberians lack electricity and running water and access to sanitation is
severely limited.
16
is to reduce the water and sanitation-related disease burden through scaling up hygiene
promotion in communities and schools, and increasing access to clean water from 25% to
50% and increasing access to sanitation from 15% to 40% by 2011.
Figure 3 Sanitation coverage (%) in Liberia. Based on WHO/UNICEF JMP Statistics (2010)
Institutional arrangements
The roles and responsibilities for WASH are fragmented across three ministries and there is
no mechanism to lead or coordinate the overall strategy. As written, the Ministry of Land,
Mines and Energy (MLME) is in charge of water resources; the Ministry of Health and Social
Welfare (MoHSW) is responsible for water quality; the Ministry of Public Works (MPW)
provides water and sanitation to rural areas; the Liberia Water and Sewerage Company
(LWSC) is provides water and sanitation to populations over 5,000 urban areas (although
17
mandated for urban and rural). Donors and multi-lateral organisations have assumed a
budget support model where monies are contributed through one of several
reconstruction funds. INGOs have provided support and direction with the
implementation and scaling up WASH activities. It is not clear, however, from the
institutional arrangements exactly who has the responsibility for the oversight and regulation
of communal sanitation in urban areas.
18
75,000 people share 11 public toilets; and in West Point, Monrovia an estimated 70,000
people share four public toilets.27 Therefore, while communal sanitation is provided in slums,
access remains limited, and a high number of people are forced to defecate into plastic bags
and dispose of them as flying toilets or resort to open defecation.
With sanitation conditions such as these, diarrhoeal diseases are a major health concern in
Monrovia and in 2008 the WHO reported that 18% of all deaths in Liberia are WASH-
related.28 Cholera is endemic in Montserrado, Grand Basa, Grand Gedeh and Maryland
counties. Data from MoHSW reports 888 cumulative (suspected) cholera cases from 31 Dec
2008 to 18 Oct 2009. In River Cess County (2009) there were two reported cholera deaths.
The highest attack ratesor number of cases/populationoriginated in Bushrod Island
(0.02%), Sinkor (0.07%), Central Monrovia (0.10%) and West Point (0.21%). At least 47% of
randomly collected specimen (n=79) tested positive for vibrio cholera serogroup 01 in the
lab.29
7. Results
***
When there is a suspected cholera case, the General Community Health Volunteer (GHCV) reports the case to the
Environmental Health Team (EHT). The EHT then submits the report to the County Health Team (CHT), which is responsible
for making the final report to the MoH. Cholera reports are also sent to the MoH when a person receives treatment at a
government clinic.
19
Pay-per-use facility
There are 2,362 people in the pay-per-use catchment area. For the month of July, the mean
number of paying users per day is 15, with a minimum of 11 users and a maximum of 26.
The mean number of users represents 6% of the target population. Calculations of users
from 6 February 2011 to 10 July 2011 found that the mean number of users per month is
353. This means that on average, only 15% of the target population is using the latrines per
month.
Pay-monthly facility
There are 2,871 people in the pay-monthly catchment area, and there are 18 rooms paying
each month to use the facility. Assuming that the average household size is 7.8, as reported
in the household survey, the pay-monthly facility serves an average of 140 users per month.
This represents about 3.2% of the target population.
20
Table 2: Operating characteristics of facilities
Of the total cubicles observable: 13% had faeces on the floor; 44% had faeces on the toilet
seat/slab; 25% had faeces on the wall; 25% had a foul smell; 75% had cobwebs; and 33%
were locked from the outside and there was no caretaker around with a key. The pay
monthly facility was cleaner than the pay-per-use facility at Zinc Kamp. All of the facilities in
Bilimah were pay-per-use and there no marked difference between the cleanliness of either
toilet block.
21
Table 4: Ages and occupations of communal latrine users
22
7.5 Household resources
Households in the communities do not have a large resource base to draw from in terms of
assets or infrastructure. The average household does not own a refrigerator/icebox. Only
23% reported owning a generator and 22% reported owning a TV. The most common asset
that households owned was a mobile phone (62%). A woman heads the average household
and the main occupation for female-heads of households is homemaker and does not earn
an income. Families are large, on average about 7.8 household members, with only 65% of
head of households involved in income generating activities. Remittances account for some
of the resource base as 11% of respondents reported remittances as a form of support.
There was no association between household resources and reported communal latrine use.
While self-reported data show that communal latrines significantly affect open defecation in
Zinc Kamp, group interviews confirmed that promiscuous defecation is a big problem,
particularly at night. In the morning you walk outside and you see faeces all over the place.
You dont know who did it. You cant find the person, Ms. Jones exclaimed! Ms. Ellis
nodded in agreement. Its bad. If you see someone you tell them, this place is not for
you!35
23
Table 7: Frequency of communal latrine use
Group discussions with women from the Logan Town Womens Development Association
revealed that WASH Committee members found that it was socially acceptable for children
to defecate in the open and that the cost to use the latrine was prohibited when it had to be
paid for multiple times for multiple children. Some of us have five or six children and we
dont have money to pay $5, $5, $5, $5 at the end of the day its [LD] $35. We need that
money to feed our children Ms. Jones said. Another woman added, The children are
supposed to go to the toilet but the money is too much, so they go in a small bucket but
sometimes outside near the house. Questions on what happens to the childrens faeces in
the bucket were met with different answers. One woman said that mothers dig a hole and
cover it, but Ms. Morrison shook her head and said, We just let the children see to it.
Sometimes they throw it in a ditch.36 Findings suggest that cost and social acceptance of
children defecating in the open made it less likely for mothers to insist that children use the
communal latrines.
24
price was LD $5 for 2 uses. Many of the public toilets in Monrovia charge "LD $5 for three
uses" and this recommendation is in line with the status quo. There was no separate fee
structure for children and the poorest community members.
Facility Fee
Zinc Kamp (pay-per-use) LD $5 per use
Zinc Kamp (monthly) LD $100 per month/per room
New Kru Town (I and II) LD $5 per use (closed)
Zinc Kamp & New Kru About right Too high Too low Dont use Dont know
Town
Users (n=51) 14 (18) 20 (25) 1 (1) 28 (35) 16 (20)
CI: 9,26 CI: 16,35 CI: -1,4 CI: 25,46 CI: 11,29
7.9 Sanitation access and plans for future use of communal latrines
The primary reasons for not having a household latrine were cost, 43% (CI: 32, 54), and
space 25% (CI: 16, 35). Plans for future use is high amongst the majority of respondents
57% (CI: 46, 69) with some variations between the two communities. Data reveal that more
users at Zinc Kamp do not expect to use the communal latrines compared to New Kru Town
residents. The difference could be attributable to access to sanitation, for example, New Kru
Town have no access whereas Zinc Kamp residents have some access and have expressed
dissatisfaction with cleanliness, cost and opening hours. More Zinc Kamp respondents plan
to build a latrine in the near future while no respondents in New Kru Town reported any such
plans.
Qualitative research revealed that aside from cost, land disputes prohibited latrine
construction. The majority (88%) of respondents in New Kru Town are from the Kru tribe,
and second to cost, lack of space, 38% (CI: 20, 50) was the second most common barrier to
latrine ownership. Transect walks through the community revealed physical space on the
plots; key informants revealed that lack of space referred to disagreements with
neighbours/kin on the location of septic tanks and to avoid disputes with ones neighbours/kin
many people would rather go without a toilet as this is traditionally how houses are built.
People build a house first, then they think about the toilet and at that time, it is too late,
there is no space.37
25
Table 10: Percentage of users who expect to use the latrines in the future
Table 11: Percentage of users who plan to build a latrine in a years time
There were some differences in satisfaction according to gender. Women reported being
very satisfied 71% (CI: 51, 92) compared to 50%(CI: 25,75) of male respondents. Group
discussions with women found that they felt insecure when they had to defecate in the open
and that men sometimes stood and looked. Women said they preferred to use the communal
latrine or ask a neighbours toilet because open defecation is risky. You can be harmed at
any time, one woman said.38
8. Discussion
26
primarily for defecation. Transect walks in Zinc Kamp and New Kru Town communities
revealed a higher level of faecal pollution in New Kru Town community, which has no
communal sanitation access at all. This observation provided further proof that communal
latrines do lead to less open defecation in the community but the manner and scale of
communal latrine provision does not stop open defecation.
At least 53 respondents reported that a child under five-years old (U5) lived in the
household. Most of the U5s defecated in a plastic bucket or outside. The fee structure and
the social acceptance of child open defecation influenced the decisions of mothers to allow
children to practice open defecation. Some mothers interviewed associated the childrens
runny stomach (diarrhoea) with poor sanitation, and at least 26% (CI: 14, 39) of the
respondents reported that an U5 in the household had experienced runny stomach within
the past seven days. A limitation of this association is that this study relied on self-reports of
diarrhoea prevalence and did not adjust for other factors. However, positive associations
between diarrhoea in children and unhygienic child defecation and faeces disposal practices
have been reported in 15 rigorous studies.39 These findings raise serious doubts on
communal latrine provision as an adequate response to cholera if the peri-domestic domain
is polluted with fecal matter that exposes and re-infects household members.
Concern Liberia does not have a child-friendly toilet design and the WASH Committee has
established a standard fee for all users. Children must often rely on adults to accompany
them to the latrines and pay the user fees. As a result, they are often left no choice but to
defecate in the open. This has adverse affects on their health, and organisations that provide
communal latrines should take steps to ensure target communities do not neglect the
sanitation needs of its most vulnerable members. Inclusiveness can be encouraged though a
progressive price structure and child-friendly designs that make it easy for mothers to bring
their children to use the communal latrines.
27
The MDGs do not specify or conceptualise what is meant by sustainable sanitation, but
most definitions encompass technical, financial, environmental and social aspects. The
EcoSanRes criteria for sustainable sanitation reads: protecting and promoting human health;
not contributing to environmental degradation; and being technically and institutionally
appropriate, economically viable and socially acceptable.41 The sustainability criteria applied
to the communal latrines built by Concern Liberia encompasses the environmental, financial,
technical and community aspects of the EcoSanRes criteria.
Technical
Concern-built communal latrines are pour-flush toilets attached to septic tanks. The design
was chosen because many of the slums are located on sand and have high water tables.
The technology choice affects management if the community is unable to effectively respond
to problems on its own, with limited external assistance. The WASH committee members of
Zinc Kamp and New Kru Town have reported the incidence of tank overflow and discharge
of raw sewage into the environment (particularly during the rainy season). Users responded
by not using the latrines and complaining about the cleanliness of the toilets. It was also
reported that digging shallow wells and fetching water to flush the toilet was burdensome,
and this also had some influence on people using the communal latrines.
The topography of Liberia and the slum context make septic tanks an appropriate and a
problematic choice. With user fees as the only money available for the O&M of the latrines, it
can be difficult to raise enough money to empty the tanks, said Morris Sherman,
Construction Engineer for Concern Liberia.42 Emptying the tanks cost from USD$100 to US
$150, depending on the size of the community and tank. The communities tell us that the
cost is too much, Mr. Sherman said. The LWSC (LWSC) is responsible for emptying the
tanks, although the United Nations Mission in Liberia (UNMIL) has assisted communities on
request at a charge of US $75. Large tanks require about three trips (US $100 per trip),
which is expensive for low-income communities to afford. The technical aspect of the
communal latrines has made it difficult for the target population to manage the provision of
communal latrines, as the complete sanitation cycle has not been well considered from the
birth of the project.
Financial
If the money raised from user fees is not enough to operate and maintain the toilets, the
tanks become full, the toilets smell and people will avoid using the facility. In the Monrovia
28
example, user fees are the only source of revenue for the O&M of the toilets. Community
sources report that the user fees will not cover the cost of de-sludging the tanks at the time
that they need servicing. Alternative financing mechanisms must be explored as 25% (CI:
16,35) of users said that the current fee is too high. Therefore, increasing the fee to meet
O&M costs could have an adverse affect on use. As the new Liberia WSSP emphasises pro-
poor policies, Concern Liberia could advocate with the LWSC to empty septic tanks in the
slums at a reduced rate. This could be an entry point for strategic partnerships with the local
government. The Umande Trust and the Greater Mumbai SSP have demonstrated ways to
achieve full cost-recovery without charging burdensome user fees. This model should be
explored for its transferability to the Monrovia context.
Community
When Concern Liberia builds a communal toilet it hands the facility over to the community for
use and upkeep. Community members serve on the WASH Committee, which comprises 10
members including: two Community Health Volunteers, community water pump mechanic, a
sanitation representative, and community leaders with influence. Concern Liberia
coordinates the capacity building and training of the committee through inviting partners to
give workshops on different aspects of O&M. Key informants revealed that motivation is of
Committee members is sometime low, and the lack of tangible incentives mean that
participation can be unsatisfactory.
The WASH Committee is solely responsible for the management of the latrines and
communal latrine provision has suffered in both communities because of management-
related issues. A dispute over the handling of funds led to the locking of the communal
latrines in New Kru Town for nearly five months. Self-reported defecation is quite high 92%
(CI: 84,100) and transect walks revealed a high prevalence of faecal contamination in the
environment, and an open defecation site that was only 100 metres away from the
beachside communal latrine. The WASH Committee chairman said that he would soon
schedule talks with the local authority about re-opening the latrines.
29
Figure 5: New Kru Town communal toilets that has been locked nearly five months in community dispute.
In Zinc Kamp the toilet block near the rear of the settlement was locked nearly four months
from the time it was built, because the WASH Committee couldnt find anyone to take the
role of caretaker. The WASH Committee wanted to base the caretaker salary as a
percentage of the user fees collected, but couldnt predict how much the facility would collect
without previous intake. Without a caretaker, there was no way to collect money and de-
sludge the toilet that would certainly fill with use. The toilets remained locked until the
Committee set up a monthly card allotted by the room.
The fee is LD $100 per room, and 18 rooms are currently paying for the monthly card that
gives them 24-hour key access. This has increased ownership of the facilities, but it has also
prohibited community members who do not participate in the scheme from using the now
semi-private toilets. Comparisons were made of the cleanliness of the pay-per-use toilet and
the pay-monthly toilet. The latter was cleaner the former and informal talks with users found
that they had a sense of ownership of the toilets.
In both cases the management issues were not reported to Concern Liberia, even though
directives are given to the Committees on when and how to report issues with the
management of the latrines. Key informants report that the reporting system is inadequate
because many people in the communities are related to one another and it becomes difficult
to make complaints. As this is a post-conflict setting with a relatively weak government,
30
people have also experienced making complaints to the local authorities with no results. It is
reported that many community members view making complaints as a waste of time.
Concern Liberias informal reporting/monitoring mechanism has therefore not been
responsive to realities in the community. Concern Liberia is piloting a Complaints Response
Mechanism (CRM) in target communities, which will provide participant populations with
ways to communicate problems with Concern Liberia and partners. This should assist with
the monitoring and support of community-managed communal latrines.
Environmental
The current design of Concern Liberia communal latrines is not environmentally sustainable
as emptying the septic tanks means that raw sewage must be emptied into the environment,
because the sewer network does not function properly. Although expansion of the sewerage
network is not the mandate of Concern Liberia, choosing sanitation technologies that do not
further degrade the environment is the responsibility of the organisation. Other technologies
such as composting toilets, for example, a double-vault VIP latrine (built up in case of high
water tables), or an Arborloo toilet.
Given the above findings and studies highlighted in the literature search, it would seem
sensible to conduct a qualitative study on the sanitation knowledge, attitudes and practices
of the target population to better inform the INGO response to sanitation provision in the
slums. This study was not able to assess the financial sustainability of the latrines but it
would be appropriate to thoroughly investigate the Umande Trust (Nairobi) and Greater
Mumbai Slum Sanitation Project for transferability to the Monrovia context.
All diarrhoea cases and sanitation behaviour relied on self-reports and were subject to
courtesy bias. The enumerators were not blinded to the research question and triangulation
revealed variations between the responses in the household survey and individual/group
31
interviews. Logistical restraints prevented the focus-group discussions with users and non-
users from taking place. This wouldve provided more in-depth analysis of user satisfaction
and insights into the management of the latrines.
Published information on WASH in Liberia is limited, as many of the ministries do not have
Internet access and the country. While the literature search was done in a systematic way, I
did not do a systematic review of communal sanitation provision in Africa slums. This would
have yielded mixed results as many African countries face the same limitations to
information provision as the ministries in Liberia.
Some information and methods included in the protocol were not included in the study. The
exit surveys were not included because transport to the survey sites was delayed and teams
arrived after the peak time to conduct interviews. This limited the ability to assess user
satisfaction and the extent that the latrines provide for the daily sanitation needs of the target
population. An examination of other-low cost technologies was excluded because it would
have made the focus of the study too broad.
9. Conclusions
The findings from this report are based on a small sample in the capital city of Liberia. More
research is needed to determine whether the findings are generalisable to other settings.
While some people in the target population are using the communal latrines, the manner and
scale that facilities have been provided is not sufficient to stop open defecation. There were
disparities in access within and across intervention communities, with children most often
excluded.
The health implications of the communal latrines inability to stop open defecation and
decrease cholera have severe consequences for child survival. Children in slums tend to
have poorer nutritional status and overall health and are highly susceptible to diarrhoea,
which kills nearly 1.5 million children U5 each year.43 Childrens faeces also have a higher
prevalence and intensity of intestinal worms and both stages of the transmission cycle (the
excretion of worm eggs, and the infection of the next host44 frequently occur when children
stools lie on the ground, particularly in the yard. Communal latrine provision as a response to
cholera will not prevent the endemic presence of the bacteria because a majority of the
population does not use the facilities and hand-washing basins with soap are unavailable.45
32
The level of communal latrine use and sustainability are inextricably linked. The findings
suggest that the community-management of communal latrines in Monrovian slums is not
sustainable under the current model. User fees have been barely enough to operate the
structures and alternative financing mechanisms have not been identified. Furthermore, the
absence of the caretakers during operational hours implies that not all users are paying the
fee. The capacity of the various WASH Committees is disparate and Concern Liberia has not
found a way to address the dearth of knowledge and skills in the community.
Sustainability also requires the engagement and participation of all stakeholders. The lock-
down of two communal latrines in New Kru Town is proof that not all actors have been
mobilised to value the importance of sanitation in the health and human rights of the
community and the WASH Committees do not have enough power to assert these rights.
While the technical design is responsive to the soil conditions, the septic tanks are not
environmentally friendly because the waste is being dumped untreated into the sea. While
water is abundant in Liberia, the absence of nearby water sources has proven burdensome
to those who must walk distances to fetch water to flush the toilet.
10. Recommendations
Findings from the study were presented to the Liberia WASH Consortium and stakeholders
at Oxfam GB Liberia on 29 July 2011 in Monrovia, Liberia. The recommendations are aimed
at Concern Liberia and Consortium partners.
Ensure that all communal latrines are built with hand-washing facilities with soap.
Advocate with municipalities for a reduced rate to empty septic tanks in slum
communities.
Create a demand for sanitation through well-planned hygiene promotion activities in slum
communities as part of the Concern Liberia WASH programme.
Explore low-cost ecological sanitation options composting toilets such as double-vault
33
VIP latrine (built up in case of high water tables) and/or Arborloo toilets.
Educate and build the capacity of WASH Committees through standardised trainings to
ensure a basic level of skills. Curricula should include trainings (and refresher trainings)
on handling complaints, responding to feedback, O&M requirements and bookkeeping.
Promote gender equity on the WASH Committees.
34
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