WSP sought to create and demonstrate a viable sanitation approach that could be implemented at scale. Such an approach had to have the following features: (1) it had to be effective in eliminating open defecation and increasing sanitation access and (2) it had to be sustainable and implemented in a way that fostered its replication at scale even after the TSSM program ended.
To create an effective approach, WSP began by considering optimal strategies for reducing diarrhea. Diarrhea is the second-leading cause of death among children younger than 5 globally; nearly one in five child deaths, about 1.5 million each year globally, is due to diarrhea (WHO/UNICEF 2009). Diarrhea is caused in large part through the spread of pathogens found in human excreta of infected individuals. These pathogens can be transmitted to others through the fecal-oral transmission route that describes the principal pathways for the spread of infectious diarrheal diseases shown in Figure I.1 (Hunt 2006). This cycle is fuelled by the ―five Fs‖: fluids (drinking contaminated water); fingers (unwashed hands preparing food or going into the mouth);
flies (spreading disease from feces to food and water or directly to people, particularly problematic where open defecation is the norm); fields (the contamination of soil and crops with human fecal matter); and food (eating contaminated food). WSP designed TSSM to block these pathways, focusing initially on increasing access to safe sanitation facilities for households, thereby preventing the spread of disease through flies, contamination of drinking water, and contamination of soil as represented by the first set of barriers in blue in Figure I.1 (WSP 2006).
WSP recognized that individual household progress would not be sufficient for reducing diarrheal diseases and adopted a collective approach. It was important for an entire community to be ODF for individuals to avoid contact with fecal matter. Otherwise, households not defecating in the open would still be exposed to contamination from other households in the community that did
Figure I.1. The F Diagram and the Fecal Oral Transmission Route
Sources: Hunt (2006) and WSP (2006).
defecate in the open and through contamination of public places and water sources. To ensure that entire communities could make progress toward becoming ODF, the TSSM program design incorporated two elements: (1) it promoted collective action for improved sanitation behavior and set collective outcomes as its target; and (2) it recommended an incremental approach to improvement in sanitation behavior to ensure that all households, irrespective of their wealth, could take some action to eliminate open defecation, thereby sustaining broad-based engagement in the program. The sanitation ladder shown in Figure I.2 indicates the stages of household sanitation behavior change.
Figure I.2. Sanitation Ladder
Sources: TSSM Jakarta presentation 2010; TSSM Manual, pp. 16 19.
Tot al Sanit at ion Im proved Sanit at ion
Achieve ODF St at us Open Defecat ion
Sanit at ion Clean Wat er Supply Hygiene
Fields/
Floor s Flies Finger s
Feces
Fluids
Food New
Host
Rather than prescribing a particular type of latrine, the program encouraged local innovation and choice to ensure that communities found ways of getting on the sanitation ladder. The TSSM program to promote collective progress up the sanitation ladder consisted of three elements:
4. Stimulating sanitation demand among households and communities by working closely with local government and community stakeholders to raise sanitation awareness and promote hygiene. The program did this in two ways: (1) by holding ―triggering‖
events and related follow-up activities for households in target areas using CLTS techniques (such as making households aware of the dangers of open defecation and invoking shame) to generate collective commitment for ODF attainment;1 and (2) by using behavior change communication (BCC), developed as part of sanitation marketing, to raise awareness of affordable latrines options and the dangers of open defecation.
5. Increasing the supply of sanitation products and services by (1) working with and supporting manufacturers and providers of sanitation products and services to create and provide affordable, context-appropriate sanitation options and train suppliers in their provision; and (2) using sanitation marketing promotion materials to market these low-cost options to households.
6. Creating a strong enabling environment by collaborating closely with and supporting national-, district-, and local-level political leaders to create policy, institutional, and financial frameworks to facilitate implementation at scale.
WSP planned on implementing this three-pronged TSSM program at scale. In Indonesia, it created a TSSM implementation team with which it worked closely to implement the program in all districts of East Java.2 Within each district, the TSSM team would demonstrate implementation of the program in 30 hamlets. Districts would then be responsible for scaling up the program.
To foster sustainability and scalability, WSP decided to implement the program directly in collaboration with districts. The TSSM team would solicit district demand for participation and require districts to provide funds to co-invest in program delivery. It would assign districts to one of three phases based on the order in which districts expressed interest to participate and demonstrated availability of funds to implement the program. The TSSM team would implement the program in 30 communities in each district, providing districts with a ―limited window of opportunity to learn‖
how to implement this integrated approach to sanitation promotion (WSP 2009).
The TSSM team assumed that the three elements of the TSSM program—strengthening demand, increasing supply, and improving the enabling environment—would work in conjunction to eliminate open defecation. In Figure I.3, we map TSSM assumptions on how the program would result in scaled-up improvements in access to sanitation, ultimately leading to
1 Triggering is a process that was pioneered by Dr. Kamal Kar of India, and first implemented in Bangladesh, to mobilize communities to eliminate open defecation completely. The approach entails using a facilitated process to trigger self-realization of community members that they need to change their own behavior. The triggering process is described in greater detail in Chapter IV.
2 For simplicity, we often use the term ―TSSM team‖ or ―TSSM‖ in this report when referring to actions taken by either the core TSSM team or jointly with WSP staff.
Figure I.3. TSSM Program Logic
TSSM t arget ed hamlet s become and st ay ODF
Program get s scaled up as ot her hamlet s, villages, subdist rict s, dist rict s, and provinces get impressed by ODF hamlet s and adopt TSSM, init ially wit h TSSM Tr igger desir e to eliminate open defecation by r aising collective awar eness of sanitation behavior and r isks
Sanitation Marketing: Dem and Use behavior change communication based on mar ket r esearch to increase knowledge of sanitation and of Reducing open defecation and increasing access to hygienic sanitation in target areas
Imp roved
reduced incidence of diarrhea and health improvements.3 The program logic underlying the TSSM approach is shown in the top half of Figure I.3. The assumption was that CLTS and sanitation marketing, conducted in a strengthened enabling environment, would decrease open defecation and increase sanitation access, and in the longer term lead to ownership of improved latrines. Making households aware of the nature and consequences of open defecation through CLTS techniques would result in collective action to improve sanitation behavior. BCC from the sanitation marketing component would increase progress toward ODF attainment and encourage maintenance of ODF status when it was achieved. As communities became ODF, sanitation marketing would increase demand for better sanitation products and training of sanitation marketing suppliers would increase supply. This would result in increased access and use of improved sanitation products, enabling households to move up the sanitation ladder.
The lower half of Figure I.3 shows how scale-up would occur. The first step would be to demonstrate effectiveness by successfully implementing the program in a target set of hamlets.
Scale-up would occur as this success created demand for replication of the approach in other areas.
TSSM’s efforts to strengthen capacity for program implementation among local government officials would facilitate expansion to these areas.
The TSSM team requested districts at the outset of the program to commit funds for TSSM implementation and scale-up. They also provided technical assistance to local government officials for a certain period. TSSM based its program targets for scale-up on the assumption that TSSM-targeted hamlets would become ODF and that districts would scale up the program, making additional hamlets ODF. In East Java, the target was that 1.4 million people would become ODF in the course of program implementation (WSP 2006). Successful outcomes in target areas coupled with efforts to build capacity and strengthen the enabling environment would result in the approach being scaled up even after the TSSM program ceased to operate until full coverage was achieved.