er and Sanitation r,sion Paper Series i-ral Sanitation In ri m iin Pilot Project to National Program /9 .. - Aid~ t - -- *-;9* ~;,1 ,'~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~' ~' ~+: 7s - -C-t RURAL SANITATION IN LESOTHO From Pilot Project to National Program A Joint Publication of the UNDP-World Bank Water and Sanitation Program and PROWWESS U UNDP-World Bank Water and Sanitation Program The UNDP-World Bank Water and Sanitation Program was organized as a joint endeavor of the United Nations Development Programme and the World Bank and has been one of the primary players in worldwide efforts to meet the challenge of the International Drinking Water Supply and Sanitation Decade. The goal of the UNDP-World Bank Water and Sanitation Program is to bring basic water supply and sanitation services to those most in need in the developing world. Partners in this venture are the developing countries themselves and the multilateral and bilateral agencies that fund the Program's activities. The UNDP-World Bank Water and Sanitation Program publishes its own publications and also releases works under the auspices of the World Bank. The Program's publications are divided into two series, a Water and Sanitation Program Report Series and a Water and Sanitation Discussion Paper Series. The Program Report Series presents formal discussions of the Program's operations and research activities as well as examinations of relevant projects and trends within the water and sanitation sector. Program Reports are subject to rigorous external review by independent authorities from appropriate fields. The Discussion Paper Series is a less formal means of communicating timely and topical observations, findings, and opinions conceming Program activities and sector issues. PROWWESS PROWWESS stands for "Promotion of the Role of Women in Water and Environmental Sanitation Services." PROWWESS is a program of the Division of Global and Interregional Programs of the United Nations Development Programme (UNDP). PROWWESS works interregionally in support of the International Drinking Water Supply and Sanitation Decade, focusing on women, in the context of their communities, as the main collectors and users of water and as the guardians of household hygiene and family health. PROWWESS is rommitted to involving women in wider community planning, operation, maintenance, and evaluation of drinking water and waste disposal schemes. RURAL SANITATION IN LESOTHO From Pilot Project to National Program '01990 The International Bank for Reconstruction and DevelopmenttThe World Bank 1818 H Street, N.W. Washington, D.C. 20433 U.S.A. Photo credits: Cover. Mary McNcil Page 7: Richard Pollard Page 15: Richard Pollard Page 17: Mary McNeil Page 19: Deepa Narayan-Parker Page 21: Richard Pollard Page 24: Curt Carnemark All rights reserved Manufactured in the United States of America This discussion paper is based on texts by Philip Evans, Richard Pollard, and Deepa Narayan-Parker, with contributions by Robert Boydell, Michael Kerwin, and Mary McNeil. This document has been prepared and published by the UNDP-World Bank Water and Sanitation Program, Water and Sanitation Division, Infrastructure and Urban Development Department, the World Bank. Copies may be obtained from the Water and Sanitatiou Division. Material may be quoted with proper attribution. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors and s,.quld not be attributed in any manner to the UNDP-World Bank Water and Sanitation Program, the United Nations Development Programme, the World Bank, or any affiliated organizations. Any maps that accompany the text have been prepared solely for the convenience of the readers; the designations and presentation of material in them do not imply the expression of any opinion whatsoever on the part of the UNDP-World Bank Water and Sanitation Program, the United Nations Development Programme, the World Bank, or any affiliated organizations. vii ABSTRACT This discussion paper examines the evolution of Lesotho's National Rural Sanitation Program (NRSP). The NRSP began in 1983 as a single-district pilot project and has gradually been expanded into a nationwide improvement program. The emphasis of this documcnt is on the sequential development of the program and on the sociocultural and educational aspects of the program that have been critical to its overall success. The text is based on manuscripts from members of the UNDP-World Bank Water and Sanitation Program and the UNDP-PROWWESS program who have aided in the formulation and the expansion of the NRSP. Lesotho's NRSP is particularly interesting in that it has successfully integrated the private sector into its implementation strategy, with government playing largely an organizational and facilitative role. The NRSP has also achieved a significant degree of user cost recovery, with beneficiaries paying for construction costs of improved pit latrines, including materials and builders' wages. This level of user cost recovery has been made possible by high user demand, which has been elevated through village-level health and hygiene education campaigns. User interest and understanding of improved sanitation has been heightened through attention to community involvement and organization, which has improved not only coverage rates, but long-term sustainability as well. This history of Lesotho's NRSP is intended to serve as an example of a well-planned and creatively implemented sanitation program. While the course taken by the NRSP is by no means the only viable approach to sector development, its history is informative and instructive. The lessons learned are summarized in the final chapter of this discussion paper. ix TABLE OF CONTENTS I. INTRODUCTION .............. ........................................ 1 II. THE RURAL SANITATION SECTOR IN LESOTHO AND THE DEVELOPMENT OF THE NATIONAL RURAL SANITATION PROGRAM ................... 3 III. THE KEYS TO PROGRAM SUSTAINABILITY: COMMUNITY INVOLVEMENT, PRIVATE SECTOR PARTICIPATION, AND HEALTH AND HYGIENE EDUCATION . ..................................................... 11 Community Involvement and the Extension of the NRSP ...................... 11 Participation of the Private Sector ......................... 14 Health and Hygiene Education . ......................... 18 [V. SUMMARY: LESSONS LEARNED ................................ 25 I. INTRODUCIION The rural sanitation program in Lesotho offers an excellent opportunity to study the process of sector development, from the implementation of a small-scale pilot project through the establishment of a nationwide improvement program. The rural sanitation pilot project, begun in Lesotho in 1983 with financial assistance from the United Nations Development Programme (UNDP) and the United Nations Children's Fund (UNICEF), laid the groundwork for a large-scale integrated rural sanitation program at the national level by demonstrating the importance of carefully planned, sustainable approaches to development. The pilot project emphasized the need for the involvement of rural communities and the private sector, and the need for sociocultural considerations, including an emphasis on hygiene education and the involvement of women, to be taken into account in project design. Long-term planning and improved collaboration among donors were other important elements of project success. Within a period of ten years, rural sanitation in Lesotho has risen from a neglected sector, devoid of planned improvements, to a model sector, under an integrated national program supported by the national government and a number of external donors. Lesotho's rural sanitation program is of particular interest because of the level of responsibility it places on users to pay for improved on-site sanitation. This emphasis on user cost recovery may prove to be the decisive factor in ensuring acceptance of low-cost sanitation technology (the program utilizes the ventilated improved pit latrine, which has a total cost of US$75-150 per unit) and the long-term sustainability of the rural sanitation program. Sustainability has also been enhanced through the successful transfer of construction and maintenance skills to members of rural communities. Those persons with latrine construction skills are able to market their skills in their communities, and have a direct economic incentive to promote improved sanitation. Tlhe transfer of responsibility for the financing and construction of sanitation facilities to the user community improves the prospects for sustainability and self-reliance from the point of view of government as well. While the major expense of many rural sanitation programs is in latrine construction, in Lesotho very little government or donor money is spent in this area. In the well- established district sanitation programs, a privately supplied and privately financed market for latrines has been created, and latrines would continue to be built even if all government support were to come to a halt. The purchase of a latrine under an unsubsidized program shows that a high priority has been given to sanitation, which suggests that improvements have been made in hygiene attitudes and behaviors. The emphasis on user cost recovery has also been welcomed by donors. With a reasonably well-defined and tested strategy and cost recovery policy in place, the program was more attractive to donors when support was sought for national expansion. Requiring households to meet the full cost of improved latrines, however, has an effect on the rate and style of implementation. The pace of construction will be almost entirely dependent on the financial situation of potential users and the level of priority given to improved on-site sanitation. Because of this, a long time-frame and intense organizational activity is required. Donors need to take a longer-term view in evaluating sanitation programs of this type; success cannot be gauged on simple "number counting," but needs to be based on broader goals such as the development of local capacity. The rural sanitation program's requirement for relatively high levels of user cost recovery also raises the issue of affordability. It is clear that some percentage of the population in rural Lesotho 2 will not be able to afford improved sanitation at current costs. However subsidies have been avoided for two main reasons: first, current rates of construction are high without subsidies being provided; and second, introduction of a subsidy might undermine the self-help philosophy of the program and misallocate resources to those who can afford to pay the full cost of their own latrines. The Lesotho program has tried several strategies to increase affordability without subsidies, including a credit union scheme for financing latrine construction. Success in this area has been mixed and further efforts are needed to enable the program to reach more of the very poor. Relatively high levels of user cost recovery can only be achieved when sanitation demand is high; demand is largely a function of an appreciation of the advantages of improved sanitation, particularly the potential health benefits. In the Lesotho program, extensive interaction with community members was required to convey the advantages of improved sanitation, and to instruct users on the hygiene behavior needed to maximize associated health benefits. Participatory approaches, which involved community members in discussions and activities related to latrines and health, were found early on to be essential in changing attitudes and behaviors, and such approaches were significantly more effective than the usual educational methods (such as distribution of flyers and posters). Increased demand for latrines and reduced incidence of diarrhea among young children were seen where participatory methods were used systematically. Integration of health and hygiene education (or "software" project elements) with construction and technical activities (the "hardware" project elements) often proves to be a serious challenge in sectoral development projects, however, and this was certainly the case in Le-sotho. Within the Lesotho government, this challenge revolved around the need for coordination and cooperation between two separate agencies, the Ministry of the Interior (concerned largely with the project's hardware aspects), and the Ministry of Health (generally responsible for software aspects). While initial attempts at cooperation brought rather discouraging results, over time, the meshing of health and hygiene components with the technical aspects of the rura! sanitation program met with greater success, as a broader, integrated perspective developed. Coordination of sanitation with the water supply sector also became easier over time, as water supply professionals became increasingly aware that sanitation and health education needed to accompany water supply if significant health impacts were to be achieved The Government of Lesotho's commitment to the rural sanitation program is high, with the program currently rated as one of the country's most successful development initiatives. To date, the Lesotho program has been successful in achieving the goal of "sustainable and effective use." As of mid-1989, approximately 900 local latrine builders had been trained and an estimated 12,000 pit latrines had been constructed by the private sector. If the program can broaden this success, maintaining a high level of implementation on a truly self-reliant basis, it will surely be a program that other developing countries can learn from. 3 II. THE RURAL SANITATION SECTOR IN LESOTHO AND THE DEVELOPMENT OF THE NATIONAL RURAL SANITATION PROGRAM Lesotho is a small country with a relatively dispersed, largely rural population. Most of the country is extremely mountainous and has a harsh climate, which limits agricultural productivity (only 13 percent of the land is arable). Partly for this reason, migrant labor in neighboring South Africa is an extremely important source of income in rural areas, with roughly 40 percent of Lesotho's active male labor force employed outside of the country. This means that unlike many other developing countries, the rural economy in Lesotho is largely cash based. Environmental health conditions in Lesotho as a whole are poor, especially in rural areas. Although Lesotho is frce of most major tropical diseases due to its altitude, infant mortality is high, typhoid is endemic, and a high incidence of gastro-intestinal diseases causes much suffering and debilitation. These diseases are caused, in part, by the lack or poor quality of drinking water; inadequate facilities for bathing, washing, and excreta disposal; poor housing; and malnutrition. This situation is compounded by generally low standards of personal and domestic hygiene. Water supply and sanitation services in Lesotho have improved significantly since the nation gained its independence in 1966, but coverage is far from universal. Recent estimates show that only about 20 percent of rural households have sanitation facilities (generally pit latrines, one in four of which is of the improved design). Rural water supply coverage is approximately 35 percent. In urban areas about 40 percent of households have unimproved pit latrines, 9 percent have improved pit latrines, 11 percent have waterborne systems, 20 percent have bucket latrines, and 20 percent have no sanitation facilities whatsoever. For the first ten years of Lesotho's independence, government development efforts in the rural water and sanitation sector focused solely on improving rural water supplies. The only form of improved sanitation provided by the government was the bucket latrine system used in urban government housing. Government promotion of pit latrines began in the 1970s, but there was no technical capacity to assist in implementation. In 1975, an evaluation funded by the United Kingdom Overseas Development Lesotho: Basic Administration (ODA) of Lesotho's water Socioeconomic Indicators supply program laid out the program's shortcomings, and recommended that a broader approch tosectoral development be Population: 1.6 million approach to sectoral development be 19% urban, 81% rural undertaken, which would supplement water Annual growth rate: 2.6% supply activities with improvements in sanitation Density: 53 per square kilometer and hygiene (the study's results were published in Water, Health and Development, by R.G. Infant mortality: Feacham et al., 1978). 100/1,000 live births GNP per capita: US$370 A broader, integrated approach was also recommended by the Technology Advisory Group (TAG), a UNDP-funded, World Bank- executed project aimed at developing low-cost Source: World Bank (1987) 4 technologies to augment the extension of water and sanitation services. TAG began working in Lesotho in the late 1970s, helping to develop an on-site sanitation project for urban areas and a phased rural sanitation project to be integrated with village water supply and primary health care programs. Between 1978 and 1983, more than a dozen TAG missions of varying durations were undertaken. At the same time, in 1978-1979, the United States Agency for International Development (USAID) was helping Lesotho's government to design a major rural water supply project, which initially had no sanitation or health education components. At the request of USAID and the government, TAG assisted in the design of these components for the project, with the understanding that the sanitation component would be implemented through a linked long-term rural sanitation program. As Lesotho's need for coordinated development in water supply, sanitation, and health care became clear, it was also clear that piped sewerage systems would be prohibitively expensive and that sanitation services could not be extended to the country's dispersed rural population unless affordable, on-site technoiDgy was employed. Fortunately, research work done in other countries of the region (particularly Zimbabwe and Botswana) on low-cost, on-site sanitation technologies had led to the development of the ventilated improved pit (VIP) latrine in the 1970s. The VIP latrine had emerged as a superior form of on-site sanitation hardware due to the fact that it circumvented the two major disadvantages of traditionally designed pit latrines--odors and fly infestation--through the inclusion of a screened vent pipe in the design. By the early 1980s, Lesotho was able to turn to the VIP latrine as a tested and proven technology. While many sanitation programs begin with a strong technical bias due to the need to test and select a technology to use, Lesotho could be more immediately concerned with broader software *ssues, such as commun'ty participation and health and hygiene education. Improved and effective low-cost sanitation technology, in the form of the VIP latrine, was first put to use in Lesotho through several urban development and housing projects that were implemented in the capital city of Maseru in the early 1980s. The basic VIP design was adapted for Lesotho, and private sector production of the VIP was encouraged through design improvement workshops. The plans for the improved VIP were also distributed to urban housing contractors. These early efforts were important in establishing the VIP as the preferred pit latrine style in Lesotho. Late in 1983, a TAG-executed pilot rural sanitation project, funded by UNDP, UNICEF, and the Government of Lesotho, was launched through the Ministry of Health. This pilot project was designed as a means of testing and refining methods of service provision that were effective, sustainable, and cost-effective, with a view toward gradual expansion into a large-scale national program. The project employed a decentralized strategy for rural sanitation improvement, based on the principles of self-help and minimal long-term reliance on government funding. The pilot phase was designed to last three years, and was the country's first systematic approach to rural sanitation. The southern district of Mohale's Hoek was selected as the location for the pilot project, as it was representative, both in size and topography, of conditions in the country as a whole. The first year was devoted to team building, technical design and modification, and sociocultural field investigations. In mid-1984, a series of planning workshops were held during which members of rural 5 communities were invited to review a variety of VIP latrine designs and to discuss possible implementation strategies. The VIP latrine was already gaining strong recognition, and thus the main technical problems facing thc rural sanitation project were to modify designs to suit the rural environment and reduce unit costs to an acceptable level. Due to severe budgetary constraints, the Government of Lesotho stipulated that beneficiaries of the project would be required to make a significant contribution to overall costs, through direct payment of latrine construction expenses. Construction of VIP latrines was to be handled by the private sector, with government playing a largely facilitative role through organizing and training. Prospectivc latrine builders were to be recruited from the local population, and would then receive instruction in VIP construction from project technical assistants. These local latrine builders (LLBs) could then offer themselves for hire to householders, at rates agreed between the community and the rural sanitation project; householders were given the responsibility for procuring materials and employing the LLB. It was hoped that this method of execution would allow latrine construction to become integrated into the local economy, creating income opportunities for local artisans and stimulating cash flows. The transfer of construction and technical skills to the communities was The Improved Design cf the VIP Latrine Traditionally designed pit latrines have two main odors flies disadvantages: their interiors smell bad and they attract flies. The VIP latrine is designed to avoid both of these problems through / the use of a vertical screened vent pipe; in other respects the VIP is designed like a traditional pit latrine. screen The VIP's vent pipe is able to control odors because of the suction effect of wind across the top of the pipe and the thermal effect of solar radiation on the pipe's external surface. The effect vent pipe of wind passing across the top of the vent pipe is to create a suction pressure within the pipe, which Jraws air and odors up from the pit below. Solar radiation works to heat up the vent pipe and thus the air inside of it. As this air becomes less dense, it rises, and is replaced by cooler air from below. In this way air circulates from the outside, into the superstructure, through the pit, and up the vent pipe, pulling odors up with it. t . cola U foir currents pit coIIoir Flies are attracted to pit latrines by the odors emanating from them. In VIP latrines flies are attracted -to the top of the vent pipe where odors dissipate, so this is covered with a fly screen and flies are unable to enter the pit and lay their eggs. A few flies PIT will enter the pit through the superstructure and eventually their offspring will emerge from the pit. Since newly emergent flies are phototropic, however, they will fly toward the light at the top of the flies vent pipe (the only light source since the superstructure is kept dark) where the fly screen prevents their egress and in time they fall back into the pit and die. The VIP latrine is highly effective at reducing fly infestation: experimecal data have shown that the IPt contents VIP design lowers the numbers of flies in a latrine by upwards of 99 percent in comparison to traditionally designed pit latrines. 6 essential to the development of self-sufficiency in implementation and to long-term absorption of on- site technology. The contributions of beneficiaries and the involvement of the private sector in construction also allowed the government to devote more of its resources to software issues such as community involvement and health and hygiene education. Coordinating the technical aspects of latrine construction with the need for village level self- sufficiency was not always a straightforward proposition. As an example, four different approaches to the fabrication and distribution of concrete components were tried in succession: central production by the rural sanitation project technical assistants; larger-scale central production by inmates of the district prison; village-level production by commercial concrete block makers; and on- site production by LLBs. On-site production by LLBs turned out to be the most cost-effective method, reducing the logistical problems associated with central production, and keeping costs down by eliminating the profit margin required by local commercial producers. Central production was necessary in the initial stages to maintain quality control, but LLBs proved capable of high standards of work, and component production was progressively handed over to them, with government technical assistants maintaining regular checks on standards. An obvious benefit of this approach was that all stages of production were placed in the hands of local artisans. Field implementation Lesotho of the pilot project began at two sites in t'W.1 , _;tw October 1984. The DiSkid B&IrJaria construction target for rUT-A-BUTHE the pilot phase was modest, requiring that Z J\ LERBE ({ \ only 400 latrines be built during the three-year project cycle. This MOKH\IOTLONG target was surpassed by MASERU 50 percent, with 600 latrines being built by o MASERU \ THABA-TSEKA the end of 1986. Almost two-thirds of the latrines < MAFETENG) \ were built in the final year, underscoring the \ J 2 QACK^tS NEKJ long lead-up time that the project's approach \/ HOEK - required. Roughly 90 percent of the latrines built in 1986 were fully -*jt QUTHING g tI tEsclmO paid for by rural householders, who purchased the required |~w~ -materials and paid builders' fees. 7 Local Latrine Builders: Entrepreneurship Promoting Health in Lesotho Latrine building has been a kind of "saving grace' for Teboho Raleteng, who has constructed 34 latrines in Liphiring, Lesotho. Before he was trained in latrine building, Mr. Raleteng's only source of income was whatever unskilled labor he could find in his rural area, where only 14 percent of the labor force is employed in non-farm work; e drove tractors, fixed fences, and took on odd jobs. He had no steady form of income, and with only one vear of education, he had little chance of nroviding more than a subsistence level of income for himself. __ -. ,In 1984, Mr. Raleteng--functionally illiterate -. < and inexperienced in construction work--attended a - , . @ two-week latrine building course, sponsored by the ;*' -H-.vi ; ,homefrom the mines. His daughter is sufferingfrom diarrhea so the village health worker convinces hin to invest in a latrine. In the photo to the right a health assistan il contacted, who describes the VIP latriie - d' tdenhtfes a local trine builder. .' V t" ~ ~ I kt ' *~ X'AS t * | In the photo on the left, the builder and health assistant discuss v 4 simil how a rIP latrine workss how it is built, how much it costs, and how a .P slar issues. Follow-up evaluation in Mohale's Hoek after presentation of the play revealed increased discussion and awareness of VIP latrines and heightened demand. In one village, several people bought latrine kits immediately after the performance, while others joined an informal credit union. Internal evaluations conducted one year after the play was performed in the Berea district revealed significantly increased latrine sales and construction. The evaluation revealed that of those households that had latrines, 25 percent had built thnem after seeing the play. A majority of this group, 63 percent, claimed that they had been directly influenced by the play to build a latrine. 22 Participatory activities typically ask village residents to take stock of community resources and to identify community problems. These activities are followed by group discussions and presentations, as community members verbally assess sanitary and environmental conditions around their villages. Dialogue and brain-storming sessions follow, focusing on the goals of the community and the means of solving the problems it faces. Participatory training sessions have been found to be highly effective in involving people in problem investigation, analysis, and resolution. The program has also developed an extensive set of educational aids, such as games, slide shows, flip charts, and posters. These materials are being produced and distributed by PROWWESS with assistance from ODA and the Irish government. A participatory training manual and curriculum for workshops for different health cadres has been developed and provides the model for district workshops. Proper hygiene and sanitation practices are perhaps most important and are easily taught to children, so education among students has been an integral component of the rural sailitation program. Efforts have been cxtensive in the rural school systems, with hygiene education becoming a part of overall school sanitation programs. School teachcrs have been trained in interactive techniques as well. Children become highly involved through activities such as community mapping, which provides valuable information to extension workers on the water and sanitation situation in communities and establishes whether or not latrines are being used. Women have also been identified as a specific segment of the rural community to whom hygiene education needs to be targeted. It is estimated that at any given time half of the able-bodied men in Lesotho are away as migrant workers, leaving women with the major responsibility for managing rural economic and social life. De-spite the fact that women hold senior positions within the government, head a majority of households, are more physically present in the villages, and have higher levels of education than men, they have proven to be a difficult group to reach in the health and hygiene education effort. To identify strategies to actively involve women in decision making, and to ensure that the benefits of extension services reach them, a women's liaison adviser position was created within the NRSP with UNDP-PROWWESS assistance. The mandate of the women's liaison adviser was to work closely with the health education officers and monitoring and evaluation officers at the national level. At the district level, the women's liaison adviser worked closely with the district sanitation teams to identify existing women's groups and their modes of functioning, as well as their needs and problems. Participatory approaches have been very successful in raising the level of involvement of women's groups in the rural sanitation program, as the groups have come to take on more of the responsibility for overall community improvement. One women's group has created an informal revolving credit system to build household latrines, while other groups have recently sought advice on how to set up and manage credit systems for undertaking construction of latrines and communal water systems. For the rural sanitation program as a whole, the effectiveness of the participatory education strategy is apparent. Despite a lack of effective follow-up to health education in some areas (mainly due to a lack of health assistants), internal monitoring and evaluation documents consistently report increased demand for latrines after a thorough health education and promotion campaign. 23 Conversely, low demand for latrines is often linked to poorly conducted community health education campaigns. The efficacy of the comprehensive approach of the rural sanitation program in improving health in Lesotho was dramatically illustrated in the findings of a 1988 health impact study performed in Mohale's Hoek. The evaluation was completed with joint funding from the Ministry of Health, UNDP, ODA, and UNICEF. This study was carried out using a case-control design, with data collected from mothers of children under five years of age. Three groups of respondents were examined: those who reported to health clinics with children with diarrhea; those who reported to clinics with diseases unrelated to sanitation, such as respiratory illnesses or traumatic injuries; and a third group of mothers from the community who had not attended local health clinics. A comparison was then made between the groups rcgarding latrine ownership, nutritional status, hygiene behavior, and other factors. Overall, the study found that those children who lived in households with latrines suffered 24 percent less diarrhea than children who lived in homes without a latrine. The importance of Participatory Education and Research with School Children If health-promoting behavior is not adopted by a majority of the people in an environment, changes in health status will be difficult to achieve. Despite the fact that the majority of rural household members are children, they are rarely included in sanitation education programs. Within the NRSP, participatory techniques have been used both to educate children on the benefits of better hygiene and to improve the understanding of extension health workers on the problems of individual communities. The results of a simple community mapping activity with school children from four villages in the Leribe district demonstrate the ease and the utility of reaching school children in a community. The instructions for the mapping activity were simple. Working in groups, fifth grade children were i A asked to draw their communities, including problems, resources, water sources, and places of defecation. The activity unleashed such energy and enthusiasm that the K _ children were moved outdoors. All four groups of _ *, students reported three major community problems: 'h public drunkenness, bad roads, and little use of latrines. The resources identified included people, trees, VIP latrines, shops, water supplies, animals, and forms of transportation. Latrines, bushes, and forests were |4_ commonly depicted as defecation sites. Water sources included unprotected springs, wells, ponds, and standposts. What the children reported in their drawings was confirmed by their school teachers. The mapping activity produced valuable information on the community water and sanitation situation and helped to establish whether or not latrines were being 4 2 used. The next step in the learning process is group discussion and the introduction of hygiene techniques A student's community map showing a number of local needed to avoid sanitation problems. resources, including a VIP latrine 24 integrating hygiene education and water use into the sanitation package was emphasized by the study's finding that when latrine ownership was complemented by hand washing after defecation and use of large quantities of water in the household (for washing, bathing, cooking, etc.), incidence of diarrhea was reduced to an even greater extent--more than 30 percent. Children coming from households with latrines were also found to be more healthy overall and less likely to suffer from malnutrition than those without latrines. The study indicated that the strategy adopted by the NRSP was effective in improving the health of rural children, the most important criterion of project success, and it lent strong support to continuing and expanding the program. The study recommended further strengthening of the health _Jt education component of the program, with special emphasis on improved hand washing practices, use of greater quantities of water, and safer disposal of children's feces. It also advocated increased attention to hygiene education Changes in hygiene behavior, including increased hand washing and use of and promotion in primary health care water, were confirmed as inportant complements to sanitation in inproving programs. health conditions among children. 25 IV. SUMMARY: LESSONS LEARNED The experience of Lesotho's rural sanitation sector demonstrates that successful sector development is a slow process that best begins with a small-scale project that can be gradually expanded to a larger scale. Pilot projects provide a good opportunity to develop and refine project management and implementation strategies. The viability of these approaches can thereby be demonstrated to government and donors, fostering their support and commitment to wider-scale programs. Clear and extensive documentation of pilot projects is an essential element in "selling" project expansion and helps subsequent and related projects to learn from past experiences, both positive and negative. In Lesotho, careful mon.toring and evaluation has been effective in gaining and preserving government support for the NRSP, and has facilitated communication among the village, district, and national levels of the program. The Lesotho experience also illustrates the importance of formulating sectoral improvement plans that work within existing budgetary constraints and administrative structures. Working within the district-based administrative structure of Lesotho's government has allowed program expansion to occur in a logical and systematic manner. Developing the NRSP through the ministries of Health and the Interior has kept government costs down by avoiding the creation of new bureaucracies. It has also required a commitment to cooperation between two government agencies with very different functions, which can be a significant challenge. Lesotho's success in coordinating these agencies has allowed thorough integration of software elements into overall project design, and has led to a gradual change in attitudes among "hardware administrators" toward community involvement and education. The spirit of cooperation has also been reflected in the actions of the external support agencies involved in the NRSP. From the initiation of the rural sanitation pilot project in 1983, technical and capital assistance from UNICEF, UNDP-PROWWESS, and the World Bank has been coordinated to ensure successful implementation of the program. Country-level coordination and cooperation has also occurred between these organizations, the government, and the bilateral agencies involved in the sector in Lesotho (the United Kingdom Overseas Development Agency, the Government of Ireland, the Swiss Development Corporation, the Federal Republic of Germany's KfW, and the United States Agency for International Development), which has enhanced overall compatibility and efficiency, and has improved chances for program success. An outstanding lesson to be drawn from Lesotho's rural sanitation program is that sanitation, water supply, and health care and hygiene are indisputably interrelated sectors. If projects in these sectors are to have significant impacts on overall health conditions, planning must take into account the relative status of each of the sectors and provision must be made for coordinated efforts. In Lesotho, intersectoral coordination has taken place not only at the institutional level, but at the local and the individual levels as well. Great efforts have been made to increase the awareness of rural residents of the advantages of improved sanitation and to alter hygiene practices to maximize health benefits. Changing the attitudes and behaviors of a large percentage of a population is no simple task, and as shown in the Lesotho program, it is contingent upon diligent efforts and effective communication. The use of participatory education methods has allowed district health assistants and village health workers to reach the people, and changes in attitudes toward sanitation and hygiene behavior are certainly apparent in those districts with well-established projects. In Lesotho's NRSP, 26 increased use of water and altered health and hygiene practices have been sold as part of the same package with improved sanitation. Community participation and education has ensured that the rural sanitation program is understood by, approved of, and supported by its beneficiaries. This is, of course, essential in the introductory phases of project implementation, but it is also a key factor in assuring long-term sustainability. The belief of the people in improved sanitation, their acceptance of low-cost technology, and the sense of ownership and pride that has been instilled in those who now own their own latrines are invaluable assets which work to improve levels of maintenance and the chances for long-term project success. Such high standards of maintenance can only be realized through government channels at a very high cost (which in most cases means it is not provided at all). The Lesotho case speaks strongly for private responsibility as a highly viable alternative to government provision of sector services. Raising levels of community involvement, education, and approval has also been essential in achieving the high levels of user cost recovery required under the NRSP. Significant contribution by beneficiaries has allowed the use of the private sector as an alternative to government service provision and has allowed services to be extended to many more people than would have been feasible under complete subsidization, given the limited resources of the national government. The use of the private sector in Lesotho not only works as an alternative means of project implementation, it also imparts consequential economic benefits. Employment is generated for local latrine builders, and local industries and materials distributors benefit from their linkages to construction activities. The training and building experience gained by local latrine builders are valuable skills which can be used in other income-generating activities, an important consideration in light of the severely restricted employment opportunities in Lesotho's rural areas. The potential to increase rural employment was an important factor in obtaining government endorsement of the NRSP strategy and its inclusion in the national five-year development plan. By inducing individual households to bear the responsibility for financing latrine construction, the program has been able to demonstrate the value that rural villagers place on improved sanitation and hygiene. The mobilization of women in this effort has been crucial. As the overseers of health and hygiene practices within families, women play a leading role in promoting the construction and proper use of latrines. Health education, particularly through participatory training methods, has proven essential in raising demand for latrines by enhancing women's understanding of the need for proper hygiene and improved sanitation. The most basic means of assessing the success of any sanitation program is evidence of sustained improvements in the health of the population. The health impact evaluation conducted in Mohale's Hoek showed that the NRSP strategy was successful in improving health conditions among young children, with latrine use and improved hygiene behavior leading to a significant decline in the incidence of diarrhea, one of the leading causes of child mortality. This study gave concrete evidence of the efficacy of the NRSP's total package of improved sanitation, and it encouraged continued support for the program. It is hoped that as the program becomes firmly rooted in the other districts of Lesotho, the country as a whole will see similar results, reducing the suffering and debilitation of sanitation-related diseases for both children and adults. The additional benefits of the NRSP, including employment and income opportunities, increased convenience and privacy for latrine users, and a raised sense of confidence in individual and community problem-solving abilities, will certainly add to the long-term viability and sustainability of the program.