WATER AND SANITATION PROGRAM: LEARNING NOTE
Scaling Up Rural Sanitation Key findings
Understanding Determinants During 2014 and 2015, three research studies
were carried out to examine the drivers and
of Access to Hygienic Latrines
barriers to latrine adoption and the availability
of desirable, affordable latrines in rural areas
of Vietnam. The findings were used to develop
for Rural Households in Vietnam integrated behavior change communication
(BCC) and sanitation supply chain
strengthening programs in Hoa Binh Province
From Research Findings to Campaign Development and the Mekong Delta region. Insights and
June 2016 lessons learned from these activities include:
• Socio-graphic conditions such as proximity
to other households, population density,
INTRODUCTION access to transport and geography (flatlands
vs. highlands) – not ethnicity – are key
Vietnam has achieved impressive re- been completed. For 2016-2020, the factors that affect a community’s access to
sults in increasing sanitation coverage. New Countryside Development Pro- information, products and services, as well
In 1990, only 31% of rural households gram will be the umbrella program un- their motivations for latrine adoption.
had access to improved sanitation.1 By der which sanitation is to be addressed. • Common drivers for latrine adoption
2015, this rate had increased to 70%.2 across all three regions include a desire for
The Joint Monitoring Program (JMP) of PROBLEM STATEMENT convenience and safety for family members.
Moreover, social drivers of belonging,
the World Health Organization (WHO) Despite overall progress in sanita-
harmony and a desire to keep up with
and the United Nations Children’s Fund tion coverage, the national average in ones’ neighbors (i.e status) also influenced
(UNICEF) established criteria for ‘unim- Vietnam masks significant disparities purchasing decisions for latrines and other
proved’3 and ‘improved’ latrines, while among regions. Of the total number of household items.
the Vietnam Ministry of Health (MoH) households that do not have improved • An integrated program that combines
has developed a more stringent set of sanitation facilities in the country, 50% evidence-based BCC with a sanitation
supply chain strengthening component can
criteria for ‘hygienic’ latrines used for are in the Mekong River Delta and an-
increase latrine uptake. This approach was
setting national targets and for monitor- other 25% are in the Northern Moun- used in Hoa Binh Province and resulted
ing. The Vietnam Health and Environ- tains and Central Highlands regions. in a significant jump in the proportion of
ment Management Agency (VIHEMA) While the national rate of open defe- households with latrines that meet the
under the MoH is responsible for rural cation is only 3%, over 20% of house- Ministry of Health standards for hygienic
construction, operation and maintenance.
sanitation and hygiene. Within com- holds practice open defecation in the
• Sanitation programs that aim to apply an
munities that have sustained open def- Northern Mountains and Central High-
integrated approach can leverage existing
ecation free status4, VIHEMA aims to lands areas.6 resources – including research insights
increase the rate of households with and communication materials – but new
hygienic latrines to 75% by 2020, and Findings from a global review of forma- programs may need to adapt their model
to 90% by 2030.5 Since 2010, the gov- tive research studies on latrine adoption to fit the local context: small-scale, targeted
research is still needed to determine
ernment’s delivery mechanism for rural reveal that non-health drivers such as
differences in physical, social and emotional
water supply and sanitation has been a social status, privacy and convenience drivers for latrine uptake in other regions,
series of five-year National Target Pro- are among the key factors that moti- followed by pretesting and refinement of
grams (NTPs).The third NTP (NTP3) for vate households to invest in latrines, communication materials.
rural water supply and sanitation has while past approaches in Vietnam have
1
Improved latrines are those that hygienically separate human excreta from human contact. Improved latrine types include: water flush to
sewer/septic tank/pit, composting, VIP, and simple pit with slab and cover latrines.
2
World Health Organization and UNICEF. Joint Monitoring Program for Water Supply and Sanitation, 2015.
3
Unimproved latrines include flush/pour flush to elsewhere, pit latrines without slabs, bucket latrines, hanging latrines, shared sanitation
facilities, no facilities, and bush/field.
4
No one in the village will revert to open defecation.
5
The Statement of Commitments for Sanitation and Water of the Government of the Socialist Republic of Vietnam at the Spring Forum,
2015.
6
Ibid.
2 Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam Scaling Up Rural Sanitation
focused mostly on health-based messaging.7 More recently, Research findings from the studies were then used to devel-
Community Led Total Sanitation, BCC, and sanitation mar- op BCC campaigns and supply chain strengthening programs
keting also have been applied in some areas of Vietnam. So for the Mekong River Delta region and for Hoa Binh Province,
far, there has been no effort to deliver an integrated program which was selected as representative of the Northern Mountains
to address both demand creation and supply chain strength- region. Hoa Binh Province has a population of approximately
ening at scale in the lagging regions. 850,000 people from seven main ethnic groups – the Muong,
Kinh, Thai, Tay, Dao, Mong and Hoa – and a poverty rate of
ACTION 15%.8 The province also served as a “laboratory for lessons”
In 2013, the Water and Sanitation Program (WSP)—a multi-do- to inform development and implementation of the strategy and
nor partnership that is part of the World Bank Group’s Water BCC and supply chain strengthening tools for other regions.9
Global Practice—began implementing a three-year technical
assistance program entitled “Scaling up Rural Sanitation in This Learning Note summarizes key findings and insights
Vietnam”. The assistance aims to strengthen government ca- from the research and design process used for the BCC
pacity for scaling up sanitation promotion with a particular fo- campaigns and supply chain strengthening programs for Hoa
cus on households in low access areas. Through the program, Binh Province and the Mekong River Delta.
WSP, SNV (the Netherland’s Development Organization),
CODESPA (a Spanish non-governmental organization) and RESULTS
other partners have supported VIHEMA to develop a strategy This section describes in detail the steps taken to develop
and set of tools on BCC and supply chain strengthening for both the demand generation and supply chain strengthening
several regions of Vietnam, including the Northern Mountains, activities for the Hoa Binh and Mekong River Delta programs,
Central Highlands and Mekong River Delta. A consistent de- including the research, development of activities, and evalua-
sign process was used for each of the regions, based on for- tion results from the Hoa Binh program.10
mative research to understand the factors that influence con-
sumer demand for, and the supply of, hygienic latrines. 1. FORMATIVE RESEARCH
Figure 1. Regional Map of Vietnam During 2014-2015, WSP and UNICEF supported three san-
itation market research studies: an initial study in Hoa Binh
Province; a second study in the Mekong River Delta provinc-
es of Soc Trang, An Giang, Kien Giang and Ca Mau; and a
final study led by the London School of Hygiene and Tropical
Medicine in the Northern Mountains and Central Highlands
provinces of Ha Giang and Kon Tum.11
The studies sought to provide insights into household defeca-
tion practices in these areas, uncover the barriers and drivers
of hygienic latrine adoption, and determine the strengths of,
and challenges to, the sanitation supply chain to deliver aspi-
rational yet affordable hygienic latrines. Data collection meth-
ods included key informant interviews, in-depth interviews,
focus group discussions, and structured surveys with house-
hold members. Behavior change frameworks were used to
guide the development of the detailed research questions and
to inform the design of the demand generation components
of all three studies. The first two studies applied the Sani-
FOAM12 framework while the study in the Northern Mountains
and Central Highlands regions applied the Evo-Eco13 model.
7
Other key determinants include: access, availability, social norms, product attributes, affordability, skills and self-efficacy, and competing priorities. See O’Connell, Kathryn. What Influences Open Defecation and
Latrine Ownership in Rural Households? Findings from a Global Review. WSP. 2014.
8
Hoa Binh Statistics Book, 2014.
9
Development of a BCC campaign for the Northern Mountains and Central Highlands is currently underway.
10
At the time of writing at-scale results from the Mekong Delta program were not available.
11
The first studies were supported by WSP and the last study was supported by UNICEF and WSP. Water and Sanitation Progam, World Bank, SNV & CODESPA, Rural Sanitation Consumer Demand and
Supply Chain Assessment for Hoa Binh; Jensen, Lene and Usswald, Craig Sanitation Consumer Demand and Supply Chain Assessment for the Rural Mekong River Delta, 2014; London School of Hygiene and
Tropical Medicine. Sanitation and Hygiene in the Northern Moutains and Central Highlands of Vietnam: Report of a Formative Research Study and Recommendations for SupRWS, 2015
12
Devine, Jacqueline. Introducing SaniFOAM: A Framework to Analyze Sanitation Behaviors to Design Effective Sanitation Programs. Water and Sanitation Global Scaling Up Project, Working Paper, 2009.
http://www.wsp.org/sites/wsp.org/files/publications/SaniFOAM_Report409_3.pdf/
13
See http://www.hygienecentral.org.uk/research-behaviour.htm
www.wsp.org
Scaling Up Rural Sanitation Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam 3
A. Current Defecation Practices • Product attributes: Pour flush latrines are the most de-
Based on NTP3 monitoring data, by June 2015 roughly 50% sired. Cleanliness and the absence of smell are considered
of households in the three regions had a hygienic latrine, among the most important benefits by members of rural
compared to the national rural sanitation coverage rate of households. Pour flush latrines with ceramic pans are pre-
64%. Only 25% of poor households, on average, have a hy- ferred for their durability and ease of cleaning. Flushing with
gienic latrine. Table 1 provides an overview of the situation in water also prevents odors and allows for the latrine to be
the three regions. located closer to, or in, the home. Households prefer “all-
in-one” latrines that include a bathroom, water tank and
B. Demand For Latrines septic tank, which increases cost.
Behavioral Determinants Common to All Three Regions • Social norms: Open defecation is not acceptable, but
Analysis of the studies revealed that the three geographic re- unhygienic latrines are perceived to be ‘normal’. Although
gions have some common barriers and opportunities related open defecation is not socially acceptable and there is
to demand creation for latrines. These are presented below shame and stigma attached to the practice, the use of
by behavioral determinant. unhygienic latrines is a normal, accepted behavior. In the
Northern Mountains and Central Highlands regions, smelly,
• Access/availability: Materials are available in most com- dirty latrines are the norm, while in the Mekong River Delta,
munities but may be harder to access for households in fishpond and ‘field combat’ latrines (i.e. pour-flush latrines
remote communes. While latrine construction materials are without any sub-structure) are common. Because the use
available in the majority of communes in flat, lowland or of unsanitary latrines is so pervasive, there is little pressure
midland regions, more remote communities face challeng- to change.14 Open defecation is more common in the Cen-
es in accessing materials. tral Highlands because adults spend the majority of their
day in the fields far away from their homes and latrines.
Table 1: Overview of Sanitation in Three Regions
Region Sanitation Coveragea Common Latrine Type
Northern Mountains • 46% of households use • Great variation in latrine designs but the
unhygienic latrines and 20% do most common include dry sanitation
not own latrines. options such as unimproved dry pits and
• Only 30% of poor households double vault latrines.
own a hygienic latrine.
Central Highlands • Nearly 50% of households use • Various types of latrine models exist; the
unhygienic latrines and 15% do most common types include dry pit and
not own latrines. wet latrines.
• Only 20% of poor households • Latrine designs vary greatly from area
are likely to own a hygienic to area, with households copying
latrine. their neighbors’ – often faulty – latrine
designs.
• Many latrines are not in use due to faulty
design and poor maintenance.
Mekong River Delta • Roughly 55% of households • Almost all latrines are wet latrine types.
use unhygienic latrines and 22% • Most common improved latrine type is
do not own a latrine. pour flush to septic tank.
• Only 28% of poor households • Most common unimproved latrine types
are likely to own a hygienic are ‘hanging latrines’ (simple latrine
latrine. structures suspended over a body
of water) and ‘field combat’ latrines
(unhygienic latrines with a solid super
structure that flush directly into the river
or a fishpond.
• Sharing latrines is common among
poorer households.
a
Sanitation coverage rates are based on national data as reported by the Center for Rural Water Supply and Sanitation (CERWASS) as of June 2015.
14
The only exception to this norm is the simple river latrine – similar to the fishpond latrine but built on the edge of a river. Rural residents in the Mekong Delta see defecation into the river from this type of facility
as an unacceptable practice, and many reported scolding those who engage in the practice and destroying their facilities. The social norm against the use of simple river latrines appears to be the result of more
than a decade of campaigning against river defecation by local authorities.
www.wsp.org
4 Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam Scaling Up Rural Sanitation
• Knowledge: Information is limited about hygienic latrines - Harmony and affiliation: In all three regions, households
and their affordability. A key barrier is a lack of knowledge desire harmony with neighbors and within their com-
about government requirements for a hygienic latrine. In Hoa munity. For households in Hoa Binh Province, this is
Binh Province, only septic tank latrines are thought to be achieved through the solidarity and camaraderie of work-
hygienic. In the Mekong River Delta, some residents believe ing together to build latrines. In the Mekong River Delta
that flushing into a fishpond is hygienic because the fish in region, households share canals and waterways and want
the pond consume the fecal waste. In addition, many house- to build a latrine to avoid contamination and getting into
holds think that the only hygienic latrine models are those conflicts with neighbors. In the Northern Mountains and
with septic tanks made with bricks, and they are unaware Central Highlands in particular, good relations with neigh-
that other–and less costly–types of substructures, such as bors and a sense of belonging to the community are also
tanks or pits made from concrete rings, are also suitable. important. At the same time, there was also a bit of rivalry
• Affordability: Financing options are limited. There are and desire to keep up with neighbors (i.e status), which re-
limited opportunities to access financing for household sults in purchases of similar household items and latrines.
sanitation improvements. While consumer goods and ag- • Willingness to pay: Previous subsidy programs in the
ricultural inputs can often be bought in installments, credit Northern Mountains and Central Highlands have diminished
arrangements for latrines are much more limited.15 Loans households’ willingness to pay for latrines. In the Mekong
from the Vietnam Bank for Social Policy are the exception. River Delta, fishponds serve as both latrines and a source of
Many non-latrine owners wish to take out a loan but de- income and/or food. Many households are unwilling to build
mand far exceeds supply and installment payments are not new or to upgrade to hygienic latrines if it means destroying
commonly offered by suppliers. fishpond latrines and giving up their economic benefits.
• Attitude: A hygienic latrine is a ‘nice to have’, not a ‘need
to have’, item. Most rural households in the Northern Differences among Regions
Mountains and Central Highlands regions feel that a hy- Despite the similarities presented above, there are also nota-
gienic latrine is a luxury item, but an unhygienic latrine is ble differences among the three regions as detailed in Table 2:
acceptable. In the Mekong River Delta region, dirty, smelly
latrines are not acceptable, but latrines with a flush to a • In the more remote communes of the Northern Mountains,
pond are. A hygieninc latrine is something they would build households live farther apart and the sense of belonging
if they have a lot of extra money. Households prefer to in- to a community is less of a factor; households cite disgust
vest in income generating assets.16 and desire for cleanliness as key motivations for obtaining
• Drivers: Despite these barriers, there are opportunities a hygienic toilet.
to promote latrines by emphasizing the benefits of latrine • In the Central Highlands and lowland communes of the
ownership. While not all social, physical and emotional driv- Northern Mountains, communities are linked by relative-
ers are universal, three drivers were consistently found in all ly good roads and households live closer to one another,
three regions: making a sense of community and belonging more influen-
- Convenience: All households desire a hygienic latrine that tial. In these areas, pride, belonging, respect and a desire
can be located near or within the home for easy access, to be seen as complying with government rules and regu-
particularly at night or during bad weather. lations are important.
- Safety: In the Northern Mountains and Central Highlands • In the Mekong River Delta region, safety and privacy are key
regions, fears of being bitten by animals were a concern, drivers because of the risks associated with using hanging
and meeting ghosts was a fear mentioned in all areas. In latrines. The very high population density also means that
every region, the fear that children or the elderly may fall it can be difficult for women to find a place with sufficient
into pit latrines or into waterways when using fishpond privacy.
latrines were key concerns.
15
Retailers and masons do provide partial credit for a limited period to some households. Whether or not to provide credit and to whom it is offered is at the discretion of the individual retailer/mason.
16
71.4% of survey respondents in Hoa Binh pointed to income generating activities as their top investment priority.
www.wsp.org
Scaling Up Rural Sanitation Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam 5
Table 2: Regional Differences Related to Demand Generation for a Hygienic Latrine
Regions
Determinants
Northern Mountains Central Highlands Mekong River Delta
Skills/ Households prefer and feel confident to build their The reliance on masons is very high in these areas.
self-efficacy own latrines. In Hoa Binh, over 70% of households
reported building their latrines themselves.
Social support Relatives, neighbors and friends are the key source Masons are highly influential in these regions as they are the main source
of information for latrine construction. Communities of advice on latrine models.
collaborate and share knowledge about latrine
construction, and help one another to build their
latrines.
Disgust/ Disgust from smelly, dirty latrines is a key driver in Smell is less of a factor due to the Most latrines are wet types and so
cleanliness mountainous communities as simple pit latrines climate with low humidity. households are not affected by the
can easily break down. Having a latrine offers a bad smells from latrines.
way for people to be clean and to have a cleaner
environment.
Privacy Most households have a latrine, and they tend to Latrines are more temporary (for Women, particularly river
invest more resources on the superstructure so both the underground part and the defecators, worry about being
that it provides sufficient privacy. superstructure) and privacy is not seen defecating and feeling
critical. embarrassment at being seen.
C. The Supply Chain for Latrine Products and Services Bank for Social Policy, and they are reluctant to borrow at
Once interest is generated through BCC activities (see next high interest from commercial banks.
section), there should also be a supply of sanitation products • Lack of latrine options for challenging environments:
and services to meet the demand. Supply chain research in In the water-scarce communes of the Northern Mountains
the three regions revealed similar opportunities and challeng- and Central Highlands, there are currently few options for
es to achieving this goal. latrines. There is a need to develop robust but lightweight
latrine substructures that are easy to transport from district
Challenges Common to All Regions towns to remote communes. For the Mekong River Delta,
• Complexity of shopping for latrine products and ser- land-based latrine models are not always suitable due to
vices: To build a latrine, consumers first have to purchase the large number of rivers and streams. Fiberglass septic
construction materials from multiple retailers, and then find tanks and plastic septic tanks are available but have limit-
a service provider to build or install the latrine. No supply ed market penetration and are the most expensive option.
chain actor in any of the three regions offered both prod- Plastic septic tanks17 hold promise but need further devel-
ucts and installation services. opment to make them better suited to sun exposure.
• No marketing to consumers by supply chain actors:
Since most of the products that go into building a latrine Distinct Challenges for Each Region
are also used for other construction purposes, there is little As with the drivers for latrine adoption, challenges to the san-
incentive for retailers/suppliers to market their products and itation supply chain are also context-specific and vary by re-
services specifically for latrines (i.e. there are no complete gion. The sanitation supply chain is weakest in the Northern
latrine packages that could be branded). Masons and re- Mountains region due to rugged terrain, low population den-
tailers also do not formally promote their services and prod- sity and relatively poor transport. The sanitation supply chain
ucts but instead rely on word-of-mouth for new customers. is better developed in the Central Highlands thanks to better
• Insufficient access to financing for consumers and roads, higher population density, and more communes locat-
supply chain actors: Although financing is available ed in the midlands and lowlands. The sanitation supply chain
through formal and informal channels, it is insufficient (in is most developed in the Mekong River Delta due to large
both number of financing options and amount of financing number of lowland communes, high population density and a
available). Retailers lack capital to expand their business as good network of roads or waterways. Table 3 below presents
they do not qualify for low interest loans from the Vietnam the challenges specific to each region.
17
Produced by the company ROTO Plastics Corporation.
www.wsp.org
6 Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam Scaling Up Rural Sanitation
Table 3: Differences in Supply Chains among Regions
Regions
Factors
Northern Mountains Central Highlands Mekong River Delta
The role of masons Masons are less influential The need for septic tank models and the preference to hire labor for latrine
because information about latrines building means that masons determine the size and price of latrines, and thus
is obtained from family members are very influential. However, many masons do not have formal skills or training
and friends. in building latrines.
Transportation Transport of materials is relatively easy in lowland and midland Most communes are easy to reach;
communities but more challenging for remote villages. however, in remote villages, boats may be
required to transport materials.
Market development Lower population density, lower Households have higher, more High population density, higher income
income levels and the preference diversified sources of income, levels, fewer suitable latrine types
for self-building results in lower including farming and harvesting (primarily only septic tank varieties) and
market potential for sanitation trees. Households readily accept preference to have latrines installed by
businesses. mason services. masons results in high market potential
for sanitation business.
Technological options Concrete ring septic tanks are Concrete ring septic tanks Concrete ring septic tanks can be
completely new to this region. have been adopted by some promoted for land-based households,
consumers, though their use is still though in general they were perceived
limited. to be of inferior quality and less durable.
Such product perceptions would need to
be addressed. In non-land-based areas,
plastic septic tanks have been adopted
by some consumers though their use is
still limited.
Figure 2. Process to Develop BCC Campaigns 2. BEHAVIOR CHANGE COMMUNICATION
CAMPAIGNS
7 The process to develop the Hoa Binh and Mekong River Delta
Finalize materials campaigns followed the same key steps (see Figure 2). The
first step included formative research as described above.
6 The second step involved distilling the key research results
Pretest IPC tools
into findings that were used to support development of the
creative brief (a document that defines the parameters for
5
Develop tools, materials the BCC campaign). The creative brief helped to ensure that
Stakeholder Feedback
stakeholders and the advertising agency hired to develop the
4 campaign shared the same vision and desired outcomes from
Pretest concept, messages the campaign. Based on the creative brief, several campaign
ideas were developed and underwent multiples rounds of
3 pretesting (steps 3 and 4). Based on the pretesting results,
Concept ideation multimedia, print materials and interpersonal communication
(IPC) tools were drafted (step 5). Before finalization, the IPC
2 tools were tested once more with frontline workers to ensure
Creative brief
that the tools were easy to understand and to apply in the
field (step 6). Feedback from stakeholders, including VIHE-
1 MA and the provincial Departments of Health, was obtained
Formative research
throughout.
www.wsp.org
Scaling Up Rural Sanitation Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam 7
Figure 3. Logo for Sanitation Campaigns
The Hoa Binh campaign was developed in 2014 over the
span of eight months, and included the campaign concept,
visuals, messages and tools for frontline workers to conduct
face-to-face or IPC activities. Research revealed that IPC was
the most effective channel for rural communities, and there-
fore almost all of the tools were designed for village- or house-
hold-level activities. Two packages were designed comprising
a “basic” and an “extended” package of IPC tools, as de-
scribed below:
• The basic package included guidelines for a village map-
ping activity and for village and household meetings, as well
as banners, and scripts for loudspeaker announcements.
This package was designed based on government cost
norms for communication activities and is recommended
for provinces with limited budgets for BCC activities. VIHEMA recommends that all organizations working on sanita-
• The extended package included the basic package tion in Vietnam use this logo and tagline, though regional cam-
along with guidelines for additional activities such as the paigns will be able to add specific calls to action. For example,
Sanitation Festivals (education-entertainment activities), in Hoa Binh, the call to action is “Join hands for a beautiful
newspaper article writing, mural paintings and content for village” (Chung tay vi lang que sach dep). In the Mekong River
longer radio messages. The extended package was devel- Delta, the call to action is “A hygienic latrine for your family’s
oped for provinces with resources to implement additional peace of mind” (Nha tieu hop ve sinh, an tam cho gia dinh).
BCC activities beyond the basic package.
The development of the campaign for the Northern Moun-
A logo was developed for VIHEMA to use in all future sani- tains and Central Highlands regions is currently underway and
tation campaigns. It depicts a stylized, modern latrine with a is likely to be based upon a similar concept to the one used
substructure, middle structure and superstructure. The tag- in Hoa Binh. Additional tools developed from the Northern
line “Sanitation for All” emphasizes the government objective Mountains and Central Highlands campaign may include TV
of a hygienic latrine for every family in Vietnam. It was de- spots, videos and mobile audio-visual tools.
veloped following an extensive process of pretesting, which
resulted in a visual that audiences felt represented progress, Table 4 presents more details of the two campaigns that have
modernity, cleanliness, comfort and family. been developed to date.
Table 4: Details of the Hoa Binh and Mekong River Delta Campaigns
Hoa Binh campaign Mekong River Delta campaign
Drivers: Drivers:
• pride and recognition • false belief that feces do not contaminate fish and water quality
• belonging and social cohesion • safety for children and the elderly
• cleanliness, comfort • privacy
• better health for children • status and affordability
• being a good neighbor
Campaign concept: “Join hands for a clean village” Campaign concept: “It’s not what you think it is”
Given the strong sense of community in Hoa Binh communes, the The campaign was developed based on misperceptions about the
campaign highlights the personal, family, and community benefits of risks (or lack of) of using unhygienic latrines. The four key risks are
having a hygienic latrine. It does this by emphasizing the collective food safety (fish that are contaminated by eating feces), swimming
effort by all households to create a cleaner environment. in contaminated water, falling into a fishpond, and being seen while
defecating. There were also two key positive messages about
collective action to build latrines and how even poor families can afford
a latrine.
www.wsp.org
8 Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam Scaling Up Rural Sanitation
Table 4: Details of the Hoa Binh and Mekong River Delta Campaigns (continued)
Hoa Binh campaign Mekong River Delta campaign
Messages: Nine key messages were developed that included, among Messages: Six messages were developed that included, among
others: others:
• Be a better neighbor. • Don’t feed your children fish feces - stop defecating in the water!
• Be a pioneer, be a bright example. • Don’t put the elderly and children at risk - stop using hanging latrines!
• Provide comfort for your family • Don’t let women be embarrassed - stop using a hanging latrine!
• Act for solidarity. • Be a good example and good neighbor - help each other build a
• Make your community a better place to live. hygienic latrine now!
• Choose a civilized lifestyle • Even poor families can build a hygienic latrine!
• Do you want your children to be healthier and taller?
Tone: The tone is positive and aspirational with crisp, clean visuals Tone: The tone is sharp, direct and shocking, combining disgust and
that capture the beauty of Hoa Binh Province. The encouraging and fear. The tone reflects the preference amongst southern Vietnamese for
suggestive tone reflects a preference for a more roundabout, indirect more straightforward communication style.
style of communication among northern Vietnamese.
The visuals depict realistic situations in front of fishpond latrines, unlike
The color green was chosen for its association with being clean, fresh in Hoa Binh where latrines are not featured in any of the key visuals.
and healthy; the flower depicts households that are connected together
in a community.
Hoa Binh materials Mekong River Delta materials
3. SUPPLY CHAIN STRENGTHENING APPROACH To address the lack of suitable latrine choices, the following
AND TOOLS product options were developed:
Based on the findings from the research, a market strengthen- • Hoa Binh – Lower cost substructure options were needed
ing strategy was developed that included: 1) the introduction that would reduce the total cost of a latrine yet ensure that it
of innovative and more affordable sanitation technologies to is still hygienic. The recommendation of using concrete rings
reduce cost and increase profitability for the private sector; 2) for septic tanks rather than clay bricks or cement bricks re-
support for development of sales agent and distribution net- sulted in a 50% cost reduction in cost (from approximately
works of sanitation products and services that reach house- USD 168 to USD 87) for the same size of substructure and
holds at the village level; 3) strengthening of financing mech- mid-structure – two critical components of a hygienic latrine.
anisms that facilitate rural households to invest in sanitation In addition, the concrete rings reduced the possibility of in-
products; and 4) support for capacity building of the private correctly connecting tanks, a very common mistake made
sector to operate profitably in the rural sanitation market. by both masons and households when building brick tanks.
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Scaling Up Rural Sanitation Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam 9
• Mekong River Delta – For households in flood prone ar- Existing concrete ring producers or retail shops that sold
eas or locations with limited land space, plastic tanks were construction materials such as cement, sand, gravel, and
introduced. This is the most appropriate option currently latrine pans were eligible to become a SANCON. However,
for households in this area as the tanks are durable, light only those with capacity to extend their product line to cover
weight, easy to install and affordable, especially for house- sanitation products and services were invited to participate
holds that already have invested in a toilet (see Figure 4). in the training program. The SANCON owners received train-
ing on how to operate their sanitation business. This included
Figure 4. Plastic Septic Tanks for Flood-prone Areas
learning about key latrine types, training on how to develop
a business plan, recruitment of sales agents, financial man-
agement, and on-site practice for concrete ring production,
among other things. In addition, to help the SANCONs recruit
their sales agents, the Commune Health Station helped con-
nect the owners of the SANCON with the network of Village
Health Workers, Vietnam Women’s Union members or Village
Chiefs. Training of SANCON staff was carried out by external
resource agencies because provincial health staff were inex-
perienced in this new approach.
Sales agents are responsible for actively promoting and mar-
keting sanitation products and services provided by the SAN-
CON. This is often done in two ways. In the first approach two
people pair up, with one person (a frontline worker) leading
In addition, the One-Stop-Shop model was adapted to all the IPC session and the other (a sales agent) providing infor-
three regions and renamed as Sanitation Convenience Shops mation on latrine options at the conclusion of the IPC session.
(SANCONs). SANCONs are places where customers can, in The sales agent is then responsible for placing the order with
one visit, obtain advice on latrine types, prices and opera- the SANCON and follow-up with the customer. The second
tion and maintenance requirements, and also purchase ma- scenario is for only one person to do all of these tasks. The
terials and arrange for delivery and installation of latrines by sales agent(s) receives a flat fee for each latrine sale complet-
trained masons (see Figure 5). Importantly, SANCONs allow ed with the SANCON.
households to spread out payments for latrines for up to 4-6
months, depending on the SANCON. To equip sales agents with tools (other than for BCC), product
catalogues were developed with pictures of latrine products
Figure 5. SANCON Model and information on prices of components, including combi-
nations of materials for latrines within a range of consumer
A ordable
Materials and
Masonry and budgets (see Figure 6). Guidelines were developed to explain
hygienic transport how sales agents and village motivators could work together
equipment
latrines services
in village meetings so that households could easily access
product information at the end of the IPC session.
Figure 6. Latrine Options Catalogue
Convenience
shop
Sales
agent
Household
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10 Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam Scaling Up Rural Sanitation
The SANCON model that utilizes a network of agents working 4. EVALUATION OF THE INTEGRATED
directly at the village has worked well in Hoa Binh Province. APPROACH IN HOA BINH
However, the model has needed adaptation for the other re-
gions. In the Mekong River Delta, the high population density Prior to the use of BCC in Hoa Binh, the Hoa Binh De-
and greater number of villages per commune required that partment of Preventive Medicine used traditional informa-
a commune coordinator role be created to directly manage tional methods to generate demand for latrines. Beginning
the day-to-day operations of the sales agents and consol- in 2015, the department started implementation of the
idate orders before sending them to the SANCON. On the basic BCC package alongside the supply chain strength-
other hand, in areas that are sparsely populated like parts of ening strategies. An assessment was then carried out in
the Northern Mountains, the SANCON model may need to nine pilot communes to evaluate the effectiveness of the
be modified again. For example, individual sanitation retailers evidence-based approach compared to the previous ac-
may need to develop latrine molds and provide installation tivities under the NTP. The assessment included pre- and
services on-sight at the household level in order to help ex- post-intervention evaluations conducted at the begin-
tend the supply chain to hard-to-reach consumers. ning and the end of 2015.18 The evaluation aimed to:
1) assess the impact of BCC and SANCON interventions in
increasing coverage of hygienic sanitation in nine interven-
Achievements as of December 2015 tion communes; and 2) evaluate the potential for sustain-
ability and replicability of the sanitation promotion approach
Hoa Binh: Over 1,000 health staff and sale agents in other communities characterized by limited budget and
trained and 10 SANCONs established capacity. The key endline findings are presented in Figure 7.
Mekong Delta: 60 key senior staff trained from The BCC approach and tools developed for Hoa Binh Prov-
13 Mekong provinces representing the Center for ince have been adopted by VIHEMA for roll-out within the
Preventive Medicine, Women’s Union and National World Bank-funded Results-Based Rural Water Supply and
Center for Rural Water Supply and Sanitation Sanitation Project implemented in eight provinces of the Red
River Delta in northern Vietnam.
Figure 7. Key Findings from Hoa Binh Post-Intervention Evaluation
1. Following an intensive intervention of combined BCC and supply chain strengthening activities, there was a rapid increase in hygienic
sanitation coverage in Hoa Binh – from 27.7% to 48.4% over a 20-month period. This compares with a national increase of 1.9% per
year (estimated by the JMP) to 2% per year (the NTP estimate), as shown in the chart below.
2. The increase in hygienic sanitation in Hoa Binh benefited all nine
intervention communes and was found among all income and eth- 50%
nic groups: the poor, near poor, and non-poor. Access among the
poor rose 6% (from 18% to 24%) while for the non-poor it almost
doubled (from 34% to 60%). The increase in hygienic toilets was 40%
associated with a decrease in unhygienic facilities, as most of the
households in these communes already had some form of toilet
already.
30%
3. Eighty-five percent of all respondents said they had participated
in sanitation activities in 2015. Of these, 87% had attended sani-
tation village meetings, 29% had attended sanitation festivals and
20%
13% had received a household visit by outreach workers.
2013 2014 2015
4. Approximately 83% of respondents without a toilet said they were
now planning to construct one, 44% of them within the next year
Post-intervention survey results
(compared to a baseline of 7%).
(for nine communes in Hoa Binh)
5. Ten SANCONs were set up as part of the intervention, with one
NTP3 (Hoa Binh)
dropping out and another one established independently. Approx-
JMP (Hoa Binh)
imately 43% of respondents said they were aware of the existence
of SANCONs.
18
Quattri, Maria, Demand Creation and Supply Chain Development for Scaling up Rural Sanitation in Hoa Binh province: Post Intervention Rapid Assessment Report, 2016
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Scaling Up Rural Sanitation Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam 11
LESSONS
The following lessons learned are based on research and re- marketing and information provided to households about
sults of implementation of the BCC programs in the Hoa Binh sanitation services and, importantly, financing for poorer
and the Mekong River Delta provinces. households, all require multi-faceted interventions that go
beyond communication.
• Geography influences drivers for both latrine adop- • The SANCON model has demonstrated potential,
tion and strengthening the sanitation supply chain. but requires modification, particularly in areas with
A common assumption in Vietnam is that cultural differ- dispersed villages and weak supply chains. The es-
ences between various ethnic groups (particularly between tablishment of SANCONs has provided households with
Kinh and non-Kinh groups) are key factors in influencing reasonably priced, good quality latrines that meet hygienic
latrine adoption. However, the formative research shows standards. However, in Hoa Binh Province, market pene-
that drivers are not primarily determined by ethnicity but tration by the SANCONs, particularly in remote communes,
rather by the socio-geographic situation of communities, has been somewhat limited. This is due to limited location
such as the proximity to other households, density of com- of the SANCONs in accessible district or commune cen-
munity and the physical environment (which varies signifi- ters; consumer preference for self-built latrines or the use
cantly between river delta and mountain communities). In of local, often untrained, masons; lack of consumer famil-
addition, the presence of roads is a key factor that shapes iarity with new products (latrines made using concrete rings
the supply chain and influences preference for products rather than bricks); and low profit margins for SANCONs in
and services (e.g., use of hired labor), and thus drives la- remote, dispersed locations with high transportation costs.
trine adoption. These factors also shape socio-emotional Experience in other countries has also shown that it takes
drivers. Households living in more densely populated areas time for sanitation enterprises to gain market penetration.19
were more likely to mention the influence of neighbors and For such areas, a modified approach is proposed in which
community on their decision to invest in a latrine, whereas linkages between SANCONs and local shop owners is fa-
in less densely populated areas disgust was more of a mo- cilitated and further innovations in mason-led latrine con-
tivator. struction are promoted.
• Substituting evidence-based sanitation BCC for the • The government can finance BCC activities but exter-
traditional approach of using health motivators re- nal support is still required to spur sanitation supply
quires acceptance by senior provincial implement- chains. Given sufficient political support from the national
ers. Senior government health leaders, especially at the level, provincial governments can self-finance the opera-
provincial level, may be comfortable with their established tional cost of BCC activities, resulting in significant change.
approaches to hygiene promotion that emphasize educa- However, supply strengthening activities may still require ex-
tion, information and health-based messaging rather than ternal support. Market research shows that without external
the use of emotional or social drivers, such as social norms, support, current supply chain actors may not have sufficient
which have been shown to be more powerful in changing incentives to extend their business lines to include sanitation
latrine adoption behavior. Therefore, it is critical to involve products and services. There is a role for government sup-
these stakeholders right from the beginning of developing port to actively facilitate supply chains, including training for
an innovative BCC campaign. They should be given orien- actors on new business models, particularly in remote areas
tation and training, and afforded time to adapt and appre- where access to products and services is a challenge.
ciate new tools and methodologies. While grass-root level
implementers at the commune level are usually more open RECOMMENDATIONS
to trying out “new ways”, getting the full support from pro- The following section provides recommendations that may be
vincial health systems for adopting a new BCC campaign useful for future rural sanitation programs in Vietnam.
is difficult, but essential; resistance to change from estab-
lished practices may be highest at this level. • Additional rapid research is needed to understand
• Latrine adoption requires more than BCC. Formative the drivers to latrine adoption and supply chain
research in the three regions indicates that while BCC must strengthening for other areas of Vietnam. Significant
be a central part of any effort to promote hygienic latrine evidence now exists related to both the demand and sup-
ownership and usage, other barriers must be addressed ply sides of latrine adoption in rural Vietnam. Future rural
equally. Aspirational and affordable product design, more sanitation programs can utilize these insights and avoid the
19
Similar low levels of market penetration (20%) were found in early sanitation marketing programs in remote rural areas of Lao PDR, while in Cambodia newly established sanitation enterprises typically were
able to capture 30-50% of sales.
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12 Understanding Determinants of Access to Hygienic Latrines for Rural Households in Vietnam Scaling Up Rural Sanitation
need for full scale studies. However, materials are persuasive, engaging to
Acknowledgment
small-scale, targeted studies are still audiences, and easy to use. The authors would like to thank
needed to uncover any differenc- • The role of frontline workers Susanna Smets for her overall guidance
es in social, physical and emotional should be expanded beyond IPC. and contributions to the content of the
document. We would also like to thank
drivers among community members Experience has shown that frontline
Xuan Thi Thanh Le, Duc Thi Nghiem,
residing in geographic regions out- workers have the capacity to deliv-
Almud Weitz, and Thuy Bich Nguyen for
side of those in the Mekong River er both IPC and sales information, their review of the document.
Delta, Northern Mountains and Cen- and thus toolkits should be designed
tral Highlands. Understanding the with both roles in mind. In particular,
nuances of these drivers will help where commission-based incentives About the program
program managers determine the di- from sales are insufficient, it may be
Today, 2.5 billion people live without
rection of their BCC campaigns (e.g., pragmatic for various outreach work-
access to improved sanitation. Of
the degree to which the program ers20 to carry out these dual roles these, 71% live in rural communities.
should emphasize family versus (both BCC and sales). To address this challenge, WSP is
community benefits). Supply chains • Proof of concept for the business working with governments and local
are also influenced by geography, so model needs further institution- private sector to build capacity and
targeted research is also needed to alization. Documented evidence of strengthen performance monitoring,
understand the challenges and op- the model’s feasibility is needed so policy, financing, and other components
portunities within local supply chains. that governments, with support from needed to develop and institutionalize
• New BCC and supply chain development partners, will scale up large scale, sustainable rural
strengthening tools can be de- business and sales training. Train- sanitation programs. With a focus on
veloped more rapidly if based on ing for sanitation businesses and building a rigorous evidence base to
support replication, WSP combines
existing campaign materials, but their sales agents is often outside
Community-Led Total Sanitation,
pretesting is still required. The de- the comfort zone and core capabil-
behavior change communication,
velopment of evidence-based BCC ities of the Vietnamese government and sanitation marketing to generate
campaigns and tools have typically health staff. External resources could sanitation demand and strengthen
required at least 1.5 years, espe- be used for this purpose, particularly the supply of sanitation products and
cially if broad quantitative research in large-scale projects where public services, leading to improved health
is needed. The experience of devel- funds are available for technical sup- for people in rural areas. For more
oping materials for the Mekong Riv- port. In addition, linkages to other information, please visit www.wsp.org/
er Delta, which were based on the programs – such as livelihood, voca- scallingupsanitation.
materials used in Hoa Binh Province, tional training, and small-medium en-
shows that the time needed for rapid
research, field testing of draft materi-
terprise training initiatives – may need
to be developed in the long-term to Contact Us
als, and completion of the final mate- institutionalize business training for Email: wspeap@worldbank.org
rials can be reduced. It is important, sanitation enterprises. Website: www.worldbank.org/water
however, that shorter development www.wsp.org.
periods still allow sufficient time for By Nga Kim Nguyen, Hang Diem
rapid research and pretesting of mes- Nguyen, Lene Gerwel-Jensen, Minh
sages and tools to ensure that BCC Thi Hien Nguyen, Duong Chi Nam
20
In Vietnam, outreach workers are individuals in villages who collaborate with different organizations such as the Women’s Union, the
Department of Family Planning and Population within the MoH, Youth Union, and Farmer’s Union, among others. They can work for more
than one organization and they receive allowance.
WSP is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable,
safe, and sustainable access to water and sanitation services. WSP’s donors include Australia, Austria, Canada, Denmark, Finland, France,
the Bill & Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States,
and the World Bank.
The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World
Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent.
© 2016 International Bank for Reconstruction and Development/The World Bank