PROJECT REPORT 2010 - 2011

MSc Public Health

Stream: Health Promotion Title: Communal Latrine Provision in Liberian Slums Supervisor: Adam Biran Candidate Number: 100822 Word Count: 9,277

TABLE OF CONTENTS
ACKNOWLEDGEMENTS................................................................................................................................3 EXCUTIVE SUMMARY....................................................................................................................................4 1. INTRODUCTION .........................................................................................................................................6 2. AIMS AND OBJECTIVES ............................................................................................................................8 2.1 AIM ...............................................................................................................................................................8 2.2 OBJECTIVES ..................................................................................................................................................8 3. BACKGROUND ............................................................................................................................................8 3.1 THE SLUM CONTEXT .....................................................................................................................................8 3.2 GOVERNMENT APPROACHCES TO SLUMS AND ITS IMPACT ON SANITATION ............................................8 3.3 COMMUNAL LATRINE PROVISION IN AFRICAN SLUMS ................................................................................9 3.4 GOOD PRACTICES IN THE COMMUNITY MANAGEMENT OF COMMUNAL LATRINES ................................. 10 4 JUSTIFICATION AND KEY QUESTIONS .............................................................................................. 11 5. MATERIALS AND METHODS ............................................................................................................... 11 5.1 SEARCH STRATEGY ................................................................................................................................... 11 5.2 DATA COLLECTION TOOLS ........................................................................................................................ 12 5.3 SAMPLING .................................................................................................................................................. 15 6. COMMUNAL LATRINE PROVISION IN LIBERIAN SLUMS A CASE STUDY............................ 16 6.1 INTRODUCTION ......................................................................................................................................... 15 6.2 NATIONAL SANITATION PRIORITIES ....................................................................................................... 15 6.3 POLICY ENVIRONMENT AND INSTITUTIONAL FRAMEWORK .................................................................... 17 7. RESULTS .................................................................................................................................................... 19 7.1 NUMBER OF PAYING USERS ....................................................................................................................... 19 7.2 PHYSICAL CONDITIONS AND OPERATING CHARACTERISTICS OF FACILITIES .......................................... 20 7.3 SOCIAL AND ECONOMIC CHARACTERISTICS OF COMMUNAL LATRINE USERS .......................................... 21 7.4 HOUSEHOLD LATRINE OWNERSHIP .......................................................................................................... 22 7.5HOUSEHOLD RESSOURCES ......................................................................................................................... 21 7.6 PATTERNS OF USE REPORTED BY COMMUNAL LATRINE USERS ........................................................... 21 7.7 CHILDREN AND COMMUNAL LATRINE USE .............................................................................................. 21 7.8 PAYMENT AND WILLINGNESS-TO-PAY ..................................................................................................... 24 7.9 SANITATION ACCESS AND PLANS FOR FUTURE USE OF COMMUNAL LATRINES ....................................... 25 7.9.1 COMMUNAL LATRINE USERS SATISFACTION WITH THE FACILITIES .................................................... 26 8. DISCUSSION...26 9. CONCLUSION ............................................................................................................................................ 32 10. RECOMMENDATIONS ......................................................................................................................... 33

ACRONYMS CBO GoL IDP I/NGO JMP LWSC MDG MoHSW OHCHR O&M PLWHA PRS/P SSP UN-Habitat UNICEF UN UNMIL WASH WHO WSSP Community Based Organisation Government of Liberia Internally Displaced Person International/Non-governmental Organisation Joint Monitoring Programme Liberia Water & Sewerage Corporation Millennium Development Goal Ministry of Health and Social Welfare Office of the High Commissioner for Human Rights Operation and Management People Living with HIV/AIDS Poverty Reduction Strategy/Paper Slum Sanitation Programme United Nations Human Settlements Programme United Nations Childrens Fund United Nations United Nations Mission in Liberia Water, Sanitation, and Hygiene World Health Organization Water Supply and Sanitation Policy

ACKNOWLEDGEMENTS

Acknowledgement of academic support I would like to express my gratitude to all who have assisted with this project and helped make it a success. Project development: The idea for this project was shaped after several discussions with LSHTM professors in the Department of Disease Control. The focus was sharpened after meeting my supervisor who suggested that I concentrate on aspects of the community management of communal latrines and its impact on use. Professor Claire Snowden also helped refine my qualitative research tools. Contact, input and support: I met with my supervisor three times to develop the research protocol and to discuss issues regarding ethical approval in a post-conflict country. We had further email exchanges to develop and refine my household survey and other research tools. I proposed the project to several INGOs and Yael Velleman (WaterAid UK) forwarded my proposal to Oxfam GB in Liberia, which is the lead agency of the Liberia WASH Consortium. The Consortium believed the research would prove useful to the WASH sector and agreed to host the research. In Monrovia I was based in the office of Concern Worldwide Liberia, which provided practical advice, administrative and logistical support. I intermittently contacted my supervisor by email to discuss issues in the field, initial findings and the first draft of the report. Financial support for the fieldwork was obtained from the School Trust Funds, Bob Holt (The Mears Group), Prasad Gollakota (UBS), Thomas Lilo Joycutty (HSBC), and Dr. Nelda Frater (The Frater Clinic). Unpublished documents and information was provided by Jenny Lamb and Andy Bastable (Oxfam GB), Yael Velleman (WaterAid UK), Madeleen Wegelin (IRC), David Kuria (Ikotoilet) and Aytor Naranjo. Encouragement and emotional support was provided by my dear friend and colleague Dr. Thomas Burke (Partners HealthCare). Main research work: I identified all references through my own desk review. In Liberia, I supervised the data collection of six-community based enumerators. I carried out key informant/group interviews, latrine observations and transect walks. Writing-up: My supervisor read notes from my field research and made comments and inquiries. He also read my first full draft of which no major revisions were required.

Executive Summary

Communal latrines are an inadequate policy response to the sanitation crisis of sub-Saharan Africas urban poor. It is estimated that 180 million African urbanites have no access to sanitation and if current demographic trends persist, a majority of the African population will reside in urban areas by 2015. This will result in slum densification and increase the urban need for sanitation by 50 per cent. Humanitarian organisations have responded by providing community-managed communal latrines in urban slums.

The overall aim of this policy report is to investigate communal latrine provision as a policy response to inadequate sanitation and endemic cholera in urban slums in the West African country of Liberia. It examined communal latrine provision in the Billimah, New Kru Town and Zinc Kamp slums of Monrovia where each community has two communal latrine blocks built by Concern Worldwide Liberia as part of its cholera response. The facilities have six pour-flush toilets that are connected to a septic tank. The toilets function independent of water, electricity and sewerage, and a community-based WASH Committee undertakes operation and maintenance (O&M) of the facilities. A household survey in which 79 respondents were interviewed was conducted to ascertain user satisfaction and to explore communal latrine usage rates, characteristics of users and non-users, and evidence for any groups being systematically excluded. Multiple methods of inquiry were used to triangulate the findings and strengthen the scientific argument for validity.

The study sought to answer whether communal latrines significantly reduced open defecation in Liberian slums. While adult respondents have benefitted from the provision of communal latrines, young children have been largely excluded because of cost and societal acceptance of open defecation amongst children. Although usage rates amongst the adult population were reportedly high, there was an even larger portion of the target population not using the latrine. The findings suggest that the manner and scale that communal latrines have been provided in Monrovian slums is not sufficient to stop open defecation.

The study also questioned whether the community management of communal latrines was sustainable. The findings suggest that the technical design has made it difficult for community-based WASH Committees to maintain the latrines as communities reported too small, overburdened septic tanks that leak raw sewage into the roads. The WASH
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Committees cannot mitigate this environmental and public health risk without substantial external assistance. Furthermore, the current design is not environmentally sustainable because the sewerage network does not function properly and vacuum tanks are obliged to empty septic tank contents untreated into the sea.

These management challenges are handled by the WASH Committees alone each having varying levels of skill and motivation. The inability of the New Kru Town WASH Committee to resolve a conflict resulted in the community being locked out of the communal latrines for nearly five months. The Zinc Kamp WASH Committee was unable to find a caretaker for four months and the facilities sat unused while the target population continued promiscuous defecation. Each community reported that the user fees were not enough to empty the septic tank when it first fills. These findings imply that the current management structure gives the community too much responsibility in the O&M of the toilets without sufficiently building local capacity to solve problems. This adversely affects use and threatens the sustainability of the latrines.

Communal latrines as a policy response to poor sanitation in Monrovian slums have shortfalls that can only be overcome if the factors for sustainability are systematically addressed. Concern Liberia and partners should build the capacity of WASH Committees through standardised trainings to ensure a basic level of knowledge and skills. Gender equity should be promoted to ensure that the communal latrines are responsive to the needs of mothers and children. A sanitation demand should be stimulated through social marketing activities that replace the disease-driven approach to sanitation provision. There is also a need to advocate with municipalities for a reduced rate to empty septic tanks in slum communities. These recommended actions would greatly improve the sustainability of the community-managed communal latrines, and reduce the sanitation-related disease burden of the communities.

1. Introduction

Communal latrine provision as a solution to sanitation in sub-Saharan African slums is a weak policy response to the sanitation crisis of the urban poor.

Globally 2.6 billion people lack access to improved sanitation about three quarters of who reside in sub-Saharan Africa (hereafter Africa).1 A lack of access to the safe disposal of human excreta has traditionally been worse in rural areas but a majority of the African population is expected to reside in urban areas by 2015, increasing the urban need for sanitation by 50 per cent.2 In Africa, urbanisation is synonymous with slum densification as the region has an annual slum growth rate more than double the global average (4.53% per annum). Currently about 80% of urban dwellers in poorer African countries reside in slums and Africa is expected to have the highest number of slums by 2020.3

Challenges to providing sanitation in African slums are broad. Sanitation has been severely underfinanced; there has been little investment into the research and development of cheap sanitation innovations; it is expensive to import northern technologies; and national sanitation policies fragment responsibilities across institutions. The aforementioned factors result in a weak foundation for national sanitation provision in both urban and rural areas. Urban sanitation has been further challenged by rapid urbanisation that has outpaced the provision of water and sewerage pipes, poor governance, a lack of political will, a failure to recognise and provide service to informal settlements and decentralisation with insufficient capacity building at the local level.

State and non-state providers have responded to the sanitation crisis through the provision of communal or shared latrines. This policy report will focus on communal latrine provision as an international non-governmental organisation (INGO) response to inadequate sanitation in African slums. While communal latrines do not meet the World Health Organization/United Nations Childrens Fund Joint Monitoring Programme (WHO/UNICEF JMP) definition of improved sanitation* it is the most common means by which humanitarian agencies aim to reduce open defecation and the unsafe disposal of human excreta in the slums.

JMP: An improved sanitation facility is one (private or shared with a reasonable number of people) that hygienically separates human excreta from human contact. Communal latrines are not considered improved sanitation.

2. Aims and objectives

2.1 Aim The overall aim of this policy report is to investigate communal latrine provision as a policy response to improve sanitation amongst urban slum dwellers in Liberia.

2.2 Objectives The objectives were to: 1. Summarise existing knowledge regarding communal latrines and other low cost technologies with a focus on how management and fee structures impact sustainability. 2. Carry out a case study of a select communal latrine in a cholera-endemic Monrovia slum to explore usage rates, characteristics of users and non-users, and evidence of any groups being systematically excluded. 3. Highlight good practices in communal latrine provision in select African slums including latrine design/user fees/ cleanliness/ maintenance/ distance/ opening times/gender sensitivity/child friendliness and how these features impact use. 4. Critically review the policy of (communal) sanitation provision in Monrovia slums in light of the desk and field research, and make recommendations relating to urban slum sanitation policy. 5. Make policy recommendations to the Liberia WASH Consortium and the Liberia Water and Sewer Corporation based on evidence from field research and selected good practices on sanitation provisions in the slums.

3. Background 3.1 The slum context The United Nations Expert Group Meeting in Nairobi (2000) defined a slum as a contiguous settlement where the inhabitants are characterised as having inadequate housing and basic services. A slum is often not recognised and addressed by the public authorities as an integral or equal part of the city.4 Slums can be found on the land that nobody wants such as rubbish heaps, swamps, and other unsafe areas. Strategic settling provides some protection against eviction but also increases the populations risk to infectious diseases and makes it difficult to find an appropriate sanitation solution. Because of the mainstay features of the slums, there is little sanitation demand, as poor tenants may fear that an investment in sanitation will result in an unaffordable rent hike, and landlords do not feel compelled to offer
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household latrines.5 A lack of sanitation coupled with other environmental factors is associated with the high levels of ill health found by Rhaman et al (1980)6 in the Dhaka slums; and Gulis et al (2003)7 in the Nairobi slums.

3.2 Government approaches to slums and its impact on sanitation Arimah et al (2010) conceptualised three ways in which African States have dealt with slums: Benign neglect, forced eviction/demolition, and resettlement/upgrading. Each approach has implications for sanitation provision. Countries adopting the approach of benign neglect have deemed slums illegal, temporary and prone to disappearance with the financial growth of the country. Settlements with illegal status are often not serviced by municipal authorities and have no access to credit because their homes cannot be used for collateral.8 In a resettlement situation, families are allocated land in which they are expected to build their own houses (or low-cost housing is provided), and the burden of sanitation falls on the household. In slum-upgrading programmes the environment is targeted for improvement and communal latrines are typically provided. 3.3 Communal latrine provision in African slums The provision and management of communal latrines varies according to context. In African slums a common practice is for community members to pay at the point of use or to gain access through the purchase of a monthly card. The structures are often built by I/NGOs or government agencies that either lease the latrines to private contractors, or donate them to the community to manage. User fees pay the caretaker who maintains the toilet block on a daily basis. Fees also pay the municipality or private contractor that empties the pit/tank. This fragmentation has profound implications for partnerships, because it is very difficult to link the three segments and their role players into the delivery chain needed for effective service delivery.9 Communities are then expected to take ownership of facilities that have no institutional home, accountability or oversight. The end result is that facilities often fall into disrepair and disuse even in sanitation-stressed areas.10 Research has found that communal latrines are often just receptacles for excreta11 that are inaccessible and unresponsive to the needs of the target population because of issues related to cost, access, security and overuse.12 In Harare, Zimbabwe 1,300 people are supposed to share six seats. In Kibera, Nairobi, 190 shared facilities serve a population of 250,000 (1:1300 users).13 In Nairobi slums women have reportedly been raped en route to
Health problems found included intestinal problems, measles, fever, skin diseases, chronic respiratory infections.

the communal latrine.14 Researchers have found that mothers sometime worry that children will catch diseases from adult faeces on toilet slabs and fear that small children will fall into poorly designed toilets.15 These aforementioned factors discourage use and open defecation is still prevalent in communities where communal latrines are provided. 3.4 Good practices in the community management of communal latrines Progressive community-based organisations (CBOs) have introduced community management schemes that have a wider focus than simply providing toilet seats. The CBO, Umande Trust, built 20 communal bio-sanitation centres in the Kibera, Nairobi slum the largest being the Katwerkera Tosha Bio Centre. The facilities were found to be sustainable in a number of ways when evaluated against ten criteria put forth in the Good Practices Related to Access to Safe Drinking Water and Sanitation outlined by the Office of the High Commissioner for Human Rights (OHCHR).16,

Community processes to build and operate the bio-centres were found to promote democracy and inclusiveness through the engagement of already-established community groups that select sites of the bio-centres and manage services. The community groups directly profit through a community-shareholding scheme in which 60% of the fees are allocated to members as dividends; 30% pays for the O&M of the facility; and 10% is deposited in a sanitation development fund.17 The technology of the bio-centres is equally important as communities do not have to spend money to empty pits/septic tanks as the toilets are connected to a bio-digester in which biogas is produced. Collectively the biocentres service about 12,000 users per day.

Another example of a good practice is the Greater Mumbai Slum Sanitation Programme (SSP), which focuses on building strategic partnerships for the successful community management of communal latrines.18 Under the SSP, NGOs lead a community-wide consultative process, which results in the formation and registration of CBOs in sanitationstressed areas. Families must express demand through the contribution of a small membership fee.** CBO members provide assistance and oversight of the latrine construction throughout the building process. The integrated contracts feature of the SSP formally links all actors in the provision of communal latrines in the slums. Unifying the fragmenting service delivery of communal latrine provision in the slums, generating demand
Ten criteria include: availability, accessibility, affordability, quality/safety, acceptability, non-discrimination, participation, accountability, impact, and sustainability. TV/video room, caf, clinic, water kiosk, meeting rooms ** The fee is Rs.100 per adult (US $2.25) (up to a maximum of Rs. 500 (US $11.25) per family.

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for sanitation at the household level, and introducing mechanisms for the accountability and regulation of the structures, provides the necessary conditions for the management of communal latrines in the slums.19

4 Justification and key questions Access to the safe disposal of human excreta is a fundamental human right that protects health and upholds human dignity. Liberia has a population of 3.6 million and nearly 2.9 million lack access to improved sanitation. The sanitation situation has been affected by the countrys two brutal civil wars that spanned over a 14-year period from 1989 to 2003. Pre-war sanitation coverage was 27% but a massive influx of people into the capital of Monrovia, along with destruction of the nations infrastructure and WASH institutions reduced national sanitation coverage to 17%.

Inadequate sanitation is the key protagonist in a web of interrelated diseases such as diarrhoea, malnutrition, acute respiratory infections and endemic cholera. Cholera is endemic in Monrovia and about 888 cumulative (suspected) cholera cases occurred from 31 Dec 2008 to 18 Oct 2009, nearly 98%
originated in the capital city.20 About 50% of Monrovias population lives in slums and INGOs respond to cholera hotspots through the provision of communal latrines, public tap stands and hygiene promotion.

This case study sought to answer: 1. Do communal latrines significantly reduce open defecation in Monrovias slums? 2. Is the community management of communal latrines sustainable?

5. Materials and methods The study was comprised of a desk-based review and field research in Monrovia. The fieldwork portion took place over a five-week period from 27 June to 31 July 2011. Access to the research site was made possible with support of the Liberia WASH Consortium, which comprises five INGOs including Oxfam GB, Concern Liberia, Tearfund, Action Contre la Faim and Solidarits International. Concern Liberia is the only INGO that has built communal latrines in three of the nine Monrovian slums. The sites comprise Billimah, Zinc Kamp, and New Kru Town. All three communities participated in some of the research activities.

Civil war dates: 1989-1996 and 1999-2003

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COMMUNITY Logan Town

VILLAGE Zinc Kamp (pay-per-use) Kinc Kamp (Shared)

POP 2,362

BUILT 2010

HOURS 24 hours

MANAGEMENT WASH Committee

ACTIVITIES HH survey Transect walk Individual/group interview Latrine observation

2,871

6.00-22.00

WASH Committee

Freeport

New Kru Town (Beach) New Kru Town

3,783

2009

LOCKED

WASH Committee

HH survey Transect walk Individual interview

LOCKED

WASH Committee

Bushrod Island

Billimah I

3,520

2010

6.00-22.00

WASH Committee

HH survey pilot Latrine observation

Billimah II

6.00-22.00

WASH Committee

Figure 1: Research sites and activities

5.1 Search strategy Database searches of OvidSP, Eldis, and Ovid Medline were conducted that combined the keywords shared latrine communal latrine or toilet or communal flush toilet or sanitation block and sanitation or excreta management or CBO or fe#cal sludge management or ULTS or CHC or demand or participation or MDG or open defe#cation or hygiene or behavio#r change or technolog* and Africa and slum* or informal settlemen or urbani#ation or urban area*. Searches were limited to English language articles, and citation searching was conducted to identify additional references and titles on the research topic.

5.2 Data collection tools The case study employed qualitative and quantitative methods. The quantitative data was analysed using Statistics/Data Analysis (STATA), while interviews were audio recorded and coded with NVivo 8.

5.2.1 User counts Delays in reaching the field prohibited enumerators from conducting a traditional user tally at the Zinc Kamp site. Therefore the number of users was derived by dividing the cost-per-use
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(LD $5) by the sum of fees collected at the Zinc Kamp pay-per-use facility. On 7 July, the day of the household survey, 20 users paid to use the Zinc Kamp facility. The monthly toilet at Zinc Kamp has an average of 18 rooms (mean household size of 7.8), which means an average of 140 have access to the pay-monthly facility. No information on the gender and age of users was ascertainable from these data, and all rooms and users reportedly paid the same established fees. No user count for New Kru Town was possible because the facilities have been locked for nearly five months in a community political spat.

5.2.2

Latrine inspections

Visual inspections were conducted in Zinc Kamp and Billimah to ascertain the physical conditions of the latrines and whether the latrines safely separated human excreta from human contact. The survey assessed whether there were visible faeces in the cubicles, if there materials for hand washing or anal cleansing, if a foul smell existed and whether the facility was well maintained or needed repairs. At the Billimah facilities, the caretaker was not on duty and two of the six cubicles were locked. At one of the Zinc Kamp facilities one of the caretakers was not on duty and only a partial observation was possible. Observation of the areas outside of latrines in New Kru Town revealed many instances of open defecation near the facilities. [See Appendix 11.3]

5.2.3

Household survey

Six community-based enumerators were deployed to New Kru Town and Zinc Kamp slum sites on 7 July 2011. Billimah was not included in the household survey because after learning that New Kru Town community had no access to communal sanitation the survey was used to measure variations in the defecation practices and attitudes toward communal sanitation in the two intervention communities. The survey gathered data on household composition, household resources, sanitation practices, communal latrine use and frequency, satisfaction with the facilities, perceptions of established fees and prevalence of self-reported diarrhoea. A comparison of the mean values between Zinc Kamp and New Kru Town communities were done using simple group comparisons. Statically significant differences were revealed in regards to defecation practices of adults, but no significant differences were found between the defecation practices of children or the diarrhoea prevalence in the households of both communities.

LD $5 equals US $0.07.

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The enumerators were trained on 4-5 July and the survey was piloted in Billimah on 6 July. Systematic data cleaning took place on 9 -10 July to eliminate errors that took place during collection or data entry. [See Appendix 11.2]

5.2.4

Key informant interviews

Six key informant interviews were conducted with WASH Committee members and WASH and programme mangers working at Liberia WASH Consortium partner agencies. Interview topics covered topics including capacity building and training of WASH Committees, monitoring activities and communal latrines as a response to cholera. The interviews were audio recorded to increase the validity of the data. Coding took place with NVivo 8.

5.2.5

Group interview

A group discussion was conducted with the Logan Town Womens Development Association on 11 July to ascertain the gender-and-child responsiveness of the communal latrines. Questions included childrens use of the toilet, considerations of cost for childrens use, womens safety and privacy. Due to security concerns, the group interview was not audio recorded. Coding took place with NVivo 8.

5.2.6 Transect walks Transect walks took place at Zinc Kamp and New Kru Town slums. On 1 July a transect walk took place with the New Kru Town WASH Committee chairman. He revealed that the toilet facilities had been locked for nearly five months in a community political spat. Near the communal latrines there was nearly half a dozen piles of faeces covered with flies. The WASH Committee Chairman then lead the team to an open defecation site on the beach, about 100 metres away from beachside toilet facility. Groups of children were observed defecating on the beach, and adults were observed going to-and-fro the site. The WASH Committee chairman said that meetings were planned with the local administrator of the slum to regain access to the latrines.

On 6 July a transect walk took place with the Zinc Kamp chairman. The walk started at the pay-monthly facility and ended at the front of the settlement. He pointed out areas where households were squatting on unpaved government roads and explained how this prevented any potential sanitation upgrades for large portions of the community because no tankers could access pits or septic tanks for emptying. The poorest households lived in this

The group interview took place outside.

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area. He also pointed out the section where many people owned homes, and stated that although some homeowners could afford to build household toilets, the tradition was often that people built the house first and thought about the toilet later. He also pointed out abandoned latrines and non-functioning tap stands due to poor design and people stealing the metal taps to pawn for money. He cited access to water and sanitation as one of the biggest issues in the community.

5.2.7 Ethical Considerations The LSHTM Ethics Committee approved this study on 3 June 2011. An amendment to the application was filed on 6 June 2011 to include the household survey as an additional method.

5.3 Sampling 5.3.1 Selection of latrine facilities Concern Liberia has built communal latrines in three slum communities in Monrovia: Billimah, Zinc Kamp and New Kru Town. Each facility has two toilet blocks with six cubicles. The user-latrine ratio is: 293:1 at the Billimah facilities; 393:1 at the Zinc Kamp pay-per-use; 478:1 at the Zinc Kamp monthly; and 315:1 at the New Kru Town facilities. All communal latrines were observed either inside or outside for cleanliness and maintenance.

5.3.2 Selection of households A near straight line from the latrine to 100 metres was taken with a Vonlen-511 etrex handheld GPS. The sample was not adjusted for spatial clustering. Enumerators knocked on every other house as a form of random selection of respondents. Interviewers then asked to interview the head of the household, or a member of the household that was at least 18years old and had knowledge of the sanitation practices of the household. Information and consent forms were completed before the interview took place.

5.3.3 Selection of key informant/group interviewees As part of the collaboration with the Liberia WASH Consortium, WASH and Public Health officers of Liberia WASH Consortium agencies were targeted for key informant interviews. Concern Liberia WASH staff identified and called WASH Committee members from the intervention communities to participate in the study. The chairman of Zinc Kamp community contacted the chairwoman of the Logan Town Womens Development Association to

15

arrange the meeting with the women of the association.

6. Communal Latrine Provision in Liberian Slums a case study 6.1 Introduction Liberia is a West African country on the North Atlantic coast of Africa. It is bordered by Guinea to the north, Cte d'Ivoire to the east, Sierra Leone to the northwest, and the Atlantic Ocean to the south and southwest. The population is estimated at 3.6 million, about 48% of which are urban inhabitants. Liberia was entrenched in two brutal civil wars over a 14-year period from 1989 to 2003 (1989-1996 and 1999-2003). The conflict destroyed the nations infrastructure, institutions and systems of governance; uprooted families and killed an estimated 250,000 Liberians. A direct result of the war is high levels of poverty in the country, with at least twothirds of the population surviving on less than US $1 per day. About 99% of Liberians lack electricity and running water and access to sanitation is severely limited.

Figure 2 Topographical map of Liberia21

6.2 National sanitation priorities The Government of Liberia (GoL) has expressed its commitment to tackling poverty in its poverty reduction strategy paper (PRSP) for 2008-2011. Sanitation and water are included under Pillar IV, Infrastructure and basic services. The Governments goal vis--vis the PRS

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is to reduce the water and sanitation-related disease burden through scaling up hygiene promotion in communities and schools, and increasing access to clean water from 25% to 50% and increasing access to sanitation from 15% to 40% by 2011.

Figure 3 Sanitation coverage (%) in Liberia. Based on WHO/UNICEF JMP Statistics (2010)

6.3 Policy environment and institutional framework Liberia passed its Water Supply and Sanitation Policy (WSSP) in 2009. In regards to urban sanitation, the government aims to provide basic services for all through the provision of piped sanitation or on-site sanitation systems.22 Funding to implement the WSSP has been minimal and financing of the sector was a paltry 1% of the total budget in 2008/9. This meager allocation took place even though Liberia signed the eThekwini Declaration on Sanitation in 2010, in which African governments pledge a minimum commitment of 0.5% of national GDP for sanitation and hygiene. The government has since increased its commitment to WASH, and allocated sector ministries and agencies 7.3% of the total PRS costs for 2010/2011.23 The 2010 United Nations Development Programme Country Status Overview found that US $68 million would be needed annually to expand and sustain sanitation in the country and only one-third of the necessary investment has been funded.24

Institutional arrangements The roles and responsibilities for WASH are fragmented across three ministries and there is no mechanism to lead or coordinate the overall strategy. As written, the Ministry of Land, Mines and Energy (MLME) is in charge of water resources; the Ministry of Health and Social Welfare (MoHSW) is responsible for water quality; the Ministry of Public Works (MPW) provides water and sanitation to rural areas; the Liberia Water and Sewerage Company (LWSC) is provides water and sanitation to populations over 5,000 urban areas (although

17

mandated for urban and rural). Donors and multi-lateral organisations have assumed a

budget support model where monies are contributed through one of several reconstruction funds. INGOs have provided support and direction with the implementation and scaling up WASH activities. It is not clear, however, from the
institutional arrangements exactly who has the responsibility for the oversight and regulation of communal sanitation in urban areas.

6.4 Sanitation in urban Monrovia The LWSC is responsible for providing water and sanitation services to Monrovia, the 15 County capitals, and other urban centres with populations greater than 5,000. An estimated 25% of Monrovia is connected to the sewer system, while 75% of the urban population uses either on-site sanitation (pit latrines and septic tanks) or unimproved forms of excreta disposal. There are no official figures on the number of people with flush toilets connected to septic tanks, however, vacuum trucks empty the septic tank and drive outside of the city to dump the contents into the sewer network. The contents are then released untreated into the swamps and sea because of dilapidated sewerage network is not functioning.25

6.5 Sanitation provision in Monrovias slums There are nine slum communities in Monrovia, most of which are located in flood prone areas that pose significant sanitation related risks due to constant flooding and close proximity to major refuse dump sites. The slums of Monrovia are vestiges of the war as a majority of its inhabitants are internally displaced persons (IDPs). From 1980 to 2000, the annual population increase in the capital city was 3.8% of unplanned growth. Monrovias population alone increased from 0.7 to 1.2 million people over the last 10 years of the conflict and now stands at about 1.5 million. Slums began to form in the 1950s but slum densification took place during and after the war. A 2011 Norwegian Refugee Council report asserts that early on in the conflict, municipalities started charging yearly squatters rights fees. This practice stems from a 1957 Zoning Code on non-conforming structures. Charging squatters rights is a de facto practice that is broadly accepted but not clearly legal. Paying the fee entitles the holder to occupy the area until such time as the government fines [sic] it necessary to use the land in which case, one month notice will be given to vacate the premises.26

While there is a dearth of information on sanitation in Monrovias slums, a 2009 Integrated Regional Information Networks (IRIN) report found that in Clara Town, Monrovia nearly
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75,000 people share 11 public toilets; and in West Point, Monrovia an estimated 70,000 people share four public toilets.27 Therefore, while communal sanitation is provided in slums, access remains limited, and a high number of people are forced to defecate into plastic bags and dispose of them as flying toilets or resort to open defecation.

With sanitation conditions such as these, diarrhoeal diseases are a major health concern in Monrovia and in 2008 the WHO reported that 18% of all deaths in Liberia are WASHrelated.28 Cholera is endemic in Montserrado, Grand Basa, Grand Gedeh and Maryland counties. Data from MoHSW reports 888 cumulative (suspected) cholera cases from 31 Dec 2008 to 18 Oct 2009. In River Cess County (2009) there were two reported cholera deaths. The highest attack ratesor number of cases/populationoriginated in Bushrod Island (0.02%), Sinkor (0.07%), Central Monrovia (0.10%) and West Point (0.21%). At least 47% of randomly collected specimen (n=79) tested positive for vibrio cholera serogroup 01 in the lab.29

The INGO provision of communal latrines in Monrovias slums is one component of an institutional response to cholera. Cholera hotspots or communities that dominate the cholera reports*** have first priority in the INGO consideration of providing communal latrines.30,31 Communal latrine provision is only one aspect of the cholera response. All partners to the Liberia WASH Consortium implement other WASH activities in urban slums including the construction of public tap stands, and hygiene promotion.

7. Results

7.1 Number of paying users The number of users was calculated using financials made available from the Zinc Kamp WASH Committee. The data was given for the number of months the latrines have been operational as it took nearly four months to find a caretaker and open the latrines for use. The pay-monthly facility is located in a more isolated section of the community and the WASH Committee converted it to a monthly payment scheme to make it financially viable. While this fee structure has allowed the facility to operate, it has excluded those who are unwilling or unable to pay the monthly fee, as it is accessible by key to members only.
***

When there is a suspected cholera case, the General Community Health Volunteer (GHCV) reports the case to the Environmental Health Team (EHT). The EHT then submits the report to the County Health Team (CHT), which is responsible for making the final report to the MoH. Cholera reports are also sent to the MoH when a person receives treatment at a government clinic.

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Pay-per-use facility There are 2,362 people in the pay-per-use catchment area. For the month of July, the mean number of paying users per day is 15, with a minimum of 11 users and a maximum of 26. The mean number of users represents 6% of the target population. Calculations of users from 6 February 2011 to 10 July 2011 found that the mean number of users per month is 353. This means that on average, only 15% of the target population is using the latrines per month.

Pay-monthly facility There are 2,871 people in the pay-monthly catchment area, and there are 18 rooms paying each month to use the facility. Assuming that the average household size is 7.8, as reported in the household survey, the pay-monthly facility serves an average of 140 users per month. This represents about 3.2% of the target population.

Table 1: Number of facility users over one day FACILITY Zinc Kamp I (Pay-per use) EST POP32 2,362 TOTAL USERS33 Feb Mar Apr May Jun 10 Jul Zinc Kamp II (Monthly card) 2,871 330 437 376 354 460 162 % of total pop Feb Mar Apr May Jun July 14 % 19 % 16 % 15 % 19 % 7%

140 users

7.2 Physical conditions and operating characteristics of facilities Latrine observations took place at Zinc Kamp and Billimah communities. The New Kru Town facilities were locked but observation of the areas near the toilet block revealed many instances of open defecation. The pay-monthly toilet block at Zinc Kamp is more similar to a shared latrine and was much cleaner than the pay-per-use toilet block. Only one of the caretakers was on duty during the site visits, therefore two of the latrines were locked. Observation was therefore only possible on the unlocked cubicles.

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Table 2: Operating characteristics of facilities

COMMUNITY Logan Town Freeport Bushrod Island Village Zinc Kamp (Pay-per-use) Kinc Kamp (Shared) New Kru Town (Beach) New Kru Town Billimah I Billimah II POP 2,362 2,871 3,783 3,520 BUILT 2010 2009 2010 HOURS 24 hours 6.00-22.00 LOCKED LOCKED 6.00-22.00 6.00-22.00 MANAGEMENT WASH Committee WASH Committee WASH Committee WASH Committee WASH Committee WASH Committee

Of the total cubicles observable: 13% had faeces on the floor; 44% had faeces on the toilet seat/slab; 25% had faeces on the wall; 25% had a foul smell; 75% had cobwebs; and 33% were locked from the outside and there was no caretaker around with a key. The pay monthly facility was cleaner than the pay-per-use facility at Zinc Kamp. All of the facilities in Bilimah were pay-per-use and there no marked difference between the cleanliness of either toilet block. Table 3: Physical conditions of facilities

7.3 Social and economic characteristics of communal latrine users The most common occupations of the head of household included caring for the family (22%), casual work (21%) and informal business/petty trade (16%). The protracted civil conflicts destroyed the economy and severely reduced livelihood options. The informal sector is therefore a major provider of employment for the population. The informal sector includes casual work, petty trade, construction, food/janitorial/security services and provides some source of income for the officially unemployed.34

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Table 4: Ages and occupations of communal latrine users

Figure 4: Age distribution of respondents

7.4 Household latrine ownership The mean household size is 7.8 (CI: 6,9). Of the 12 households reporting latrine ownership, only 7 (58%) owned toilets that qualified as improved sanitation. The remaining 5 (42%) owned hanging latrines, which do not safely dispose of human excreta. The two most common reasons given for not having a household latrine is cost 43% (CI: 32, 54) and space 25% (CI: 16, 35).

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7.5 Household resources Households in the communities do not have a large resource base to draw from in terms of assets or infrastructure. The average household does not own a refrigerator/icebox. Only 23% reported owning a generator and 22% reported owning a TV. The most common asset that households owned was a mobile phone (62%). A woman heads the average household and the main occupation for female-heads of households is homemaker and does not earn an income. Families are large, on average about 7.8 household members, with only 65% of head of households involved in income generating activities. Remittances account for some of the resource base as 11% of respondents reported remittances as a form of support. There was no association between household resources and reported communal latrine use.

7.6 Patterns of use reported by communal latrine users Of the households interviewed for the household survey, 65% (CI: 54, 75) reported having ever used the communal latrines. All (100%) of Zinc Kamp users (n=28) reported that the primary purpose for using the communal latrine was defecation, and 70% (CI: 52,89) of users had used the latrines one day prior to the survey. Because the communal latrines at New Kru Town have been inaccessible for nearly five months, the question of communal latrine use was modified to investigate any instance of communal latrine use in the past. Of those surveyed, 67% (CI: 51, 82) reported using the latrines at least once in the past.

While self-reported data show that communal latrines significantly affect open defecation in Zinc Kamp, group interviews confirmed that promiscuous defecation is a big problem, particularly at night. In the morning you walk outside and you see faeces all over the place. You dont know who did it. You cant find the person, Ms. Jones exclaimed! Ms. Ellis nodded in agreement. Its bad. If you see someone you tell them, this place is not for you!35

Table 6: Communal latrine use Facility Zinc Kamp (n=39) New Kru Town (n=40) Use (%) 26 (67) 25 (63) 95% CI (51, 82) (47,78)

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Table 7: Frequency of communal latrine use Zinc Kamp (n=39) Once a day Once a week Twice per week More than three times per week Dont use Frequency 18 (46) 3 (8) 2 (5) 3 (8) 13 (33)

7.7 Children and communal latrine use At least 53 respondents reported that a child under five (U5) lived in the household. Respondents reported that the usual place of defecation for U5s was the potty, 29% (CI: 19,39), bush, 20% (CI: 11,30), or beach 16% (CI: 8,25). While the use of a potty is hygienic, the most common method of stool disposal is unhygienic. Of the total sample, 58% (CI: 47,70) reported that the faeces in the potty are customarily tossed in the drain/ditch, while 9% (CI: 3,15) reported disposing of the faeces with solid waste. Only 14% (CI: 6, 22) reported throwing the stool down the toilet. Of these 26% (CI: 14, 39) reported that the U5 had experienced runny stomach (diarrhoea) within the past seven days. Upon entering the yards to interview people, field workers observed scattered faeces near many of the houses.

Group discussions with women from the Logan Town Womens Development Association revealed that WASH Committee members found that it was socially acceptable for children to defecate in the open and that the cost to use the latrine was prohibited when it had to be paid for multiple times for multiple children. Some of us have five or six children and we dont have money to pay $5, $5, $5, $5 at the end of the day its [LD] $35. We need that money to feed our children Ms. Jones said. Another woman added, The children are supposed to go to the toilet but the money is too much, so they go in a small bucket but sometimes outside near the house. Questions on what happens to the childrens faeces in the bucket were met with different answers. One woman said that mothers dig a hole and cover it, but Ms. Morrison shook her head and said, We just let the children see to it. Sometimes they throw it in a ditch.36 Findings suggest that cost and social acceptance of children defecating in the open made it less likely for mothers to insist that children use the communal latrines.

7.8 Payment and willingness-to-pay Of communal latrine users, 37% (CI: 26,48) reported that the fee was too high while 25% (CI: 16,35) thought that the fee was about right. A majority of respondents (46%) (CI: 15, 76) reported that they were willing-to-pay LD $5 for three uses, while 38% thought that a fair
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price was LD $5 for 2 uses. Many of the public toilets in Monrovia charge "LD $5 for three uses" and this recommendation is in line with the status quo. There was no separate fee structure for children and the poorest community members. Table 8: Established fees Facility Zinc Kamp (pay-per-use) Zinc Kamp (monthly) New Kru Town (I and II) Fee LD $5 per use LD $100 per month/per room LD $5 per use (closed)

Table 9: User perception of established fees (%) Zinc Kamp & New Kru Town Users (n=51) About right 14 (18) CI: 9,26 Too high 20 (25) CI: 16,35 Too low 1 (1) CI: -1,4 Dont use 28 (35) CI: 25,46 Dont know 16 (20) CI: 11,29

7.9 Sanitation access and plans for future use of communal latrines The primary reasons for not having a household latrine were cost, 43% (CI: 32, 54), and space 25% (CI: 16, 35). Plans for future use is high amongst the majority of respondents 57% (CI: 46, 69) with some variations between the two communities. Data reveal that more users at Zinc Kamp do not expect to use the communal latrines compared to New Kru Town residents. The difference could be attributable to access to sanitation, for example, New Kru Town have no access whereas Zinc Kamp residents have some access and have expressed dissatisfaction with cleanliness, cost and opening hours. More Zinc Kamp respondents plan to build a latrine in the near future while no respondents in New Kru Town reported any such plans.

Qualitative research revealed that aside from cost, land disputes prohibited latrine construction. The majority (88%) of respondents in New Kru Town are from the Kru tribe, and second to cost, lack of space, 38% (CI: 20, 50) was the second most common barrier to latrine ownership. Transect walks through the community revealed physical space on the plots; key informants revealed that lack of space referred to disagreements with neighbours/kin on the location of septic tanks and to avoid disputes with ones neighbours/kin many people would rather go without a toilet as this is traditionally how houses are built. People build a house first, then they think about the toilet and at that time, it is too late, there is no space.37

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Table 10: Percentage of users who expect to use the latrines in the future Facility Zinc Kamp (n=39) New Kru Town (n=40) Frequency (%) of users who do not expect to be using the facilities a year from now 26 (67) 8 (20)

Table 11: Percentage of users who plan to build a latrine in a years time Facility Zinc Kamp (n=26) New Kru Town (n=8) Percentage of users who do not expect to be using the facilities in a years time and plan to build a latrine 7 (27) 0 (0)

7.9.1 Communal latrine users satisfaction with the facilities The majority of current communal latrine users (Zinc Kamp) reported being Satisfied or Very satisfied with the provision of communal latrines. The top reason cited for liking the communal latrines was privacy 36% (CI: 23, 48), and clean environment, 22% (CI: 11, 33). The aspects of communal latrines that were not liked included cost, 42% (CI: 22, 63), night closure of the facility, 27% (CI: 9, 45), and faeces on the toilet seat, 19% (CI: 3, 35). Table 12: User satisfaction Zinc Kamp (n=39) Satisfied/V Satisfied Unsatisfied/V unsatisfied Dont use Frequency (%) 24 (62) 2 (5) 13 (33) 95% CI (46,76) (-2, 12) (18,49)

There were some differences in satisfaction according to gender. Women reported being very satisfied 71% (CI: 51, 92) compared to 50%(CI: 25,75) of male respondents. Group discussions with women found that they felt insecure when they had to defecate in the open and that men sometimes stood and looked. Women said they preferred to use the communal latrine or ask a neighbours toilet because open defecation is risky. You can be harmed at any time, one woman said.38

8. Discussion 8.1: Do communal latrines significantly reduce open defecation in urban slums? This small sample size allowed for the drawing of some general conclusions on the effectiveness of communal latrines in reducing open defecation. In Zinc Kamp an average of 155 people use the facilities each day and respondents reported that the facilities were used
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primarily for defecation. Transect walks in Zinc Kamp and New Kru Town communities revealed a higher level of faecal pollution in New Kru Town community, which has no communal sanitation access at all. This observation provided further proof that communal latrines do lead to less open defecation in the community but the manner and scale of communal latrine provision does not stop open defecation.

At least 53 respondents reported that a child under five-years old (U5) lived in the household. Most of the U5s defecated in a plastic bucket or outside. The fee structure and the social acceptance of child open defecation influenced the decisions of mothers to allow children to practice open defecation. Some mothers interviewed associated the childrens runny stomach (diarrhoea) with poor sanitation, and at least 26% (CI: 14, 39) of the respondents reported that an U5 in the household had experienced runny stomach within the past seven days. A limitation of this association is that this study relied on self-reports of diarrhoea prevalence and did not adjust for other factors. However, positive associations between diarrhoea in children and unhygienic child defecation and faeces disposal practices have been reported in 15 rigorous studies.39 These findings raise serious doubts on communal latrine provision as an adequate response to cholera if the peri-domestic domain is polluted with fecal matter that exposes and re-infects household members.

Concern Liberia does not have a child-friendly toilet design and the WASH Committee has established a standard fee for all users. Children must often rely on adults to accompany them to the latrines and pay the user fees. As a result, they are often left no choice but to defecate in the open. This has adverse affects on their health, and organisations that provide communal latrines should take steps to ensure target communities do not neglect the sanitation needs of its most vulnerable members. Inclusiveness can be encouraged though a progressive price structure and child-friendly designs that make it easy for mothers to bring their children to use the communal latrines.

8.2: Is the community management of communal latrines sustainable? There are two dominant forms of communal latrine management: Municipality-based and community-based. This case study focuses on the community-based management of communal latrines through the critical lens of sustainability. This is a necessary critique as MDG Goal 7, Target 7c, aims to reduce by half, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation.40

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The MDGs do not specify or conceptualise what is meant by sustainable sanitation, but most definitions encompass technical, financial, environmental and social aspects. The EcoSanRes criteria for sustainable sanitation reads: protecting and promoting human health; not contributing to environmental degradation; and being technically and institutionally appropriate, economically viable and socially acceptable.41 The sustainability criteria applied to the communal latrines built by Concern Liberia encompasses the environmental, financial, technical and community aspects of the EcoSanRes criteria.

Technical Concern-built communal latrines are pour-flush toilets attached to septic tanks. The design was chosen because many of the slums are located on sand and have high water tables. The technology choice affects management if the community is unable to effectively respond to problems on its own, with limited external assistance. The WASH committee members of Zinc Kamp and New Kru Town have reported the incidence of tank overflow and discharge of raw sewage into the environment (particularly during the rainy season). Users responded by not using the latrines and complaining about the cleanliness of the toilets. It was also reported that digging shallow wells and fetching water to flush the toilet was burdensome, and this also had some influence on people using the communal latrines.

The topography of Liberia and the slum context make septic tanks an appropriate and a problematic choice. With user fees as the only money available for the O&M of the latrines, it can be difficult to raise enough money to empty the tanks, said Morris Sherman, Construction Engineer for Concern Liberia.42 Emptying the tanks cost from USD$100 to US $150, depending on the size of the community and tank. The communities tell us that the cost is too much, Mr. Sherman said. The LWSC (LWSC) is responsible for emptying the tanks, although the United Nations Mission in Liberia (UNMIL) has assisted communities on request at a charge of US $75. Large tanks require about three trips (US $100 per trip), which is expensive for low-income communities to afford. The technical aspect of the communal latrines has made it difficult for the target population to manage the provision of communal latrines, as the complete sanitation cycle has not been well considered from the birth of the project.

Financial If the money raised from user fees is not enough to operate and maintain the toilets, the tanks become full, the toilets smell and people will avoid using the facility. In the Monrovia
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example, user fees are the only source of revenue for the O&M of the toilets. Community sources report that the user fees will not cover the cost of de-sludging the tanks at the time that they need servicing. Alternative financing mechanisms must be explored as 25% (CI: 16,35) of users said that the current fee is too high. Therefore, increasing the fee to meet O&M costs could have an adverse affect on use. As the new Liberia WSSP emphasises propoor policies, Concern Liberia could advocate with the LWSC to empty septic tanks in the slums at a reduced rate. This could be an entry point for strategic partnerships with the local government. The Umande Trust and the Greater Mumbai SSP have demonstrated ways to achieve full cost-recovery without charging burdensome user fees. This model should be explored for its transferability to the Monrovia context.

Community When Concern Liberia builds a communal toilet it hands the facility over to the community for use and upkeep. Community members serve on the WASH Committee, which comprises 10 members including: two Community Health Volunteers, community water pump mechanic, a sanitation representative, and community leaders with influence. Concern Liberia coordinates the capacity building and training of the committee through inviting partners to give workshops on different aspects of O&M. Key informants revealed that motivation is of Committee members is sometime low, and the lack of tangible incentives mean that participation can be unsatisfactory.

The WASH Committee is solely responsible for the management of the latrines and communal latrine provision has suffered in both communities because of managementrelated issues. A dispute over the handling of funds led to the locking of the communal latrines in New Kru Town for nearly five months. Self-reported defecation is quite high 92% (CI: 84,100) and transect walks revealed a high prevalence of faecal contamination in the environment, and an open defecation site that was only 100 metres away from the beachside communal latrine. The WASH Committee chairman said that he would soon schedule talks with the local authority about re-opening the latrines.

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Figure 5: New Kru Town communal toilets that has been locked nearly five months in community dispute.

In Zinc Kamp the toilet block near the rear of the settlement was locked nearly four months from the time it was built, because the WASH Committee couldnt find anyone to take the role of caretaker. The WASH Committee wanted to base the caretaker salary as a percentage of the user fees collected, but couldnt predict how much the facility would collect without previous intake. Without a caretaker, there was no way to collect money and desludge the toilet that would certainly fill with use. The toilets remained locked until the Committee set up a monthly card allotted by the room.

The fee is LD $100 per room, and 18 rooms are currently paying for the monthly card that gives them 24-hour key access. This has increased ownership of the facilities, but it has also prohibited community members who do not participate in the scheme from using the now semi-private toilets. Comparisons were made of the cleanliness of the pay-per-use toilet and the pay-monthly toilet. The latter was cleaner the former and informal talks with users found that they had a sense of ownership of the toilets.

In both cases the management issues were not reported to Concern Liberia, even though directives are given to the Committees on when and how to report issues with the management of the latrines. Key informants report that the reporting system is inadequate because many people in the communities are related to one another and it becomes difficult to make complaints. As this is a post-conflict setting with a relatively weak government,
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people have also experienced making complaints to the local authorities with no results. It is reported that many community members view making complaints as a waste of time. Concern Liberias informal reporting/monitoring mechanism has therefore not been responsive to realities in the community. Concern Liberia is piloting a Complaints Response Mechanism (CRM) in target communities, which will provide participant populations with ways to communicate problems with Concern Liberia and partners. This should assist with the monitoring and support of community-managed communal latrines.

Environmental The current design of Concern Liberia communal latrines is not environmentally sustainable as emptying the septic tanks means that raw sewage must be emptied into the environment, because the sewer network does not function properly. Although expansion of the sewerage network is not the mandate of Concern Liberia, choosing sanitation technologies that do not further degrade the environment is the responsibility of the organisation. Other technologies such as composting toilets, for example, a double-vault VIP latrine (built up in case of high water tables), or an Arborloo toilet.

Given the above findings and studies highlighted in the literature search, it would seem sensible to conduct a qualitative study on the sanitation knowledge, attitudes and practices of the target population to better inform the INGO response to sanitation provision in the slums. This study was not able to assess the financial sustainability of the latrines but it would be appropriate to thoroughly investigate the Umande Trust (Nairobi) and Greater Mumbai Slum Sanitation Project for transferability to the Monrovia context.

8.3 Limitations of the study The household survey was conducted with six community-based enumerators: three were capable performers and three were not. None of the enumerators had previous survey experience as specified in the agreement with the host organisation. This was partially mitigated with practice gained from piloting the household surveys and an additional day of training to allow more time for practice. If I were to repeat this study I would insist on experienced enumerators and allow for a longer period of training in the chronogram.

All diarrhoea cases and sanitation behaviour relied on self-reports and were subject to courtesy bias. The enumerators were not blinded to the research question and triangulation revealed variations between the responses in the household survey and individual/group
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interviews. Logistical restraints prevented the focus-group discussions with users and nonusers from taking place. This wouldve provided more in-depth analysis of user satisfaction and insights into the management of the latrines.

Published information on WASH in Liberia is limited, as many of the ministries do not have Internet access and the country. While the literature search was done in a systematic way, I did not do a systematic review of communal sanitation provision in Africa slums. This would have yielded mixed results as many African countries face the same limitations to information provision as the ministries in Liberia.

Some information and methods included in the protocol were not included in the study. The exit surveys were not included because transport to the survey sites was delayed and teams arrived after the peak time to conduct interviews. This limited the ability to assess user satisfaction and the extent that the latrines provide for the daily sanitation needs of the target population. An examination of other-low cost technologies was excluded because it would have made the focus of the study too broad.

9. Conclusions The findings from this report are based on a small sample in the capital city of Liberia. More research is needed to determine whether the findings are generalisable to other settings. While some people in the target population are using the communal latrines, the manner and scale that facilities have been provided is not sufficient to stop open defecation. There were disparities in access within and across intervention communities, with children most often excluded.

The health implications of the communal latrines inability to stop open defecation and decrease cholera have severe consequences for child survival. Children in slums tend to have poorer nutritional status and overall health and are highly susceptible to diarrhoea, which kills nearly 1.5 million children U5 each year.43 Childrens faeces also have a higher prevalence and intensity of intestinal worms and both stages of the transmission cycle (the excretion of worm eggs, and the infection of the next host44 frequently occur when children stools lie on the ground, particularly in the yard. Communal latrine provision as a response to cholera will not prevent the endemic presence of the bacteria because a majority of the population does not use the facilities and hand-washing basins with soap are unavailable.45

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The level of communal latrine use and sustainability are inextricably linked. The findings suggest that the community-management of communal latrines in Monrovian slums is not sustainable under the current model. User fees have been barely enough to operate the structures and alternative financing mechanisms have not been identified. Furthermore, the absence of the caretakers during operational hours implies that not all users are paying the fee. The capacity of the various WASH Committees is disparate and Concern Liberia has not found a way to address the dearth of knowledge and skills in the community.

Sustainability also requires the engagement and participation of all stakeholders. The lockdown of two communal latrines in New Kru Town is proof that not all actors have been mobilised to value the importance of sanitation in the health and human rights of the community and the WASH Committees do not have enough power to assert these rights. While the technical design is responsive to the soil conditions, the septic tanks are not environmentally friendly because the waste is being dumped untreated into the sea. While water is abundant in Liberia, the absence of nearby water sources has proven burdensome to those who must walk distances to fetch water to flush the toilet.

Communal latrines as a response to inadequate sanitation and cholera in Monrovias slums has major shortcomings that can only be mitigated through revising the management structure of the latrines, ensuring that all factors for sustainability are systematically addressed.

10. Recommendations Findings from the study were presented to the Liberia WASH Consortium and stakeholders at Oxfam GB Liberia on 29 July 2011 in Monrovia, Liberia. The recommendations are aimed at Concern Liberia and Consortium partners.

The key recommendations are to:

Ensure that all communal latrines are built with hand-washing facilities with soap. Advocate with municipalities for a reduced rate to empty septic tanks in slum communities.

Create a demand for sanitation through well-planned hygiene promotion activities in slum communities as part of the Concern Liberia WASH programme.

Explore low-cost ecological sanitation options composting toilets such as double-vault

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VIP latrine (built up in case of high water tables) and/or Arborloo toilets. Educate and build the capacity of WASH Committees through standardised trainings to ensure a basic level of skills. Curricula should include trainings (and refresher trainings) on handling complaints, responding to feedback, O&M requirements and bookkeeping. Promote gender equity on the WASH Committees.

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1 Progress on Sanitation and Drinking-Water 2010 Update. 2010. WHO/UNICEF JMP, Genenva. 2 Toubkiss, J 2008. Financing sanitation in sub-Saharan cities: a local challenge. IRC Symposium: Sanitation for the Urban Poor Partnerships and Governance Delft, The Netherlands. IN: IRC Symposium: Sanitation for the Urban Poor Partnerships and Governance, Delft, The Netherlands. 3 Uwejamomere, T 2008. Turning Slums Around: The case for water and sanitation. London: WaterAid. 4 "United Nations Expert Group Meeting on Urban Indicators Secure Tenure, Slums and Global Sample of Cities, 2002." Nairobi: UN Habitat, 21. 5 Cairncross, S 2004. The case for marketing sanitation. WSP-AF (Water and Sanitation Program for Africa) Field Notes, Nairobi, Kenya, digitally available at: http://www. wsp. org/publications/af_marketing. pdf. 6 Rahman, S., S. Banu, and F. Nessa, Health situation of slum dwellers of metropolitan area of Dhaka. Bangladesh Medical Research Council bulletin, 1989. 15(2): p. 90. 7 Gulis, G., et al., Health status of people of slums in Nairobi, Kenya. Environmental research, 2004. 96(2): p. 219-227. 8 Allen, A, Hofmann, P and Griffiths, H. "Moving Down the Ladder: Governance and Sanitation That Works for the Urban Poor." In IRC Symposiyn: Sanitation for the Urban Poor, Partnerships and Governance. Delft, The Netherlands, 2006, 4. 9 Schaub-Jones, D 2005. Sanitation Partnerships: Beyond storage:. BPD Sanitation Series 10 Eales, K. "Partnerships for Sanitation for the Urban Poor: Is It Time to Shift Paradigm?" Paper presented at the IRC Symposium: Sanitation for the Urban Poor Partnerships and Governance Delft, The Netherlands, 2008 11 Op cit, Eales (2008), 6. 12 Morella, E., V. Foster, and S.G. Banerjee. "Climbing the Ladder: The State of Sanitation in Sub-Saharan Africa." Background Paper 13 (2008). 13 Allen, A, Hofmann, P & Griffiths, H 2006. Moving down the ladder: governance and sanitation that works for the urban poor. IRC Symposiyn: Sanitation for the Urban Poor, Partnerships and Governance. Delft, The Netherlands. 14 Odongo, G 2010. Insecurity and indignity : womens experiences in the slums of Nairobi, Kenya. London, UK, Amnesty International Publications. London: Amnesty International. 15 Gil, A., C.F. Lanata, E. Kleinau, and M. Penny. "Children's Feces Disposal Practices in Developing Countries and Interventions to Prevent Diarrheal Diseases: A Literature Review (Strategic Report 11)." Washington, DC: Environmental Health Project, USAID (2004). 16 "Good Practices Related to Access to Safe Drinking Water and Sanitation: Bio Sanitation in Nairobis Peoples Settlements." Nairobi: UNHCR, 2010. 17 "Kenya: Cooking on Biogas from Toilets in Kibera." WordPress.com, washafrica.wordpress.com/2011/04/04/kenya-cooking-on-biogas-from-toilets-in-\ kiberia/entries 18 Sarkar, S , and S Moulik. "The Mumbai Slum Sanitation Program: Partnering with Slum Communities for Sustainable Sanitation in a Megalopolis. ." Washington, DC: World Bank, 2006. 19 Schaub-Jones, D. "Sanitation Partnerships: Beyond Storage:." BPD Sanitation Series (2005). 20 Lamb, J 2009. Monrovia Urban Slum WASH Assessment, Liberia Oxfam GB. 21 Topographic Map of Liberia. Retrieved 28 April 2011, from http://upload.wikimedia.org/wikipedia/commons/thumb/e/ed/Topographic_map_of_Liberia-en.svg/2000pxTopographic_map_of_Liberia-en.svg.png 22 Water Supply and Sanitation Policy (2009) Government of Liberia, Ministry of Lands, Mines and Energy in Collaboration with the Ministry of Health and Social Welfare (MOH), Ministry of Public Works (MPW), Liberia Water and Sewer Corporation (LWSC), UNICEF, WaterAid and the Liberia WASH Consortium. 23 Liberia Sanitation and Water Agenda (LISWA). 2010. Monrovia. 24 Statement of Work Joint Mission: Government of Liberia and its Development Partners Improved National Planning for Water, Sanitation and Hygiene (WASH) Monrovia, United Nations Development Programme and Government of Liberia. 25 Sitali, M 2010. Life and Dignity at Risk: The Water, Sanitation and Hygiene Sector in Liberia. Oxfam.

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26 Beyond Squatters Rights - Durable solutions and development induced displacement. 2011.Oslo: Norwegian Refugee Council, 22. 27 LIBERIA: Disease rife as more people squeeze into fewer toilets. 2009. Integrated Regional Information Network. Available: http://www.irinnews.org/report.aspx?reportide=87110. [Accessed 23 August 2011]. 28 "Safer Water Better Health." Geneva: World Health Organization, 2008. 29 Lamb, J 2009. Monrovia Urban Slum WASH Assessment, Liberia Oxfam GB. 30 Interview. Patrick OKoth, Public Health Officer, Oxfam GB Liberia, Monrovia, 28 June 2011. 31 Interview. Morris Sherman, Construction Engineer Concern Worldwide Liberia, Monrovia, 28 June 2011. 32 Based on figures from CONCERN Montserrado WASH programme. 33 Based on caretaker financial records. 34 The State of Food and Nutrition Insecurity in Liberia: Liberia Comprehensive Food and Nutrition Survey. Ministry of Agriculture and World Food Programme, VAM Food Security Analysis, Monrovia, 2010, 57. 35 11 July 2011, Focus Group Discussion with Logan Town Women Development Association, Zinc Kamp, Logan Town, Monrovia. 36 Focus Group Discussion with Logan Town Women Development Association. 11 July 2011. Zinc Kamp, Logan Town, Monrovia. 37 Transect Walk. 6 July 2011. Zinc Kamp, Logan Town. Chairman Alex W. 38 Focus Group Discussion with Logan Town Women Development Association. 11 July 2011, Zinc Kamp, Logan Town, Monrovia. 38 1 July, 6 July (2011) 39 Gil, A., C.F. Lanata, E. Kleinau, and M. Penny. "Children's Feces Disposal Practices in Developing Countries and Interventions to Prevent Diarrheal Diseases: A Literature Review (Strategic Report 11)." Washington, DC: Environmental Health Project, USAID (2004). 40 Goal 7: Ensure environmental sustainability [Online]. New York: United Nations Development Programme. Available: www.undp.org/mdg/goal7.shtml [Accessed 23 August 2011]. 41 EcoSanRes. 2009. Stockholm: Stockholm Environmental Institute. Available: www.ecosanres.org. [Accessed 30 August 2011]. 42 Interview. Morris Sherman, Construction Engineer Concern Worldwide Liberia, Monrovia, 28 June 2011. 43 "Diarrhoea: Why Children Are Still Dying and What Can Be Done?". 68. New York City: UNICEF/WHO, 2009. 44 Cairncross, S., and U. Blumenthal, et al. "The Public and Domestic Domains in the Transmission of Disease." Trop Med Int Health 1, no. 1 (1996): 27-34, p. 28. 45 Said, B & Drasar, B (1996) IN Curtis, V., S. Cairncross, and R. Yonli. "Domestic Hygiene and Diarrhoea - Pinpointing the Problem." Trop Med Int Health 5, no. 1 (2000): 22-32.

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