Appropriate Approaches To Hygiene and Environmental Sanitation in Western Nepal - 0

Appropriate Approaches to Hygiene and
Environmental Sanitation in Remote

Communities of Mugu and Humla
Districts, Western Nepal
Will Tillett
January 2008
Technical Department
WASH sector, ACF-France
Will Tillett, 01-2008
Executive Summary
Mugu and Humla are among the least developed of the 75 districts of Nepal; which itself is one of the poorest
countries in the world. The mountainous districts are remote and drought prone, and the prolonged conflict in the
area has impaired local governance, social organisation, and community based services. Action contre la Faim
(ACF), has been operating water supply, sanitation and hygiene activities in the area since 2006, and launched
this study, in association with the University of Cranfield (UK), to investigate the most appropriate approaches to
sanitation and hygiene for the remote communities in the districts. The research, undertaken over 2007-2008
included over 80 qualitative interviews with communities and key informants, along with meetings to build on the
experience of a diverse range of sanitation and hygiene actors operating across Nepal. A range of approaches to
sanitation and hygiene have been piloted, and applied across the country, but little research as been undertaken
in Mugu and Humla; districts with some of the lowest sanitation coverage of the nation.
Open defecation is prevalent in the area, and poor hygiene and environmental management practices create
serious public health risks. Diarrhoea is the biggest cause of mortality in the districts, and there is a widespread
prevalence of intestinal worms, skin infections, and child malnutrition. Personal and clothes washing is infrequent,
and child hygiene is an area of particular concern. Although hygiene and sanitation may be the priority of the
outsider, they are lower priorities to the communities, particularly in light of uncertainties of food and water
supplies. Whilst not necessarily health related, interviewees perceive issues with their current situation, and
barriers to attaining improved practices, such as soap, external material and water access, time availability of
mothers, and the dirtiness of the villages. Children are deemed autonomous for their hygiene and sanitation
needs from an early age, and there is limited parent to child teaching on these topics. The post-conflict
communities experience a lack of social cohesion, leadership and initiative, although the recent emergence of
Mothers groups hold potential to drive change. The few sanitation actors in the area mention issues of poor
coordination of activities, and conflicting policies for community incentives and subsidies are leading to increasing
community demands and expectations. Due to material and transport costs, conventional latrine designs incur
both high per-capita costs, and hold poor potential for replicability without assistance. Due to restricted field
access, many projects have taken a hardware focus, with limited software activities of mobilisation, participation
and demand building; limiting the uptake and usage of latrines, and the future sustainability of interventions.
Future approaches in the area could take on longer-term, software orientated activities, building demand, and
empowering communities to drive change by themselves. Strong mobilisation and sustained follow-up support is
crucial. Projects could strengthen the local private sector and supply chains, build up the local skills base, and
develop partnerships with local institutions for ongoing sustainability.
The issue of sanitation should be addressed as a community initiative, through participatory mobilisation
techniques, driving for 100% coverage, and usage. Projects offering no material subsidy for latrines may be
ineffective in this context. Therefore a basic (minimal) subsidy is suggested, augmented with sanitation marketing
for households aspiring for higher standards of latrines. Local government could play a key role in coordinating
sanitation approaches and for the ongoing support for community driven sanitation in the area.
Hygiene promotion (HP) should be prioritised to address the key risk practices, and relevant to the communities
perceptions of the issues. Community level mobilisation and problem identification, should be followed by more
targeted HP sessions, and enabling factors should be addressed. Low-cost solutions for environmental sanitation
hold strong potential to contribute to improving food security, and should be promoted as such. Child hygiene is a
complex issue, and could be addressed through a multi-channel approach, including; improving environmental
sanitation, developing child care practices and direct HP to children, through schools and community based
activities.
Implementing sanitation and hygiene projects in the area is challenging. However, change can occur, albeit with
time, and should be driven by the communities themselves. In light of national targets and financial constraints,
approaches to hygiene and sanitation in the area need to be coordinated, low-cost, replicable, and sustainable. A
holistic and integrated approach should be taken to work towards the common goal of reducing mortality and
morbidity through malnutrition and sanitary related diseases.
Acknowledgements
I would like to extend my gratitude to both ACF and Cranfield University for giving me the opportunity to take part
in this study.
Thank you to Richard Carter and Jean Lapegue for all their support, knowledge and insights in this research, and
for their time spent reviewing a gigantic draft.
Thanks to all the NGOs and sector workers who contributed to this research, particularly to Oliver Jones of
WaterAid, and the team at NEWAH, from whom I learnt a great deal.
Thanks to all the staff of ACF Nepal for your insights, assistance and company over the study period, particularly
the logistics team, who seem to make miracles happen. Thanks to all the French expatriates for keeping up stocks
of wine and pate, in a sea of rice and lentils.
My gratitude, as always, extends to my parents, for their constant encouragement, support and understanding.
Finally, my gratitude extends to the inhabitants of Mugu and Humla districts, for their kind hospitality, and for their
openness to discuss at length about their defecation habits to a strange looking outsider.
Will Tillett
Water, sanitation and Hygiene Researcher
willtillett@hotmail.com
The photographs in this manual were taken by and are reproduced with the permission of Will Tillett.
Presenting ACF-IN Approaches and Programmes

Action Contre la Faim (ACF) (formerly Action Internationale Contre la Faim) is an independent, a-political nongovernmental humanitarian organisation which is internationally recognised as one of the world's premier
organisations in combating hunger. ACF intervenes in humanitarian situations involving war, famine, natural
disasters and other crises to bring help to displaced people, refugees and any other populations in danger. After
the emergency is over, continuity of action helps affected people recover their independence through medium and
long-term programmes. The prevention of disasters is also one of its objectives. ACF developed an international
network with the opening of Accion Contra el Hambre in Madrid and Action Against Hunger in London and New
York and recently an office in Toronto. ACF-IN has 350 international volunteers and 4,000 national staff working in
over 40 countries and responds in all four areas involved in the fight against hunger and malnutrition: nutrition,
health, food security, and water, sanitation and hygiene.
The Charter
Action Contre la Faim (ACF) is a non-governmental organisation. Private, non-political, non-denominational and
non-profit making, it was set up in France in 1979 to intervene in countries throughout the world. ACF vocation is
to save lives by combating hunger, disease, and those crises threatening the lives of men, women and children.
ACF intervenes in the following situations:
In natural or man-made crises which threaten food security or result in famine,
In situations of social/ economic breakdown linked to internal or external circumstances which place particular
groups of people in an extremely vulnerable position,
In situations where survival depends on humanitarian aid.

ACF intervenes either during the crisis itself, through emergency actions, or afterwards, through rehabilitation and
sustainable development programmes. ACF also intervenes in the prevention of certain high risk situations. The
ultimate aim of all of ACFs programmes is to enable the beneficiaries to regain their autonomy and selfsufficiency as soon as possible.
ACF respects the following principles:
INDEPENDENCE - ACF acts according to its own principles so as to maintain its moral and financial
independence. ACFs actions are not defined in terms of domestic or foreign policies nor in the interest of any
government.
NEUTRALITY - ACF maintains strict political and religious neutrality. Nevertheless, ACF can denounce human
rights violations that it has witnessed as well as obstacles put in the way of its humanitarian action.
NON DISCRIMINATION - A victim is a victim. ACF refutes all discrimination based on race, sex, ethnicity, religion,
nationality, opinion or social class.
FREE AND DIRECT ACCESS TO VICTIMS - ACF demands free access to victims and direct control of its
programmes. ACF uses all the means available to achieve these principles, and will denounce and act against
any obstacle preventing it from doing so. ACF also verifies the allocation of its resources in order to ensure that
the resources do, indeed, reach those individuals for whom they are destined. Under no circumstances can
partners working together with or alongside ACF become the ultimate benefactors of ACF aid programmes.
PROFESSIONALISM - ACF bases the conception, realisation, management and assessment of its programmes
on professional standards and years of experience, in order to maximise its efficiency and the use of its
resources.
TRANSPARENCY - ACF is committed to respecting a policy of total openness to partners and donors and
encourages the availability of information on the allocation and management of its funds. ACF is also committed
to providing guarantees of proof of its good management.
Table of Contents
Executive Summary ...................................................................................................................................... 3
Acknowledgements....................................................................................................................................... 5
Presenting ACF-IN Approaches and Programmes......................................................................................... 6
Glossary of Abbreviations ........................................................................................................................... 10
1
Introduction ........................................................................................................................................ 11
1.1
Nepal ......................................................................................................................................... 11
1.2
Humla and Mugu Districts .......................................................................................................... 12
Aims and Objectives ............................................................................................................................... 15
2
Literature Review................................................................................................................................ 16
2.1
The Importance of Hygiene and Sanitation ................................................................................. 16
2.2
Sanitation in Nepal ..................................................................................................................... 17
2.2.1
The Sanitation Status......................................................................................................... 17
2.2.2
The Provision of Sanitation in Nepal................................................................................... 18
2.2.3
Strategies and Policy in Rural Sanitation and Hygiene Promotion....................................... 20
2.3
Approaches to Sanitation ........................................................................................................... 23
2.3.1
Conventional Approaches .................................................................................................. 23
2.3.2
Subsidies........................................................................................................................... 23
2.3.3
Subsidy or Self Respect: Community Approaches ............................................................ 24
2.3.4
CLTS in Nepal ................................................................................................................... 25
2.3.5
Community Led Basic Sanitation for All (CLBSA) ............................................................... 26
2.3.6
School Sanitation & Hygiene Education & School Led Total Sanitation............................... 26
2.3.7
Revolving Funds and Loans ............................................................................................... 26
2.3.8
Sanimart ............................................................................................................................ 27
2.3.9
The Model Approach ........................................................................................................ 27
2.4
Hygiene Promotion..................................................................................................................... 28
2.5
Summary ................................................................................................................................... 28
3
Methodology....................................................................................................................................... 29
3.1
Field Research ........................................................................................................................... 29
3.1.1
Community Selection ......................................................................................................... 29
3.1.2
Interviews .......................................................................................................................... 29
3.1.3
Interviewee Selection ......................................................................................................... 30
3.1.4
Style and Topics for the Interviews ..................................................................................... 31
3.1.5
Structured and Non-Structured Observation ....................................................................... 32
3.2
Coordination with Other Sector Workers..................................................................................... 32
3.3
Research Limitations.................................................................................................................. 32
3.3.1
Logistics, Coordination and Planning.................................................................................. 32
3.3.2
Timing of the Field Research.............................................................................................. 33
3.3.3
Interviews .......................................................................................................................... 33
4
Findings & Analysis ............................................................................................................................ 34
4.1
Context and Community Descriptions ......................................................................................... 34
4.1.1
Community Habitation, Location, Distribution and Orientation............................................. 34
4.1.2
Society, Culture and Religious Beliefs ................................................................................ 35
4.1.3
Livelihoods and Economy .................................................................................................. 36
4.1.4
Roles, Responsibilities and Gender.................................................................................... 36
4.1.5
Community Organisation, Leadership and Local Governance............................................. 37
4.1.6
Health and Healthcare ....................................................................................................... 38
4.1.7
Transport, Local Supply Chains and Consumption Practices .............................................. 40
4.1.8
High community expectations............................................................................................. 41
4.2
Environmental Health in the Communities: Practices, Perceptions, Aspirations and Barriers ....... 42
4.2.1
Environmental Health Situation from Observations ............................................................. 42
4.2.2
Interviewee Perceptions of Environmental Health Issues in the Villages ............................. 44
4.2.3
Defecation Practices and Latrines ...................................................................................... 44
4.2.4
Experiences of Latrine Ownership and Usage .................................................................... 47
6
7
8
4.2.5
Future Aspirations for Latrines ........................................................................................... 51
4.2.6
Locations of Latrines .......................................................................................................... 51
4.2.7
Institutional Sanitary Facilities ............................................................................................ 53
4.3
Environmental Sanitation............................................................................................................ 53
4.3.1
Solid waste disposal .......................................................................................................... 53
4.3.2
Roof and Greywater disposal ............................................................................................. 54
4.3.3
Livestock and composting practices ................................................................................... 55
4.3.4
Road Paving ...................................................................................................................... 56
4.4
Personal Hygiene ....................................................................................................................... 56
4.4.1
Personal washing .............................................................................................................. 56
4.4.2
Clothes Washing................................................................................................................ 58
4.4.3
Hand Washing ................................................................................................................... 58
4.5
Child Hygiene & Sanitation ......................................................................................................... 59
4.5.1
Parenting, Responsibilities and Care Practices .................................................................. 59
4.5.2
The Role of the School....................................................................................................... 61
Discussion.......................................................................................................................................... 63
5.1
Overall Approach ....................................................................................................................... 63
5.1.1
Community Approach......................................................................................................... 63
5.1.2
Community Based Organisations ....................................................................................... 64
5.1.3
Coordination of Activities.................................................................................................... 64
5.1.4
Developing Local Capacity................................................................................................. 65
5.1.5
Timescales and Donor Funding.......................................................................................... 65
5.2
Options Available for Environmental Sanitation and Hygiene Approaches................................... 65
5.2.1
Sanitation .......................................................................................................................... 65
5.2.2
Hardware Approach & Appropriate Technologies ............................................................... 68
5.2.3
Software Approach ............................................................................................................ 72
5.2.4
Replicability and Future Sustainability ................................................................................ 73
5.2.5
Latrine Locations ............................................................................................................... 75
5.3
Promotion of Hygiene and Environmental Sanitation .................................................................. 75
5.3.1
Prioritising Interventions..................................................................................................... 75
5.3.2
Enabling Factors................................................................................................................ 77
5.4
Hygiene Promotion..................................................................................................................... 78
5.4.1
Current Approach .............................................................................................................. 78
5.4.2
Future Approach ................................................................................................................ 78
5.5
Child Hygiene Improvement ....................................................................................................... 79
5.5.1
Environmental Sanitation and Enabling Factors.................................................................. 79
5.5.2
Parent to Child Care Practices ........................................................................................... 80
5.5.3
Hygiene Promotion Directly to Children .............................................................................. 81
Conclusions & Recommendations ...................................................................................................... 82
References......................................................................................................................................... 86
Appendix ............................................................................................................................................ 89
Table of Figures
Figure 1.1. Human development status by eco-development region. Source: UNDP (2004)
Figure 1.21. Maps identifying ACF Nepals intervention areas of Bajhang and Mugu and Humla. Source:
www.googlemaps.com
Figure 1.22. A Map of the study area in Mugu and Humla districts. Developed from basemap, Source: GoN &
Helvetas (2000)
Figure 2.11. The F Diagram.Source: Almedom et al (1997) in Tabiri (2005)
Fig. 2.12. Coverage of Improved Sanitation in 2002. Source United Nations (2005)
Figure 2.212. Percentage of households with access to toilet facilities by District. Source: (CBS/ICIMOD 2003).
Fig. 2.22 Simplified Organisational arrangements for the provision of rural sanitation in Nepal. Based on Ockelford &
Shrestha (2002), modified and updated by Taylor et al (2005)
Figs 3.121 & 3.122. Demographic and caste divisions of 87 interviews.
Fig. 3.2. Division of the 44 coordination meetings and interviews.
Fig. 4.111, 4.112, 4.113. Terrace houses in Jamaldara; Melcham Village; Macinmella (seasonal high altitude
settlement).
Figure 4.114. The layout of houses in the study area.
Figures 4.162, 4.163. Understanding of disease transmission. Source: KAP Survey 2007
Figures 4.164, 4.165, 4.166. Interviewees response to diarrhoeal incidence (KAP Survey 2007); a traditional healer in
Libru village; a child showing signs of stomach scarring from traditional medicine in Nerah village.
Figures 4.171, 4.172, 4.173, 4.174. Mugu districts airport; A ropeling river crossing in Mugu; district stores in
Gamghadee (Mugus capital); a village shop in Purumeru village (Mugu district)
Figure 4.175. Household Cash for Work Scheme Expenditures. Source: ACF (2007f)
Figures 4.211, 4.212, 4.213, 4.214. Pictures of the status of environmental status of the communities visited.
Figure 4.215. Water sources used in the area. Source: KAP Survey.
Figure 4.22. Major Issues in Village Relating to Hygiene & Sanitation, as Perceived by Interviewees
Figure 4.231. Defecation sites, Results from the KAP Survey
Figure , 4.232. Defecation sites, Results from this research
Figure 4.233. Collection & Disposal of Faeces
Figure 4.234. Methods of Anal Cleansing (Adults)
Figure 4.235. Issues with current defecation practices, as perceived by interviewees
Figures 4.241, 4.242. Reasons for building a latrine in the past, and the location of the latrine.
Figure 4.243, 4.244, 4.245, 4.246. Examples of pan designs and water containers in local latrines
Figures 4.247, 4.248, 4.249, 4.2410. Examples of local functional, child and derelict latrines.
Figures 4.2411, 4.2412. Issues with, and reasons for stopping using the latrine. Findings from this research and the
KAP Survey.
Figure 4.26. Perceived Issues of Sharing a Latrine, from the KAP Survey.
Figures 4.311, 4.312. Solid Waste Management Practices from this research, and the KAP Survey, respectively.
Figures 4.321, 4.322. Domestic greywater management practice findings from this research, and the KAP Survey,
respectively.
Figures 4.323, 4.324, 4.325, 4.326. Pictures of the environmental sanitation situation in the villages
Figures 4.411, 4.412. Frequency of Personal Washing Results from this Research, and the KAP Survey,
Respectively.
Figure 4.413. Issues with personal washing, as perceived by interviewees
Figure 4.43. Box Y. Findings from the KAP Survey Regarding Hand Washing
Figures 4.511, 4.512, 4.513, 4.514, 4.516. 12 day-old baby given birth, and kept in the cattle shed; a child left alone
unsupervised at home; a child covered in flies in Humla district; baby washing with cold water; elder sister taking care
of younger sibling whilst mother works the fields.
Figure 4.517. Issues and barriers in child hygiene perceived by interviewees
Figure 4.52. School Enrolment Trends in Mugu District 2006-7. Created from data obtained in 'District Education
Office Gamgadhee, Mugu. Schools, Students, Teachers, Students of Mugu District 2064-65
Figure 5.21. Cost of sanitation financing modalities in a typical Nepali community of 99 households (33 ultra poor, 33
poor and 33 medium). Source: WaterAid 2007.
Figure 5.223. Improvised, pan structures integrating cement pan with pipe. Lower Rhimi village, Humla.
11
14
14
16
17
18
19
30
32
34
35
39
39
40
41
42
43
44
45
45
46
46
47
47
48
49
50
52
53
54
55
57
57
58
59
60
61
67
71
Glossary of Abbreviations
ACF
ADB
ARI
CBO
CBWSSP
CFW/FFW
CHAST
CLBSA
CLTS
COPD
DALYs
DDC
DEO
DHO
DMC
DoLIDAR
DTO
FCHV
FGD
GFS
GoN
HDI
HP
IEC
INGO
iPRA
KAP
LNGO
MDGs
MoU
NEWAH
NGO
NPR
OPD
PHAST
PRA
QIP
RWSS
RWSSFB
SLTS
SMC
SSHE
VDC
VIP
WASH
WATSAN
WFP
WHO
WSUC
Action Contre la Faim

Asia Development Bank
Acute Respiratory Infection
Community Based Organisation
Community Based W ater Supply and Sanitation Project
Cash For Work/Food For Work
Children's Hygiene and Sanitation T raining
Community Led Basic Sanitation for All (NEWAH)
Community Led Total Sanitation
Chronic Obstructive Pulmonary Disease
Disability-Adjusted Life Years
District Development Committee
District Education Office/Officer
District Health Office/Officer
District Management Committee
Department of Local Infrastructural Development Agricultural Roads
District Technical Office
Female Community Health Volunteer
Focus Group Discussion
Gravity Flow System (Piped water supply systems)
Government of Nepal
Human Development Index
Hygiene Promotion
Information Education and Communication (visual hygiene promotion materials)
International Non-Governmental Organisation
ignition Participatory Rural Appraisal
Knowledge, Attitudes and Practices (Survey)
Local Non-Governmental Organisation
Millennium Development Goals
Memorandum of Understanding
Nepal Water for Health (National NGO)
Non Governmental Organisation
Nepalese Rupee
Out Patient Diseases
Participatory Hygiene and Social Transformation
Participatory Rural Appraisal
Quick Impact Project
Rural W ater Supply and Sanitation
Rural W ater Supply and Sanitation Fund Board
School Led Total Sanitation
School Management Committee
School Sanitation & Hygiene Education
Village Development Committee
Ventilated Improved Pit (latrine)
W ater Sanitation and Hygiene
W ater and Sanitation
W orld Food Programme
W orld Health Organisation
W ater and Sanitation Users Committee
10
Introduction
1.1
Nepal
Nepal covers a total land area of 147181km2, which is split into 3 geographical zones; the southern plains of the
Terai bordering India; the middle hills; and the mountains of the Himalaya range. The population of Nepal stood
at 23.2m in 2006, comprising of over 60 ethnic groups, and with an annual growth rate of 2.24% (NIDI 2006).
Nepal has been in political turmoil for some time, with the last decade seeing royal massacres, popularist uprises
against an increasingly authoritarian king, and the establishment and ongoing insurgency of a radical left group
(Maoists), aimed at abolishing the monarchy and establishing a peoples republic (Ockelford 2007).
Administratively, there are 5 development regions of Nepal, (see Fig. 1.1). and the country is divided into 75
districts, each divided by 9 Village Development Committee areas, or VDCs.
Figure 1.1. Human development status by eco-development region. Source: UNDP (2004)
Nepal is one of the poorest countries of the world, ranking 142 out of 177 countries in the UNDP world poverty
index (UNDP 2007). There are large geographical disparities in terms of human development indices, with the
lowest HDI in the mountains, and mid and far western development regions (UNDP 2004). There are also strong
disparities in development and empowerment within societies. The UNDP (2004) note that discriminatory
practices rooted in the ethno-caste system have dominated Nepalese culture for centauries. The mid and far
western mountains show the largest mismatch of empowerment, which became a source of bitterness to be
exploited by the Maoists, and the areas became the stronghold for their insurgency into the rest of Nepal (UNDP
2004). Progress towards development in these areas has been slowed by Maoist activities, who limited the
access and activities of local authorities and NGOs outside district headquarters, and disrupted community and
VDC level governance structures (Ockelford 2007). Education and health were the two government sectors
allowed to continue, but due to pressure from the Maoists, many healthcare staff chose to leave the area (ACF
2007d). Action contre la Faim (ACF) is an International NGO, organized in 1979 with the aim of saving lives by
combating hunger, disease, and assisting in crises that threaten the lives of men, women and children. ACF
operates in 40 countries worldwide, and began operations in Nepal in 2005, initially in the far western district of
Bajhang, and in Mugu and Humla districts in the mid-western mountains in 2006. The Bajhang intervention was
phased out in 2007, whilst activities in Mugu and Humla were continuing into 2008 (see map on Figure 1.21.).
11
1.2
Humla and Mugu Districts
According to 2001 data, Humla and Mugu districts are ranked 68th and 75th respectively out of Nepals 75 districts
in terms of the Human Development Index (UNDP 2004).
There are no motorable roads in either of the districts, and infrastructure in the area such as river crossings were
subject to attack during the Maoist insurgency, limiting market access and economic growth. Mugu and Humla
rank 74th and 75th for both the percentage of usually economically active children (10-14 years), and literacy rates.
(CBS & ICIMOD 2003).
Table 1.2. presents a range of social, economic and health indices for the area, showing the two districts
consistently ranking at the bottom end of the 75 districts in the country.
Table 1.2. Select statistics for Nepal, and Mugu and Humla Districts
Statistic
Total Population*
Average Household Size*
Population Density (Person/km2)*
Percentage Hindu/Buddhist*
Life Expectancy at Birth**
Infant Mortality**
% Malunourished Children under 5 (stunting)
Adult Literacy**
Mean Years of Schooling**
Proportion of Labour Force Employed in Non-Agricultural
Jobs**
Population Without Access to Safe Water**
Population With Access to Sanitation**
District
Mugu
Humla
43,937
40,595
5.32
5.84
12
7
86/14
84/16
44.07
58.37
173.83
81.37
68.7
90
24.1 (5.2% female) 19.6 (4.8% female)
1.4 (0.34 female)
1.25 (0.4 female)
10.83
10.84
31.33
44.83
14.4
35.8
18.3
20.48
39.22
Nepal Global
Ranking***
142 / 177
25 / 128
134 / 156
Human Development Rankings (Out of 75 Districts in Nepal)**

Human Development Index (HDI)
Human Poverty Index
Gender-Related Development Index
Nepal
23,151,423
5.44
157
81/11
60.98
68.51
50.5
48.6 (34.9% female)
2.75 (1.95 female)
75
73
75
68
75
68
*2001 Population Census (NIDI 2006), **Nepal Human Development Report (2004), ***UNDP Country Fact Sheet (2006)
In addition to issues of the Maoists, the Karnali zone (within which both districts are located) is also drought prone,
making food security particularly precarious (ACF 2007d).
ACF undertook a nutrition and mortality survey in the Mugu and Humla in 2007, and the findings on food security
are presented in Box 1.21.
Box 1.21. Overview of the Food Security Situation in Mugu and Humla. Source: ACF (2007e)
There are chronic food shortages in Mugu and Humla: these districts have been experiencing
cereal deficits since the 1970s, and agricultural production is insufficient to cover the needs of a
growing population. Hunger periods are usually in FebruaryApril (before harvest of winter crops
as wheat and barley) and around August (before harvest of summer crops of mainly rice and
millet). The most important food gap is the one that follows the winter.
The low agricultural production in Mugu and Humla mainly results from the lack of arable land,
the poor climatic conditions, the lack of irrigation, the absence of any mechanization, the poor
quality of the seeds, the very poor management of the soil in terms of fertility and the absence of
management of crop pests and diseases.
12
The incidence of under 5 child malnutrition is high across Nepal, and was found to be particularly high in rural
communities of Mugu and Humla (ACF 2006, 2007e). Research by ACF indicated that the causes of malnutrition
in the area were multi-factoral, related not only to problems of access to quality and quantity of food; but also to
poor child-care and feeding practices; low access to health services; poor hygiene and sanitation situation; and
poor hygiene practices (ACF 2006, 2007e).
Indeed, sanitation coverage in the Humla and Mugu are way below the national average, standing at 18.3% and
th
nd
14.4% respectively in 2001, ranking them 66 and 72 out of Nepal's 75 districts (CBS & ICIMOD 2003). Box
1.22 presents results from another ACF survey, undertaken in the area 2007.
Box. 1.22. Findings of the KAP Survey undertaken in Mugu and Humla in May 2007. Source: ACF (2007b)
Out of 240 randomly selected households in rural communities of Mugu and Humla District:
Less than 10% of households used latrines
Only 28% of respondents washed hands after defecating, of which only 24% used washing
agents (soap or ash)
36% of respondents collected water from unsafe* sources, and only 2% treated water prior to
consumption
70% respondents wash themselves only on a monthly (or more) basis in winter months
97% and 93% of households indiscriminately dispose of domestic greywater and solid waste
97% of households keep livestock in the ground floor of their dwellings
31% of respondents didnt know what kind of disease could be transmitted by water and 26%
thought that cold is the main water-borne disease
Only 28% of the families interviewed had not experienced any diarrhoea cases within 1 month
of the survey
* Untreated surface water sources
ACF launched operations in selected VDCs of Mugu and Humla in 2006, in response to worsening conditions of
malnutrition, particularly following the drought and Maoist activities. Through 2 consecutive project cycles (200608), the following programmes and activities have, or will be undertaken:
Food Security. Activities of; irrigation rehabilitation; improved farming techniques; greenhouses; and
seed distribution
Nutrition. Activities of; outreach therapeutic care; training community health workers in malnutrition
detection; community education; establishment of an in-patient therapeutic feeding centre
Water Sanitation and Hygiene (WASH). Activities of Gravity Flow System (GFS) water supplies;
community hygiene promotion; training community health workers in hygiene promotion; and latrine
construction.
The WASH programme has been funded by ECHO through two, one-year donor cycles, and at the time of
inception for this research, ACF had intentions to move towards multi-year projects and donors for future activities
in the area. An evaluation by the ACF WASH technical department highlighted a number of key issues in the ACF
intervention area, including; livestock practices and environmental sanitation; child hygiene; and barriers for
household latrine construction. The evaluation concluded that the current ACF hygiene and sanitation strategy
should be developed in terms of its coherence, effectiveness, sustainability and appropriateness (ACF 2007c).
In response, a 4 month study was launched in September 2007 by ACF, in partnership with the University of
Cranfield (UK), to find the most appropriate approaches to hygiene and sanitation improvements in the
communities of Mugu and Humla Districts.
13
Figure 1.21. Maps identifying ACF Nepals intervention areas of Bajhang and Mugu and Humla. Source:
www.googlemaps.com
Figure 1.22. A Map of the study area in Mugu and Humla districts. Developed from basemap, Source: GoN &
Helvetas (2000)
*The study area incorporates the 10 WASH beneficiary communities, as planned at time of field research (October
2007), and Ruga village (north west of Gamgadhi), which is not an ACF beneficiary community. The Study area
does not directly correspond to the total ACF intervention area, especially those under non-WASH programmes.
14
1.3
Aims and Objectives
Aim:
To investigate appropriate and effective approaches to hygiene and environmental sanitation for communities
in Mugu and Humla Districts, North West Nepal
Objectives:
To investigate the priorities, needs and barriers for achieving improved environmental sanitation and
hygiene standards of the communities and local amenities (schools and health posts) in the ACF
intervention areas
To investigate and evaluate environmental sanitation and hygiene promotion strategies applied by ACF
Nepal and other organisations (governmental and non-governmental)
To identify the most appropriate software and hardware approaches to safe excreta disposal, with a focus
on sustainability, replicability, impact, coherence and effectiveness.
To make practical recommendations for ACF's environmental sanitation and hygiene promotion strategy,
for future long term development projects in the area.
Specific Focus of the Research

Following consultation with the ACF technical advisor (Jean Lapegue) and the researcher's observations in
the field, the research was focused on the following specific areas:
Promotion, design, financing, logistics, location and management of household latrines
Improved environmental sanitation regarding livestock practices, solid waste management and
grey/storm water drainage.
Improved personal hygiene of children
15
Literature Review
2.1
The Importance of Hygiene and Sanitation
Whilst the world is on track for meeting the Millennium Development Goal (MDG) targets for drinking water,
on current trends, it will miss the sanitation target by more than half a billion people (WHO & UNICEF 2006).
In 2004, 1.1 billion people were without access to safe water, however, 2.6 billion lacked adequate sanitation
(JMP 2006). Sanitation is often regarded as the poor brother to water supply, holding less political weight,
receiving far less sectoral investment, and often not subject to its own government department or programme
(WaterAid 2007).
Franceys et al (1992) state that sanitation is one of the first, fundamental, basic steps towards ensuring a
safe environment for human habitation. Inadequate faeces disposal can lead to a number of communicable
health issues, such as diarrhoea, cholera, dysentery, typhoid, helmiths and schistosomiasis (Harvey 2004).
UNICEF estimates that around 2.2 million people, most of whom are children under five, die each year from
diarrhea, often related to poor hygiene and inadequate sanitation (JMP 2006). Indeed, diarrhoea accounts for
around 21% of under-five child mortality in developing countries (Kosek 2003), claiming around 5000
childrens lives every day (WaterAid 2007)
There is an explicit link between malnutrition and diarrhoeal disease (Franceys et al 1992) and intestinal
worm infections, by inhibiting normal consumption of foods and nutrient adsorption, leading to impaired
physical growth and cognitive development, and reduced resistance to reinfection (Classen & Cairncross
2004). Diarrhea accounts for the annual loss of 62 million DALYs (Disability-Adjusted Life Years); a standard
measure of disease burden calculated from the number of years lost of productive life from morbidity and
premature mortality (WHO 2004).
While sector professionals, policy makers and many donor organisations often focus on service level of
source water quality, without adequate hygiene and sanitation practices and facilities, the quality of the water
deteriorates rapidly through to the point of consumption. In terms of reducing diarrhoeal disease incidence,
Esrey (1996) suggests that interventions in water quality and quantity reduce incidence by approximately
15% and 20%, whilst interventions in hygiene and sanitation by 33% and 35%, respectively..
Figure 2.11. The F Diagram. Source: Almedom et al (1997) in Tabiri (2005)
16
One gram of human faeces can contain 10,000,000 viruses, 1,000,000 bacteria, 1000 parasite cysts, and
100 parasite eggs (WaterAid 2007). The F diagram presented in Figure 2.11 shows various pathways of
how faeces in the environment can reinfect individuals via the faecal-oral route, and the barriers to reinfection
that can be put in place through hygiene and sanitation measures.
In 2004, only 59% of the worlds population had access to an improved sanitation facility. This global average
masks strong geographical disparity in coverage, with South Asia attaining only 38% coverage, second only
to Sub-Saharan Africa with 37%. There is also a clear disparity in coverage between urban and rural areas:
out of the 2.6 billion globally unserved, 2 billion live in rural areas (WHO & UNICEF 2006). Only 26% of
people have access in rural Southern Asia (UN 2005).
Fig. 2.12. Coverage of Improved Sanitation in 2002. Source United Nations (2005)
2.2
2.2.1
Sanitation in Nepal
The Sanitation Status
As in the rest of South Asia, progress towards sanitation coverage in Nepal (39%) lags severely behind that
of water supply (81%) (UNDP 2005). Every day, seventeen million people defecate in the open, causing a
loss of 4%GDP in Nepal (WaterAid 2006). Health data from 2001 suggests that as much as 41% of total
morbidity in Nepal is due to poor sanitary conditions (Taylor et al 2005).
Table 2.211. Morbidity due to sanitation related ailments in Nepal. Source: Department of Health Services
(2001/2002) in Taylor et al (2005)
Diseases
Diarrhoeal diseases
Intestinal worms
Skin diseases
Gastritis
Typhoid
Total due to poor sanitation
Others diseases
Total
Mountain
Hill
Terai
Total
10.4
9.9
11.9
7.0
1.9
41.1
58.9
100
9.7
7.9
13.6
6.8
2.5
40.4
59.6
100
9.0
7.1
19.7
5.3
2.1
43.2
56.8
100
9.4
7.7
16.1
6.2
2.3
41.7
58.3
100
17
There are sanitation coverage disparities between the rich and poor, with the richest quintile attaining 79%,
while the poorest quintile attaining only 10% (UNICEF, 2006), and urban and rural areas, at 81% vs. 30%,
respectively (UNDP 2005). Sanitation coverage is particularly low in the mid and Far Western Development
th
nd
Regions of the country, with Humla and Mugu ranking 66 and 72 out of the nations 75 districts (CBS &
ICIMOD 2003).
Figure 2.212. Percentage of households with access to toilet facilities by District. Source: (CBS/ICIMOD 2003).
The MDG target for sanitation in Nepal is 53% coverage by 2015, but far more ambitious is the national
governmental target of 100% coverage by 2017, under the National Water Plan 2002-2017 (UNDP 2006).
Opinions are mixed regarding whether Nepal will meet the MDGs (ADB.org 2007), UNDP 2006).
An assessment by WaterAid (2004) noted that there was a resource gap for financing the MDG sanitation
targets in Nepal of $89 million, meaning $6 million per annum. The report continued to state that 13,677
additional households would need to be served for sanitation each month between 2000 and 2015, requiring
an acceleration of provision by 235% relative to the actual 1990-2000 performance. A further report by
WaterAid (2006) describes how only 60% of the funds committed to sanitation are actually dispersed, and
despite the clear gap between sanitation and water supply coverage, only 8% of sector spending in Nepal is
allocated to sanitation. Around 65% of financing sanitation in Nepal is externally sourced, meaning the
government contributes only 35%.
2.2.2
The Provision of Sanitation in Nepal
The provision of sanitation and hygiene promotion in Nepal is undertaken by a range of stakeholders,
including several governmental departments, 2 international development banks, numerous international,
national and local NGOs and thousands of users committees (WaterAid 2007b). The diverse range of actors
can bring confusion as to who is responsible, and the lack of co-ordination at all levels is one of the most
frequently voiced concerns in the sector (Ockelford & Shrestha 2003). Figure 2.22 represents the complexity
of the arrangement of provision of water and sanitation in rural Nepal. See Appendix 4 for a map of the
distribution of key agencies involved in sanitation.
18
Fig. 2.22 Simplified Organisational arrangements for the provision of rural sanitation in Nepal. Based on
Ockelford & Shrestha (2002), modified and updated by Taylor et al (2005)
Donors
Office of the
Prime Minister
National Planning
Commission
Overall priorites/
targets
Funds and technical

support
MPPW
Fund
Board
DWSS
Executive
WSSDO
Ministry of
Finance
Funds allocation
MLD
DOLIDAR
NGOs
DDC
DTO
CBOs
SOs
WSSDO
VDC
Schemes implemented
on behalf of WUSCs
WUSCs
Within the Government, two main agencies are responsible for rural sanitation; the DWSS and DOLIDAR.
The Department of Water Supply and Sewerage (DWSS), is a centralised department for national level
planning, coordination, programming and evaluation, whilst district and community level activities are
undertaken by sub-division offices at the district level (dwss. gov.np 2007). The Department for Local
Infrastructural Development Agricultural Roads (DoLIDAR) is also involved in funding projects that are
implemented through the technical division (DTO) of the District Development Committees (DDCs). The
broad division of responsibilities between the two departments is based on the size of the project scheme,
where it is that of DoLIDAR for schemes of less than 1000 beneficiaries, and the DWSS sub-offices for larger
schemes. The Finnish Government is also working in partnership with DoLIDAR to provide rural WATSAN in
districts in mid and far western Nepal (rvwrmp.org.np 2006). The two largest programmes of the sector are
run by autonomous governmental institutions (WaterAid 2007b), namely; the World Bank supported Rural
Water Supply and Sanitation Fund Board (RWSSFB) and the Asia Development Bank funded Community
Based Water Supply and Sanitation Programme (CBWSSP). International development agencies such as
FINNIDA, CIDA, SNV, DFID, UNICEF, WHO, Helvetas, along with INGOs such as WaterAid, Concern, Care,
Plan, Oxfam are also supporting sanitation in Nepal. Partnership modalities and bilateral relationships among
donors, INGOs, national NGOs and local NGOs are diverse, with some organisations implementing the
programmes unilaterally and others working in a wide range of partnerships, cooperative and contractual
relationships varying in the number of parties (WaterAid 2007b).
Research undertaken by WaterAid (2007b) suggests that the geographic distribution of programmes
incorporating sanitation in Nepal is not necessarily focussed in the areas of least coverage. In the midwestern region, 5 to 6 agencies were found to be working simultaneously in districts that show more than
50% sanitation coverage, while only one or two agencies were promoting sanitation in the districts with the
lowest sanitation. The report continues to suggest that with integrated WASH programmes, communities may
be selected based on water, not sanitation needs, and that many agencies may be reluctant to undertake
projects in more remote areas. In Mugu and Humla districts, key organisations involved in sanitation provision
are the CBWSSP, RWSSFB, FINNIDAs RVWRMP (Humla), the DTOs, UNICEF and their partners; Saapros
and Deppros, KIRDAC, UMN, Concern, ACF, and, in the coming years, SNV.
19
2.2.3
Strategies and Policy in Rural Sanitation and Hygiene Promotion
When undertaking WASH programmes, it is essential to understand, and operate within the national and
international legislative framework, whilst striving to contribute to national strategies, and acting in line with
your ones own organisation and donors policies. This section explores the international, national and ACF
policies and strategies relevant to sanitation and hygiene, but omits a review of donor policies, due the
uncertainty of which donor(s) will support future activities.
International Standards
Unlike for water supply, there are no globally applicable and ratified standards for minimum service levels for
sanitation or hygiene. The only such international standards have been developed by the Sphere project;
however these were developed for application in disaster response contexts. These standards are
progressively becoming a standard reference point for minimal service standards provided by INGOs in their
interventions throughout the world. The following standards have been developed relating to sanitation:
Standards for hygiene promotion and relevant sections relating to domestic and personal hygiene from water
supply interventions are presented below;
Box 2.231. Sphere Standards for Hygiene Promotion and Water Use Facilities and Goods. Source: Sphere (2004,
Revised Ed.)
Hygiene promotion standard 1: program me design and implementation

All facilities and resources provided reflect the vulnerabilities, needs and preferences of the
affected population. Users are involved in the managem ent and maintenance of hygiene facilities
where appropriate.
The indicators state that; key risks to public health should be identified; the re should be representative
participation in scheme and facility design; access to facilities should be equitable for all groups; user
groups should participate in planning, im plem entation, monitoring and evaluation of prom otion.
Water supply standard 3: water use facilities and goods

People have adequate facilities and supplies to collect, store and use sufficient quantities of water
for drinking, cooking and personal hygiene, and to ensure that drinking water re mains safe until it
is consumed.
Ke y Indicators;
E ach household has at le ast two clean water collecting containers of 10-20 litres, plus enough clean
water stora ge containers to ensure there is always water in the household.
W ater collection and storage containers have na rrow necks and/or covers, or other safe m eans of
storage, drawing and handling, and are dem onstrably us ed.
T here is at least 250g of soap available for personal hygiene per person per m onth.
T he participation of all vulnerable groups is activel y encouraged in the siting and construction of
bathing facilities and/or the production and distribution of soap, and/or the use and promotion of s uitable
alternatives.
20
Box 2.232. Sphere Standards for Excreta Disposal. Source: Sphere (2004, Revised Ed.) For a more complete list
of standards, see Appendix 3.
Excreta disposal standard 1: access to, and numbers of, toilets

People have adequate numbers of toilets, sufficiently close to their dwellings, to allow them rapid, safe and
acceptable access at all times of the day and night.
Key Indicators:
A maximum of 20 people use each toilet
Toilets are no more than 50 metres from dwellings.
Excreta disposal standard 2: design, construction and use of toilets
Toilets are sited, designed, constructed and maintained in such a way as to be comfortable, hygienic and safe
to use.
Although useful as a benchmark reference point, it is not felt that all the standards outlined by Sphere are
relevant, or useful for application in context of the study area; with relatively stable populations, and chronic
issues rather than being in a state of emergency or disaster.
Action Contre La Faim International Network WASH Policy

The ACF-IN WASH policy document (06-2006) sets out to standardise the various approaches of ACF WASH
programmes, and develop a technical strategy for the sector (ACF 2007a).
Box. 2.233. Global aims and objectives of ACF-IN WASH programmes. Source: ACF (2007a)
The global objective of water and sanitation programmes is to guarantee, through access to water
and sanitation, survival or socio-economic development, especially acting as preventative care to
malnutrition, and finally impacting on the reduction of mortality.
Specific Objectives:
1.
Covering the minimum requirements necessary for life
2.
Reducing the risk of the spread of water, sanitation and hygiene related diseases
3.
Guaranteeing access to water as a necessary resource for food security and socio-economic
development
Regarding standards and guidelines, ACF-IN policy (2007a) states programmes should ensure minimal
standards are reached (e.g. Sphere) although in specific contexts.those standards may be reconsidered
and adapted and where national standards are above international standards (WHO, Sphere), ACF-IN
should at least reach national standards. In this, the policy document does not apply its own set of standards,
either in minimal service level or construction/technologies, but strives to comply with international and
national standards. The policy details the criteria for beneficiary or target group selection, and intervention
priorities, and goes on to define the ACF-IN WASH intervention modalities.
The Rural Water Supply and Sanitation National Policy & Strategy 2004
Nepals first National Sanitation Policy was produced in 1994. Replacing this, in 2004, was the integrated
National Rural Water Supply and Sanitation (RWSS) Policy and Strategy, produced with assistance of the
ADB and UNICEF (WEDC 2005). The policy had a strong focus on water supply, and does not address
sanitation to the detail of the 1994 policy (Shrestha et al 2005). Two further documents named the National
Guidelines for Sanitation and Hygiene Promotion and Guidelines for Planning and Implementation of
21
Sanitation Program have apparently been produced, but neither were available at the time of research.
Within the RWSS policy 2004, the Government of Nepal (GoN) reaffirms its commitment to the target of
100% water supply and sanitation coverage by 2017, as described in the tenth plan document (GoN 2004).
Box 2.234. Key features of the Rural Water Supply and Sanitation National Policy & Strategy 2004. Source: GoN
(2004)
Overall RWSS Policy and Strategy

Capacity of local bodies, NGOs and users committee should be developed as per the decentralised
approach, the local empowerment and management of RWSS facilities and schemes
Local resources and skills and know-how are utilised and developed in the projects
Representative participation in decision making of gender, caste and disadvantaged ethnic groups
Infrastructure and entrepreneurship will be developed to produce RWSS materials and equipment at the
local level
Selection is based on poverty or hardship; willingness to pay; cost-benefit ratio; prevalence of
waterborne/related diseases; existing facilities
Appropriate technologies are to be used that are affordable and manageable to the users, while
informing them about all available technical options.
The poorest groups in the communities will be identified, and supported with specific target grants.
There is a formalised identification criteria.
Only plans and schemes selected through a participatory DDC/VDC planning process will be
implemented
WSUCs will be organised for the implementation of all RWSS systems, irrespective of the source of
development assistance, and should be representative of gender, caste and disadvantaged groups, and at
least 30% women.
Specific Hygiene & Sanitation Points
Health education and sanitation activities will be conducted in water supply programmes NGOs or
partner organisations will train the community level health volunteers (FCHVs)
If the community demand, a stand alone sanitation project may be implemented
At least 20% of sanitation construction costs should be contributed by the community
Community managed revolving funds will be allowed, with special subsidies for the construction of
latries for poor households
100% of the operation and maintenance costs of household sanitary facilities will be borne by the
households
Although national guidelines have been developed regarding minimal standards of water supply service
delivery, like ACF-IN, there are no technical standards on latrine construction, designs or materials that can
be applied for sanitation in RWSS projects. This is evident, as the DWSS has had active involvement in
CLTS schemes, where there is no minimum design or service standards. The national RWSS policy is
discussed further in section 5, and the main features, in comparison with the ACF-IN policy, are presented in
Appendix 5.
22
2.3
Approaches to Sanitation
Sanitation projects are commonly integrated into WASH programmes, but may also come as stand alone
sanitation and health promotion programmes, the latter being on the increase in Southern Asia, where there
are such disparities in water and sanitation coverage. A summary of the various approaches to sanitation
undertaken in Nepal is detailed below;
2.3.1
Conventional Approaches
Conventional approaches to sanitation are normally orientated around health based promotion of latrines,
followed by subsidy, either in cash or materials (hardware), which is distributed directly to individual
households, or managed by a water and sanitation users committee (WSUC). The individual household
approach can mean slow progress or uptake, and less than 100% sanitation in the target community.
Therefore, whilst, for example, 70% take up latrines, 30% of the community may still be defecating in the
open, limiting the health impacts of the intervention for all in the community.
2.3.2
Subsidies
The subsidy of materials is a common practice of external agencies to support the development of sanitation,
although there is currently a debate in the sector as to whether this is appropriate or necessary (WaterAid
2007b). The degree to which materials are subsidised is generally decreasing, with full subsidy being a rarely
practiced approach. Subsidy to households in the form of cash is also a rare practice, due to the potential
misuse of funds (WaterAid 2007b). Global norms for rural sanitation projects are that the implementing
agency support the community with some form of external materials and skilled labour, whilst the community
are expected to contribute local materials and unskilled labour (except in cash for work schemes). The
superstructure construction and materials is commonly left to the household to organise and finance
(Franceys 1992).
Within Nepal, it is a common practice to subsidise up to pan level (WaterAid 2007b), with basic packages of
cement, a ventilation or drainage pipe, and a toilet pan, and will commonly be accompanied by a limited
amount of skilled labour. Some NGOs may also provide rods and wire for concrete reinforcement, metal
sheeting for roofing, buckets and brushes for maintenance. Major arguments against material subsidy are
that it can undermine the sense of ownership that the users bestow on the facility, therefore jeopardising
sustainability in the long term, it can be at a high per capita cost approach (depending on the degree of
subsidy), and that it can stifle local initiatives and technological innovations (WaterAid 2007b).
Subsidy for latrine construction or materials can be flat rate; that is, the same subsidy level is provided to all
households within the community, regardless of economic (or other) status; or graduated. The flat rate can
range from; a minimum subsidy, where the households are provided with only a small amount of external
materials, whom then have to organise skilled labour and all other materials themselves (also termed an
encouraging subsidy) (WaterAid 2007b); to full material and skill provision. The concept of graduated
subsidies is to enable all members of the community to be able to access sanitation facilities, with a clear
poverty focus. This graduated subsidy may be in the amount of materials provided to each household, or the
amount of cash contribution expected from them. This also allows the potential for cross-subsidy within the
community to finance materials or skilled labour for the more vulnerable households.
Within Nepal, communities may be ranked and categorised into socio-economic groups, either by the
community themselves, the implementing agency, or, most commonly, a combination of the two. For
example, NEWAH categorises households into; the ultra poor, poor and medium; through a so-called well
being ranking (NEWAH 2007). However, in countries such as India, the government has set objective and
clear identification criteria for those below the poverty line (WaterAid 2007b). Experiences from two INGOs
operating in Nepal have found implementing graduated subsidies can be challenging; as some communities
are egalitarian in nature, and attempt to divide all provisions and costs equally. In contrast, in some
communities the well being ranking was hijacked by the richer, more powerful households, and in some
23
circumstances, all households in the community demand support, and raise issues of equity if they are
provided with less than others (Plan, WaterAid 2007 pers comms). Community categorisation is a difficult
process that needs to be well facilitated and requires representation from all groups (WaterAid 2007b).
2.3.3
Subsidy or Self Respect: Community Approaches
In 1999, a new approach to sanitation was trialled in a rural community in Bangladesh. This approach was
based on a community level initiative to stop open defecation, and develop basic sanitation, using strong
Participatory Rural Appraisal (PRA) techniques, in the absence of external subsidy (Kar & Pasteur 2005).
This approach was found to be a great success, and has subsequently evolved, and been scaled up to be
applied in numerous countries throughout Asia and Africa (Plan Nepal 2006). The approach is termed
Community Led Total Sanitation or CLTS.
Box. 2.33. The Main Differences of CLTS to Traditional Approaches. Source: WaterAid (2006)
CLTS differs from traditional approaches in that:

CLTS focuses on stopping open defecation rather than just building latrines.
CLTS harnesses traditional collective community action to stimulate hygiene
behavior changes.
CLTS gives no subsidies to build latrines.
CLTS promotes low cost homemade toilets made from local materials which are
easily constructed by the households themselves.
Rather than targeting individual households, CLTS uses a total sanitation approach, promoting sanitation as
a public good that the whole community must attain, showing that as long as their neighbour is defecating
outdoors, their family will still become sick, regardless of whether they have a latrine. The total sanitation
approach aims at 100% of the community using some method of safe excreta disposal, thus enabling the
community to attain the status of being open defecation free.
The approach involves strong community mobilisation through ignition PRA techniques, which aim to
facilitate the community members to realise the problems in their community by themselves, and develop a
plan for change. These PRA activities include community walks to identify defecation areas in the presence
of visitors; faeces mapping; volumetric calculation of faeces in their environment; and identifying potential
contamination pathways from faeces to water or food supplies (WaterAid 2006). The PRA techniques ignite a
sense of disgust and shame in the community, as they collectively realise they are literally ingesting one
anothers shit (Kar & Pasteur 2005).
Following ignition, the community develop their own strategy to stop open defecation, which involves the
construction of basic latrine facilities, and vigilant monitoring within the community by individuals and
childrens groups, who place flags in open defecation, and literally whistle blow at continual open defecators.
In this sense, it is self monitored and driven by shame, self respect, and community level initiative, and
vigilance.
The community can eventually attain the status of open defecation free, which may include some form of
NGO or Government supported reward (Sakthivel, undated), and recognition, such as public
notices/certificates at the entrances of the village.
A key feature of this approach is that it does not involve external subsidy to assist latrine construction. The
input of the NGO or implementing agency is that of a facilitator, and is therefore referred as a software
approach, rather than the more traditional approach, with more of a hardware focus of latrine construction
and coverage.
24
With CLTS, households build basic latrines initially, using whatever local materials are available, to prevent
open defecation as the primary target, and subsequently upgrade their facilities through time, as funds
become available. This is the concept of slowly moving up the sanitation ladder. The approach promotes the
use of appropriate technologies and innovations, whilst fostering a strong sense of ownership over the
facilities, which the traditional approach of material subsidy, can undermine (WaterAid 2007b).
As the CLTS approach puts the community in control of the process, with external input mostly restricted to
initial mobilisation and software support, experiences have shown the communities find innovative ways to
work around their constraints, and meet their new demand for sanitation (Kar & Pasteur 2005).
2.3.4
CLTS in Nepal
In 2003, WaterAid Nepal, and its partner Nepal Water for Health (NEWAH) visited Bangladesh to observe
CLTS projects, and subsequently decided to pilot the approach in Karki Danda of Dhading district (CETS
2007). Success led to further piloting by NEWAH and the adoption of the technique by numerous other
INGOs, including CARE, Plan Nepal and Oxfam, and national NGOs such as RRN (WaterAid 2006).
Optimism and expectations for the new approach were high in Nepal, particularly given the low national
sanitation coverage, temporal and financial challenges attaining the MDGs and more optimistic national
targets of 100% by 2017. CLTS showed the potential for relatively rapid increases in coverage in the
intervention areas, with strong possibilities for multiplier effects in the local area, and at a relatively low unit
cost.
The progress of CLTS has been encouraging, and by March 2006, 14 villages spread across six districts
have been declared open defecation (OD) free and a further 18 villages spread across seven districts were
put under a CLTS programme (WaterAid 2006). These programmes are spread over the Terai and Hill areas
(see WaterAid 2006 for a list of areas), but no evidence was found by the author at the time of research to
suggest it had been applied in the mountain context.
Experiences with the approach have yielded success, although there have been instances where NGOs have
claimed that CLTS failed in certain communities (CETS 2007, Plan 2006). Success was found greatest in
small, homogenous communities and weakest where there was poor follow-up on the part of the NGO (Plan
2006).
An assessment of NEWAHs CLTS pilot found that; the costs of implementing CLTS per household was 1689
NPR in comparison to non-CLTS approach, at 2626 NPR; CLTS was largely sustainable; and that it helped
expand sanitation coverage within the shortest period of time (CETS 2007).
NGOs implementing the approach comment on the need for strong facilitators, the challenges of allowing the
community to fully take ownership of the process, and the need for intensive, and regular ongoing follow-up
support for the communities.
Plan Nepal (2007 pers comms) found that as there was no provision for subsidy, CLTS should be integrated
with other activities, not as a stand-alone activity, as the communities expect material or financial support/
gain from the NGOs presence within the community, and do not seem satisfied with the purely software
subsidy.
The community desire for permanent latrines (i.e. with cement and pans) has been found to be a challenge
in implementing CLTS, and the concept of climbing the sanitation ladder has not been observed widely in
practice. NGOs such as RRN and Plan are attempting to work around this issue through the provision, or
linkages with microcredit.
NEWAH and Plan found that implementing a dual approach in one area, that is, a graduated subsidy
approach in one community and CLTS in a neighboring one, led to resistance from the CLTS community,
who argued the case of inequity of material provision (CETS 2007, Plan pers comms).
25
2.3.5
Community Led Basic Sanitation for All (CLBSA)
Through the piloting of CLTS, and based on its previous experience of graduated subsidy, NEWAH
developed its own hybrid type of approach, essentially a combination of the two, termed Community Led
Basic Sanitation for All (CLBSA). This approach attempted to merge its previous dual approaches to
sanitation, and also included the provision, in line with national policy (GoN 2004), for a supporting
mechanism for the most poor and vulnerable members of the community. For more information on CLBSA,
see NEWAH (2007).
2.3.6
School Sanitation & Hygiene Education & School Led Total Sanitation
School Sanitation & Hygiene Education (SSHE) was an approach developed and applied by the IRC and
UNICEF in the 1990s. It was piloted in 1997 in Nepal, to be scaled-up to cover the 15 UNICEF supported
districts of Nepal (DWSS & UNICEF 2006a). SSHE uses a child-child approach, designed to promote water
and sanitation facilities in schools, transform students behavior, and promote community sanitation through
child clubs mobilisation and to build the school-community relationship (DWSS & UNICEF 2006b). The
approach utilises children as the agents of change within the community, and the school as a focal point of
activities and management of the process, and success of piloting led to its incorporation into the national
strategy for rural water supply and sanitation in 2004.
SSHE has subsequently evolved in Nepal, to be combined with the ignition PRA techniques of CLTS, and
capacity development activities, to form a new approach termed School Led Total Sanitation (SLTS). This
approach is analogous to CLTS, but as the name suggests, uses the school as the entry point to the
community, and uses the school catchment boundary to delimit the area of activities (DWSS & UNICEF
2006b).
SLTS was pioneered by UNICEF, and has been applied widely by them, and piloted by NEWAH and the
Nepalese Red Cross, and is now also integrated into national strategy. The experiences of SLTS have been
based in the Terai and Hill areas; however, a pilot is being trialled in Humla district, in the administrative town
of Simikot, although at the time of research, it was too premature to try to derive any findings (UNICEF pers
comms).
A WaterAid report (2007b) mentions the benefit of SLTS being linked with permanent institutions, with good
prospects for sustainability, but also states that the members of the school are not always representative of
the communities around them, with many poorer and excluded groups not sending their children to school
and therefore not part of the institution.
To aid the attainment of open defecation free status, SLTS commonly includes the provision of an award in
the form of a financial grant, or by instigating a revolving fund within the community. A comprehensive guide
to SLTS is provided in DWSS & UNICEF (2006b).
2.3.7
Revolving Funds and Loans
Another approach to financing sanitation is through the provision of microcredit and revolving funds, to enable
households, generally following broad sensitisation or hygiene promotion, to access sufficient funds to
construct toilet facilities.
The World Bank RWSSFB project utilises a revolving fund technique. In this, the RWSSFB provide the
community with grant money to begin latrine construction. Initially, funds for 25% of the households in the
community, (at a rate of 2000 NPR per household) are supplied to the WSUC bank account. The WSUC
provide these funds as a loan to 25% of the communitys households to build their latrines, but on the
condition that they pay it back within a certain period, normally 3-6 months. Once the first 25% of households
have paid back the loan, the funds are released to the next 25% to construct, and so on, until 100% of the
community has constructed latrines. The funds remaining in the account may be used to support the more
vulnerable members of the community to construct the latrines, or reserved for ongoing operation and
26
maintenance needs (RWSSFB 2006). All households of the community are expected to construct
permanent latrines within a 2 year period, and the RWSSFB has certain design criteria for latrines that must
be followed. A report by WaterAid (2007b) identified a number of key issues associated with the revolving
fund system, presented in Box 2.37.
Box. 2.37. Key issues with revolving funds for Sanitation. Source: WaterAid (2007b).
Long repayment periods slow the revolving process but too short or unrealistic repayment periods
cause households to default on payments.
Disadvantaged households often do not take revolving loans, as they are unable to repay them.
Due to the fund having to be revolved three or even four time to cover the whole community the
implementation periods for this approach are often longer than other approaches.
Generally, the amount lent is not sufficient to build a latrine and therefore some households have to
take additional loans from private moneylenders or relatives to complete construction of the latrine.
The 2004 National Policy acknowledges revolving funds as an available option to finance sanitation (GoN
2004), and the approach is being applied across the country, including in Mugu and Humla districts.
However, implementing NGOs mention that the remoteness and access of the communities in these districts,
and the requirements of consultants, often based in Kathmandu, to validate the progress of the projects
before releasing funds, can lead to long delays and poor monitoring (RWSS, Saapros 2007 Pers comms).
2.3.8
Sanimart
Whilst hygiene promotion, community sensitisation and ignition PRA, and microcredit aim to develop the
community and household demand, and ability to obtain sanitation facilities, Sanitation Marketing, or
Sanimart, aims to address the supply of sanitation materials to the communities.
Potential barriers to households constructing toilets are the lack of material and skill availability locally.
Households in more remote areas may have to travel large distances to obtain sanitation materials, spending
time on transport and overnight subsistence, whilst loosing time doing their normal income generating
activities (NEWAH 2004).
The concept of a Sanimart is to bring a range of sanitation materials and skills to be accessible and
affordable to the community consumers and sold through local shops or outlets, staffed by a trained
sanitation promoter. These outlets or sanitation centres may also be involved in local production of sanitary
materials, and produce a range of demonstration latrines.
Sanimarts are being promoted and supported widely throughout the world, with much activity in South Asian
countries of Bangladesh and India (Kar & Pasteur 2005). A pilot project undertaken in Nepal by NEWAH
proved effective; with households constructing latrines with very low financial input from NEWAH. However it
was noted that even with subsidised materials, the ultra poor in the communities could still not afford to
purchase the materials available (NEWAH 2004).
2.3.9
The Model Approach
Another approach is that of using communities, VDCs or even entire districts as model areas, whereby funds
are focussed to enable 100% sanitation, and may be extended to other activities including environmental
sanitation, water supplies and tree planting, to make the model a reference point for which other
communities aspire to be like (WaterAid 2007, RVWRMP 2007).
27
2.4
Hygiene Promotion
So far, a strong focus has been placed through this document on the importance, and modalities of promoting
sanitation. While this is of utmost importance, it should not be forgotten that hygiene behaviour holds a
significant influence on the health of communities.
A study by Curtis (2003) found that the simple act of handwashing with soap can reduce the risk of diarrhoeal
disease by 42-44%, and interventions that promote handwashing might save a million lives. Evidence is now
also mounting that handwashing can significantly reduce the other major killer of the developing world;
Acute Respiratory Infections (ARI) (Cairncross 2003).
Statistics from a national study by UNICEF indicate that in rural areas of Nepal, 37% of people wash their
hands with water only, and only 12% use soap (BCHIMES/UNICEF, 2000 in Taylor et al 2005). The relatively
low figure for washing with soap and water suggests a need for an increased focus on hygiene promotion.
However, there are no associated targets for addressing hygiene awareness, unlike water supply or
sanitation (Taylor et al 2005).
Hygiene promotion is commonly integrated into water supply and sanitation programmes, although
programmes are often criticised for bolting it on at the end of the hardware activities, rather than
incorporating it from the project inception.
Traditionally, hygiene promotion has been undertaken in the form of a top down lessons based approach
where an outside expert trains the community through health based messages, often using visual
Information Education Communication (IEC) materials.
Increasingly, more interactive and imaginative ways of message conveyance have been practiced, using
song, drama, puppetry, street theatre and even community radio. PRA techniques are now widely used in
hygiene and sanitation promotion, and perhaps the best known set of tools developed for the purpose are
that of the Participatory Hygiene and Sanitation Transformation (PHAST).
More child-orientated approaches include child-child techniques, where (as mentioned in SSHE) the children
are used as the agents of change in the communities, taking an active role in teaching siblings, friends,
peers, in addition to the elder members of their family. The training of the children in this approach is through
practical education, either in the school, in community kids clubs, or a combination of the two.
Hygiene education is essential to help to identify and tackle key risk practices within the communities.
However, without access to enabling factors, such as an adequate water supply, toilet facilities and soap, the
impacts of the intervention can be strongly limited (WHO 2005).
2.5
Summary
In summary, poor sanitation and hygiene practices are acute and chronic problems in Nepal. A variety of
approaches exist to address both, each with their own strengths and weaknesses, and particular contexts
where they may be effectively applied. There is no single, universal approach or silver bullet to rural
sanitation and hygiene.
28
Methodology
The project was undertaken in Nepal over a period of four-and-a-half months between September and
February 2008. The sequence of activities was as follows:
Table 3. Activity schedule for research project
Activity
Week
9 10 11 12 13 14 15 16 17 18
Briefing in Paris/Nepal
Coordination Meetings (Kathmandu, Mugu)
Field Research
Analysis of Findings
Coordination Meetings (Kathmandu, Nepalgunj, Mugu, Humla)
Report Writing
Translation of Report to Nepali
Presentation at Sector Workshop in Kathmandu
Dissemination of Report in Nepal
Presentation at ACF Paris and Cranfield University
The research was undertaken through a combination of community interviews and site visits; coordination
and lesson sharing with other sanitation and hygiene actors; and a bibliographic review.
3.1
Field Research
Seven weeks were spent undertaking field research in rural communities within the ACF intervention areas of
Mugu and Humla districts. See Fig. 1.22 for a map of the study area.
3.1.1
Community Selection
Thirteen communities were visited in Mugu and Humla; representing all 10 beneficiary communities that ACF
has, or plan to implement WASH activities in, and 3 further (non-ACF-WASH beneficiary) communities of
interest. The rationale for community selection is presented in table 3.11.
In addition to communities, 4 secondary and 6 primary schools, along with 2 health posts were also visited in
the area, although due to various reasons, only 3 of the institutions were open at the time of the visit. A list of
the institutions visited is presented in Appendix 1.
3.1.2
Interviews
A total of 87 interviews were conducted in the field with community members (61) and key informants, such
as traditional healers (2), teachers (7), priests (1), shop keepers (3), community health workers (6), CBOs (3),
Maoists and local leaders (4).
Figures 3.121 and 3.122 show the caste and demographic characteristics of the 87 interview respondents.
29
Figs 3.121 & 3.122. Demographic and caste divisions of 87 interviews.
Table 3.11. Community selection for field research
Community Name
VDC
District
Nerah
Taza
Nathapu
Jamaldara
Rati
Nachara
Pumeru
Jima
Melcham
Lower Rhimi
Photu
Photu
Nathapu
Nathapu
Melcham
Nathapu
Jima
Jima
Melcham
Darma
Humla
Mugu
Mugu
Mugu
Humla
Mugu
Mugu
Mugu
Humla
Humla
Libru
Photu
Mugu
Masinmela
Nathapu
Mugu
Ruga
Ruga
Mugu
Rationale for Selection
Received a GFS from ACF in

2006-07. Planned for Latrines
2008*
Planned for a GFS and

potentially latrines over 2007-8*
Specific environmental health
characteristics, in ACF
intervention area
Seasonal settlement for
residents of Nachara
Accompanied visit to sanitation
project of LNGO
Number of
Interviews
Undertaken
15
4
15
9
3
5
11
7
7
2
3
3
3
Total
87
* According to the provisional community selection at the time of field research planning (October 2007)
3.1.3
Interviewee Selection
The initial aim of a fully randomised sampling methodology was found to be inappropriate for the study. Due
to the timing of the field research (during the harvest and festival preparation period, and daytime interviews),
many villagers were very busy, particularly the lower castes and women, and often absent from the village,
working the fields. Therefore, interview selection was sometimes, unavoidably, a case of who was available
and willing to partake at that time. The following approach and criteria was applied:
Aim to get proportional representation of castes, gender and age within the communities
Aim to get a geographic-spatial spread of households throughout the communities
Aim to speak to key informants from each community where available.
30
Basic mapping of the settlements and caste distributions helped this selection, and, coupled with community
walks, allowed the identification, and targeted selection of households with particular relevance to the
research, such as vulnerable and landless households, those with latrines, those with particularly unclean
children, and so on. Therefore the selection process was flexible and adaptable to the context, whilst striving
to obtain social, economic and demographic representation. The total sample size was limited to time
constraints in the field.
3.1.4
Style and Topics for the Interviews
Two other pieces of research influenced the style of interviews and data collection, and the topics covered in
this research project.
The KAP Survey
A Knowledge, Attitudes and Practices (KAP) survey was undertaken by the ACF WASH team in the study
area in May 2007. This involved the collection of quantitative data on respondents knowledge, attitudes and
practices relating to water supply, sanitation and hygiene, through questionnaires in 240 households. The
respondent households were randomly selected throughout clusters in 4 VDCs in Mugu and 6 in Humla
Districts, where ACF have or had activities. For the full methodology, see ACF 2007b)
Investigation into Child Care Practices
This research was conducted at the same time as an investigation led by Psychologist Aurlie Bardouit, into
parent-child care practices. Aurlies methodology was both qualitative and quantitative using questionnaires
and Focus Group Discussions (FGDs), and there was a degree of overlap with topics regarding the
responsibilities and practices for child hygiene and sanitation. Questions for both researches on these
overlapping areas were developed in coordination between the two researchers.
As this research aimed to identify barriers, aspirations and perceptions of respondents regarding hygiene and
sanitation, a qualitative approach was deemed to be more appropriate than quantitative. This decision was
also in light of the wealth of quantitative data collected on hygiene and sanitation obtained by the KAP
Survey. The human resources available for the project also limited the possibility of collecting large,
statistically valid quantitative datasets.
An informal, semi-structured interview style was selected, using predominantly open questions that allowed
for elaboration, and allowing the answers given to guide the interview sequence, and the questions asked.
Therefore a wide range of qualitative information could be collected, not confined to the scope and structure
of pre-determined questionnaires, or multiple choice answer options. Given the constraints on respondents
availability at the time of field research, and the challenges of isolating individuals for personal interviews,
interviews were flexible in style, undertaking individual, multi-person, and focus group interviews (such as
mothers or children groups).
The topics for interviews were developed so as to add quality assurance, but not duplicate the KAP Survey
findings, and were tailored to the specific areas of relevance for this research. Questions included the
following broad themes:
Interviewees priorities and perceptions of environmental hygiene and sanitation issues
Current defecation habits
Previous experiences, and future aspirations for latrines
Latrine location issues
Environmental sanitation and household management
Personal, hand and clothes washing
Child hygiene and child hygiene promotion (including responsibilities within the family and the role of
the school)
Community organization, leadership, and appropriate approaches for sanitation and hygiene
improvements.
31
For a full list of questions, see Appendix 2.

Asking all questions developed for the research took around 2 hours, and some topics were not relevant to
some interviewees. Therefore a flexible approach was taken, to allow answers to initial, open questions
regarding general hygiene and environmental sanitation issues, to shape the relevant topics selected and the
opportunity to elaborate to areas outside the questions selected if appropriate. However, if time allowed,
interviewees would be led through all questions, to develop the degree of quantitative information available
for analysis. This was achieved in 44 out of the 87 interviews. Topics covered in interviews with key
informants depended on the context, and their role in society. Therefore no standardised questions were
developed for these interviews.
3.1.5
Structured and Non-Structured Observation
To aid the researchers understanding of the community, and to inform interviewee selection, basic mapping
of settlements, which identified house and infrastructure layout, and caste distribution, was undertaken as a
first priority upon arriving in the communities. This was followed by a community walk, accompanied where
possible by community members, to undertake a broad environmental health assessment, and identify key
points of interest and their respective interviewees.
3.2
Coordination with Other Sector Workers
A total of 44 interviews were conducted at the national, regional and district level, to learn from the
experiences, strategies and policy of different actors involved in sanitation, child hygiene and general
community health. Figure 3.2 shows groupings to which these 44 respondents belonged to.
Fig. 3.2. Division of the 44 coordination meetings and interviews.
ACF Staff
Donor s /Funding
organis ations
National
Gov er nment
Loc al/National
NGOs
INGOs
Local Gov ernment
A full list of names, positions and contacts of those spoke to can be found in Appendix 1.
3.3
3.3.1
Research Limitations
Logistics, Coordination and Planning
Repeat delays were incurred with recruiting the translator and attempting to incorporate an additional
consultants study, in addition to delays in the field with organizing porters and irregular flights. This made
project planning and coordination with other ACF staff challenging, and, in addition to turnover of staff, meant
that time spent with ACF (and partner) WASH implementation staff in the field was very limited.
Requirements to renew visas also limited the researchers time in the field. The repeat delays and last minute
cancellation of the consultant meant that avenues of his research, particularly on the social appropriateness
of CLTS and graduated subsidy were left uncompleted.
32
3.3.2
Timing of the Field Research
The research was conducted during harvest time, and generally during the day, meaning that community
members at this time, particularly the lower castes and women in general, were often too busy to partake in
the research. This was mitigated to some extent by holding evening time focus group discussions (FGDs). In
total, gender and caste representation is felt to have been achieved (see Figures 3.121, 3.122). As the field
research also coincided with two of Hindus biggest festival periods (Dashain and Tihar), many government
departments, schools and health posts were closed for holidays, and many staff were unavailable for
interview. This was mitigated by a return visit to district towns 3 weeks after festivals had finished, although
many local government staff were still absent from their post.
3.3.3
Interviews
The field research was undertaken by the researcher and a translator, both of whom are males. This posed
issues of undertaking individual interviews with unmarried females, due to cultural acceptability, and timidity.
This was mitigated by holding group discussions with females, in public places, and with constant
encouragement for their contribution. The males of the community often tried to participate, and even
dominate womens group discussions. This was unavoidable in some circumstances, but reduced by holding
male interviews first, giving them their own time to contribute to the research.
Respondents answers may have been influenced by the fact that both the researcher and translator
represented ACF, which is widely perceived by the communities as a rich NGO with lots of resources.
Gauging respondents feelings regarding the appropriateness of various technical and social solutions was
also challenging, as enthusiasm for assistance or new ideas may come before the evaluation of whether it is
truly appropriate. Questioning on this topic also had to be cautious as to avoid building expectations for future
assistance on each of the solutions proposed.
33
Findings & Analysis
Throughout this section, findings from this research are presented along side findings from the KAP survey
for the area. This is to capitalise on the breadth of research that has been undertaken on hygiene and
sanitation in the intervention area.
However, significant differences exist between the two methodologies, in terms of interviewee selection,
sample size, style of data collection, topics covered, and temporal differences of the research. The results
should not therefore be directly compared, but are presented here to maximise the information available for
analysis.
Where findings are presented that were not directly collected by the author, it is clearly marked in the text,
and all photos presented in this report were taken by the author.
Where possible or applicable, findings from this research have been represented graphically and
quantitatively, but often it is misleading to represent qualitative findings in such a way. In such instances,
qualitative findings have been summarised into relevant sections.
4.1
Context and Community Descriptions
The communities in the study area were found to be heterogeneous in size, orientation, demography, social
organisation and environmental health status. However, common characteristics were observed, and are
presented below.
4.1.1
Community Habitation, Location, Distribution and Orientation
Communities visited ranged in size between 13 and 110 households, with the average household size in the
area calculated at 7.7 people (KAP Survey 2007).
Most communities in the area are highly nucleated and dense, with houses built in complex terraced
arrangements, with up to 13 households per terrace, intersected by narrow public paths, grain pounding
areas and livestock pens. Some of the higher altitude seasonal settlements and smaller mid- altitude
communities however, are more dispersed, with single households or smaller terrace units of 2 to 4
households.
In both circumstances, there is generally spatial groupings and clustering of households according to caste.
Fig. 4.111, 4.112, 4.113. Terrace houses in Jamaldara; Melcham Village; Macinmella (seasonal high altitude
settlement).
Households located within the interior of the settlements were commonly surrounded by other buildings and
paths and therefore had little house frontage, whereas those households located on the settlement
periphery, or in more dispersed communities, often had frontage to land plots directly outside their house or
just the other side of a path.
34
The size of the houses varied according to settlement dispersion, and also generally correlated with caste
status. Houses consisted of 2 or 3 floors, and were generally arranged as follows;
Figure 4.114. The layout of houses in the study area.
Side View of an Average House
There may be a small storage room

for the third floor, generally used for
keeping grains.
Grain
Store
The roof is flat, except in a few high

altitude exceptions, to allow for grain
drying and processing.
The first floor is the living space for

Family Living Space
Cow Shed
Buffalo Shed
the family. This may consist of

multiple rooms for bedrooms/storage
and kitchen, but is generally one room
for all purposes. There is normally an
external overhang or balcony for this
floor.
The ground floor is for livestock

shelter (cattle shed), generally with
internal wall divided chambers for
cows, buffalos and occasionally goats.
Settlements were located on valley slopes, plateaus, ridges and alluvial fans, surrounded by terraced
agricultural land. Land ownership patterns can be complex, but, generally, the more proximal and productive
land is owned by higher-caste families of the village or surrounding area, and the more distal land owned by
the lower-castes.
4.1.2
Society, Culture and Religious Beliefs
Society within the communities is stratified by the caste system. Within the study area, the following castes
are present, listed here in descending order of social hierarchy: Brahman, Thakuri, Yogi, Chhetri, Magar, and
Dalit.
Generally only 3 different castes were present per community, with Chhetris, Takuris and Dalits being the
most commonly occurring castes.
Members of different castes were observed to socially mix, and attended and contributed at the same focus
group discussions. However, it was explained that taboos do exist, particularly with sharing facilities and
commodities with lower castes (Dalits). Older generations generally regarded caste division as more
important than the younger, relatively more educated generation in the communities.
There is an obvious disparity of resource access, land ownership, material wealth and living conditions
between Dalits and the other higher caste families in the communities.
35
4.1.3
Livelihoods and Economy
Livelihoods in the study area revolve around subsistence agriculture. Major crops include rice, millet, maize,
wheat, pulses, and, to a lesser extent, vegetables. Livestock such as buffalo and cows, and occasionally
goats and chickens are also reared.
The annual cropping cycle dictates the seasonal activities of the farmers, with harvest times being particularly
busy periods. See Appendix 6 for an annual social and cropping calendar.
Lower castes (Dalits) often have very little land for farming or low productivity plots, and are consequently
unable to produce sufficient food for their families. They often work on higher caste land in exchange for food,
or to service previous debts (commonly related to last year's food transactions).
Aside from agriculture, there is little in the way of job opportunities in the area apart from occasional local
porterage or labouring on a cash/food for work development project in the area. Seasonal economic migrancy
is practiced by males over approximately 15 years, going to India over the winter to undertake unskilled
labouring posts for between 4 and 7 months. It was stated that the migrant workers are able to save around
2200 NPR per month.
Financial (cash) resources and flows are seasonal and low. Transactions between households were often
based on quantities of crops instead of cash. However, it was difficult to determine cash ownership and flows
during the field research, as answers were often sceptically believed by the author to be distorted, in an
attempt to gain maximum benefit from projects or to make minimal contributions. The area is drought prone,
and food security is perceived as both a major issue and priority.
4.1.4
Roles, Responsibilities and Gender
The daily family chores and responsibilities are traditionally allocated to different family members. Findings
from two focus group discussions (backed by observations) on task responsibility are as follows:
Table. 4.14. Traditional task responsibilities according to gender.
Traditional Task Responsibilities (Findings from 2 FGDs)

Task
Economic migrancy to India
Plough the field
Milk cow/buffalow
Take cattle to field
Collect wood
Collect water
Harvest crops
Cook food
Supervise, clean and feed children
Pounding rice
Grinding grains for flour
Clean the house
Wash dishes
Clean families clothes
Carry compost to field
Children
Go to primary school (up to around 11 years)
Go to School > around 11 years
Supervise cattle
Wood collection
Collect water
Help mother clean house
Supervise younger brothers/sisters
Cut grass/collect leaves for composting
Gender Responsibility
, occasionally
, occasionally
, occasionally
, occasionally
, occasionally
36
The disparity in tasks is reflected in the daily burden of the women, who regularly complained about the
limited free time they have during the day. Despite this, it was generally stated that men have dominant
control over the financial and material resources of the family.
When possible, children are sent to school at primary age, however, during harvest time, or when the father
leaves for India, the elder children can be pulled out of school to assist at the home or in the fields. The
preference is to remove the girls before the boys. Girls were explained by parents to be sent to school until
the age of 10 or 11, but then often removed. This was reasoned by 3 interviewees by stating they (the girls)
will grow up, marry and leave the family, why should we invest in their education? Boys, in contrast are
perceived as a potential economic asset for the future.
4.1.5
Community Organisation, Leadership and Local Governance
Due largely to the Maoist activities in the area, local services, governance and leadership have been
impaired.
At the district level (in Mugu), the District Management Committee (DMC), who normally make decisions such
as community or VDC selection for development projects, is on-functional, and the responsibility has fallen on
meetings between political representatives. The operational capacity of the Village Development Committee
(VDC) level governance has also been affected, as work and travel outside of district capitals was
constrained by Maoist operations, and local services such as schools and health posts have suffered.
However, many of the district officials interviewed were optimistic of an improving situation in the area.
At the community level, many of the interviewees remarked on the current lack of leadership, social cohesion
and unity. A common answer to enquiries on leadership was no one listens to anybody anymore. This was
attributed to the remnants of the Maoist oppression, which actively undermined the authority and reputation of
formally recognised local leaders and VDC government, and caused some leaders to flee the area.
Willingness, self mobilisation and initiative for individuals to work on community projects have been depleted.
Previous Maoist forced labour projects (such as path construction), cash for work/food for work schemes
(CFW/FFW) by NGOs and Government for community projects, along with family priorities for food security,
limited time availability and the lack of leadership were all mentioned to be influencing factors for this.
Box 4.15. The Case Study of Nerah Mothers Group
In 2 communities next to ACF field base (Nerah & Taza), mothers groups have been relatively active. The groups
were formed during the monsoon, whilst ACF were not present in the community, and it was unclear from
interviews exactly how or why they formed. Some interviewees stated the idea came from a local teacher, with a
friend in a locally operating NGO, others said it was an idea originating from the community itself. Nethertheless,
the group was formed and received no formal training from any project. It is headed by a socially active 50 year
old Chettri mother from the community, and has around 48 members, of different castes. Their focus at the time of
research was to address problems of male gambling and drinking on the street, and 'cleaning up the village'.
Activities undertaken by the group (unassisted or pushed from an external project) have included mobilising and
undertaking community meetings, and effectively promoting the construction of child latrines and household
greywater soak pits.
Despite the aforementioned issues in leadership, key figures still exist, and have varying influence within the
communities, such as; ex. ward and VDC presidents, former and current Maoist (and other political party)
leaders, traditional healers and priests.
Out of the 12 communities visited, 7 were stated to have Community Based Organisations (CBOs) in the form
of Mothers or Womens Groups.
In 2 of the communities, the CBOs had been created by a local NGO to promote and drive social change. In
these instances, attempts by the CBOs at social mobilisation were unsuccessful, and the CBOs were not
37
provided with follow-up support. The initiatives lost momentum, leaving a sense of fatalism (observed in 4
interviewees from the CBOs), where they felt unable to change their situation.
In 3 of the communities, women/mothers groups were said to have been recently formed (in 2007), and in
two instances legally registered at the DDC. However, the presidents or secretaries of the groups were
unsure of the true purpose, or goal of the CBO, and stated that they had not yet undertaken any activities.
They were formed following suggestions from local teachers and health post staff, and stated that they were
waiting for support, training and direction from external projects to drive some form of change in the
communities. However, the villages of Nerah and Taza had more promising experiences with CBOs, outlined
in Box 4.15.
4.1.6
Health and Healthcare
Problems, Knowledge and Beliefs

Health problems mentioned by interviewees were seasonally variable, with diarrhoea, fevers and eye
infections predominating in the summer (March-May) and rainy season (May-September), and pneumonia,
common colds, respiratory and joint problems in the winter.
Other ailments mentioned by interviewees and the District Health Officers (DHO) were; dermatological
problems such as scoriasis, scabies, fungal infections, fleas/lice in clothes and blankets, infected wounds;
parasites such as roundworm, hookworm and tapeworm; stomach/digestion problems such as gastritis, food
poisoning, vomiting, abdominal pains and malnutrition. The DHOs of both Humla and Mugu stated that
diarrhoea was the biggest sole cause of mortality in the districts.
Table 4.161. Top 10 outpatient diseases in Humla District during 2006. Data obtained from the DHO in Simikot,
Humla in November 2007.
Rank
Males
Females
Diarrhoea
Diarrhoea
1
Acute Respiritory Infection (ARI)
Acute Respiritory Infection (ARI)
2
Intestinal Worms
Intestinal Worms
3
Skin Diseases
Gastritis
4
Abdominal Pain
Skin Disease
5
Eye Complaints
Abdominal Pain
6
Chronic Obstructive Pulmonary Disease (COPD)
Eye Complaints
7
Arthritis
Ear Infection
8
Toothache
Chronic Obstructive Pulmonary Disease (COPD)
9
Toothache
10 Ear Infection
Data refers to patients diagnosed in Humla Health Posts and District Hospital only
Under local belief, the concept of purity, and the belief that gods will become displeased if an impure
activity occurs within the house, means that women have to spend time in the cattle shed during
menstruation, and during and 15 days following childbirth.
All four interviewees questioned on the topic stated that their own family had experienced infant mortality
rates of over 50%, and knew of women within the communities that had died during childbirth in the cattle
sheds; however, no data was available on this from the DHOs at the time of research.
The KAP Survey identified that out of 240 interviewees, 45% to 67% of respondents knew that smoke, flies
or food can carry diseases. Concerning water, 31% of respondents didn't know what kind of disease can be
transmitted by water and 26% thought that cold is the main water-borne disease.
38
Figures 4.162, 4.163. Understanding of disease transmission. Source: KAP Survey 2007
Do you think that smoke, flies or food can
cause diseases
Do you think that w ater can carry diseases

1-No
7%
food
20
35
45
2-I don't know
26%
3-Respiratory
1-No
flies
27
67
2-I don't know

3-Yes
4-Eyes
31%
1%
6-Fever
6%
smoke
18
18
64
9%
0%
20%
40%
60%
80%
5-Diarrhoea
6%
13%
100%
1%
7-Worms
8-Skin
9-Cold
Although not a strong focus of this research, 2 of the following explanations from interviewees give an
interesting insight into some of the traditional beliefs about disease cause and effect held in the area:
Swollen stomachs are a product of too much millet rotis (bread) or from eating cold food
The cause of baby diarrhoea was a result of feeding it hot milk from the breast due to the mother
being exposed to the sunlight in the fields.
When a member of the family falls sick, they are often taken to a dhami or lama (traditional healer). The
healers may explain that the ailments are related to displeased gods, and, upon the sacrifice of a chicken,
perform a ritual to please, or expel the gods from the patient.
Common treatments from the healers includes using coals to burn stomachs (to exorcise the gods) for
diarrhoea, and rubbing herbs to reduce the swelling of children's stomachs (malnutrition caused). Figure
4.164 shows the KAP Survey interviewees response to diarrhoeal incidence.
Figures 4.164, 4.165, 4.166. Interviewees response to diarrhoeal incidence (KAP Survey 2007); a traditional healer
in Libru village; a child showing signs of stomach scarring from traditional medicine in Nerah village.
If one gets diarrhoea what do you do
1-Nothing
9%
9%
2-Traditional
medicines
3-Buy drugs
23%
40%
19%
4-Health
center/Hospital
5-Give ORS
Services and Practices

Findings from interviews with the Humla and Mugu DHOs are as follows;
The district hospital and health posts were generally affected by high turnover and regular absence of
qualified staff and chronic shortages of medical supplies, reducing their ability to function or operate
effectively. The more serious cases are often referred to regional hospitals, but due to costs of flights, this is
normally only an option for the more affluent families. Transport difficulties and the uncertainty of whether the
local health post is operational often means cases are left until they are perceived as critical before making
39
the journey to the district hospital. The effect of the traditional healers means that the family wait to see if the
patient will get better following traditional treatment, before they take them to the hospital. For both these
reasons, cases brought to the hospital are often in their advanced form, and beyond the capacity of the
district team.
Within each ward is (or should be) a Female Community Health Volunteer (FCHV). These are members of
the community, trained to varying extents by the Ministry of Health through DHOs, and, more recently
occasionally by NGOs. Their main functions are to provide community level basic care, disseminate health
and hygiene messages to the community, ad-hoc distribution of vitamins and supplements, and remind
mothers about dates for child immunisation.
The FCHVs are often well regarded by the DHOs and NGOs who incorporate them into their projects, for
their effectiveness at the field level, noting that the only problem in using them being rising demands for
incentives for attending training sessions.
However, there were discrepancies in interviews in 3 communities between the activities that the FCHVs
stated that they have undertaken in the community (such as holding monthly ward-level mothers group
education sessions, and household visits), and those which the community members said that they had done,
which was far less.
The 6 FCHVs interviewed stated that they are generally listened to and respected by the community,
particularly by the younger mothers, but the younger FCHVs said that the elder mothers may be reluctant to
listen to their advice, as a combination of respect for age, and their limited experience. Three mothers within
the communities stated that they would not visit the FCHVs for advice or assistance, stating that they did not
believe they were capable, or trained enough.
4.1.7
Transport, Local Supply Chains and Consumption Practices
For an understanding of the potential for the sustainability of access to materials, and sanimart viability, an
assessment of local supply chains was undertaken.
The study area is remote, with no road access within 4 days trek, narrow and landslide prone tracks and river
crossings using ropelings (see Figure 4.172). A combination of the infrastructure and low household income
means that the ownership and use of mules or other animal-based transport is limited, with most materials
being portered on people's backs.
There is little in the way of external materials, particularly large or bulky commodities in the communities,
except that which are brought in specifically for use in development projects (such as tin roofing, cement and
pipes etc). There is no manufacturing industry locally.
Figures 4.171, 4.172, 4.173, 4.174. Mugu districts airport; A ropeling river crossing in Mugu; district stores in
Gamghadee (Mugus capital); a village shop in Purumeru village (Mugu district)
40
Formal and informal shops exist within settlements exceeding around 40 households, which stock a limited
range of hygiene consumables. More expensive items, such as buckets and building materials are not
stocked, due to the high capital expenditure required, and respective financial risk. Soap in these shops is
generally sold for 15-25% more than at the district towns from where it is sourced.
Consumption patterns of hygiene products, particularly for soap, were stated by village shopkeepers as
seasonal, peaking during the summer months and over festival times. Interviewees stated that they generally
purchased higher priced commodities in the district towns or Kolti, to avoid mark-up costs from village stores.
External materials were also purchased in India by the seasonal migrants, commonly bringing back clothes
and shoes.
Figure 4.175 presents results from a survey on spending habits from incomes from a Cash for Work (CFW)
scheme, undertaken by the ACF Food Security team in June 2007, indicating trends and priorities for cash
expenditure in the area.
Figure 4.175. Household Cash for Work Scheme Expenditures. Source: ACF (2007f)
4.1.8
High community expectations
Due to a number of reasons, expectations of the level of support to be provided by external projects can be
fairly high in the communities. This finding is from anecdotal reports from many other locally operating NGOs,
ACF implementation staff and the researchers own experiences. This was mainly linked to; previous
activities and promises of materials or levels of subsidies, from NGOs (including ACF); pro-active, non
demand-driven community selection for projects; and the programmes utilising CFW schemes. ACFs
experience in the area has seen instances of increasing or changing community demands, and
renegotiations of community contributions. This is common to the experiences of other NGOs in the area, of
what one LNGO termed bargaining tactics. This may be understandable in the area, considering the recent
history and low level of employment in the area.
Box. 4.18. Experiences of communities actions and perceptions with development projects.
Anecdotal evidence from a Mugu based NGO:

The NGO selected, and then launched a water supply (GFS) project in a community, using cash for work (CFW)
scheme for unskilled local labour. Upon scheme completion, the NGO left the community. Some of the community
members then sabotaged the GFS, and then applied to the NGO for assistance to rehabilitate, to get repeat
employment from the CFW scheme. In this, the benefit of scheme was seen (by some) as a mode of employment,
not necessarily for the end product (a functional GFS).
Answers from 3 Interviewees regarding Operation & Maintenance (O&M) of potential future latrines:
If the toilet (pan) breaks, an NGO or the Government will come and fix it for us
41
This is not to discriminate or condemn activities, or to suggest that all members of the community act in this
way (which would be quite misleading), but just to reflect ACF, and other NGOs experience that they can be
challenging communities to work in.
4.2
4.2.1
Environmental Health in the Communities: Practices, Perceptions,

Aspirations and Barriers
Environmental Health Situation from Observations
The environmental health situation of communities was variable spatially, and, it is predicted, seasonally. This
section provides a broad overview of the situation from observations, before presenting findings from
community interviews and the KAP Survey.
At the community level, the heterogeneity of issues was linked to the relative size and dispersion of the
settlements, the distance to public, vegetated land (common defecation areas), water availability, natural
drainage, and the relative standard of development and education of the village.
Many settlements are densely populated and nucleated, holding strong potential for rapid disease
transmission.
Within, and on the paths leading into many communities, human, dog and livestock excreta is noticeable,
often in significant volumes. Poor solid waste management and livestock/composting practices result in high
quantities of debris on the paths outside homes, and domestic grey water is commonly poured indirectly onto
this, with no system of effective drainage. Most paths are unsurfaced, and the effect of livestock trampling
creates a thick organic slurry, or quagmire. This is remedied short term during harvest periods by applying
rice husks and other drying debris; however this decays and adds to the accumulation of debris in the street.
Flies are prevalent, and food is often left uncovered. The prevalence of excreta in the paths holds a strong
potential for mechanical vector transmission into households and food preparation areas, by insects, rodents
and on the soles of feet. Many people walk through the village without shoes, posing strong potential for soil
based helmiths. Children are left unsupervised to play in the street, putting hand to mouth, with limited
handwashing practices.
Figures 4.211, 4.212, 4.213, 4.214. Pictures of the status of environmental status of the communities visited.
Within the household, there are few water containers, which are often left uncovered, and used for multiple
practices. Many of the communities do not have improved or ventilated stoves, utilising instead open fires in
the centre of the kitchen, with few windows or vents to allow smoke to disperse. Livestock are kept within the
ground floor of dwellings.
Inhabitants of the communities often choose to defecate near sources of water, such as streams, protected
springs and irrigation canals, for anal cleansing purposes. For groundwater sources such as springs, this is
estimated to be only a significant risk during rainy periods, when faeces in the immediate spring catchment
get leached into the groundwater. However, many communities in the area collect water from surface water
(streams and irrigation canals) downstream of other settlements, and household drinking water treatment is
not commonly practiced.
42
The area is seasonally drought prone, and water supply shortfalls are common. Out of 12 communities
visited, 10 had GFS systems, of which; 3 were totally non-functional; 5 were in a state of disrepair, 6 are
observed to be at risk from surface contamination; and 6 were subject to permanent or seasonally low yields
or source failure. Distances from households to water sources ranged between 10-500m from in- village tap
stands, to river valley sources, with between 0-200m altitude difference. Water collection, storage and
consumption practices were not routine areas of inquiry for this research, but the following results were
collected by the KAP Survey:
Box 4.21. Water source, collection, consumption and use findings from the KAP Survey
Out of 240 Interviewees:
43% of respondents travelled less than 15 minutes to fetch water while 39% travelled between 15 and
30 minutes
68% of respondents waiting more than 15 minutes to fetch water
Animal faeces are present in 56% of water points during the rainy season, and 61% of them during the
dry season. Animals share the same water points in 40% of cases
Collection of water is generally the responsibility of women (72%)
The total water consumption per household by day was 44.5 litres [15 to 175]
84% of household water storage containers were not covered. Almost all water
containers were laid on the ground
Only 2% of respondents claimed to treat their water prior to consumption
52% collect water from storage containers by dipping a cup or hand into the vessel
Figure 4.215. Water sources used in the area. Source: KAP Survey.
Drinking water sources
2
2
10-Mill channel
4
4
9-Irrigation channel
8-River
2
5
5
7-Stream
11
10
6-Spring with protected intake
rainy season
4
4
5-Spring with unprotected intake
dry season
24
4-Spring without intake
26
12
12
3- Tap stand (irrigation channel)

9
2-Tap stand (stream catchment)
12
1-Tap stand (spring catchment)
24
0
10
15
20
25
26
30
Personal hygiene and clothes washing is visibly an issue, particularly with the children of the communities.
The environmental health status, and relative risk importance is estimated to vary temporally. For instance, in
the rainy season, the environmental sanitation, roof and greywater drainage is likely to be an issue, as is the
quality of water consumed. In the winter when yields are low, queuing times are high and sources fail, there is
likely to be less water consumed. Also during the winter months, individuals personal hygiene is likely to
deteriorate due to the cold weather and subsequent unpopularity of bathing.
43
4.2.2
Interviewee Perceptions of Environmental Health Issues in the Villages
At the beginning of 41 interviews, interviewees were questioned on the main issues present in the village
relating to hygiene and sanitation. The question was asked in an open, non-check box style, to gauge the
perceptions and priorities of the main issues, without the prompts of a multiple choice. Answers have been
grouped, and results are presented in Figure 4.22.
Figure 4.22. Major Issues in Village Relating to Hygiene & Sanitation, as Perceived by Interviewees
Major Issues in Village Relating to Hygiene & Sanitation, as

Percieved by Interviewees
Open Defecation/ lack of latrine
Access to soap
Education of the people
Greyw ater drainage
Roads follow ing rain
Livestock road trampling
Water supply distance
Domestic w aste disposal
Water supply shortages
Livestock excreta
Population Density
0
10
15
20
25
30
35
Number o f Respo ndents Who M entioned the Issue
Respondents answers may have been tailored in some instances due to what the community expected from
ACF (knowing the NGOs WASH remit of provision of GFS and latrines). Nethertheless, it shows that 75% of
respondents remarked on indiscriminate defecation within the village, particularly by children, and lack of
latrine as an issue. 36% of respondents mentioned problems relating to the reliability or yield, and to a lesser
extent, distance to water. Interestingly, no respondent mentioned water quality, or the prevalence of flies as
an issue.
This should not be misleading to suggest that sanitation is the main priority in the communities. Through
numerous interviews, it is apparent that food security is the major, overriding issue perceived by the
communities. This is followed by reliable water access and commodities such as clothes.
4.2.3
Defecation Practices and Latrines
Current Defecation Practices: Locations, Collection & Disposal

Figures 4.231, 4.232.shows results from both this study and the KAP Survey regarding locations for
defecation selected by the interviewees.
44
Figure 4.231. Defecation sites, Results from the KAP Survey
Defecation sites
11
1
6-Neighbours latrine
8
77
5-Private latrine
1 5
6
4-Irrigation channel
Children of family
Adults of family
10
3-River side
3234
32
2-In the fields/forest

1-Near the house
Interviewee
53
53
48
12
0
10
20
30
40
50
60
Figure , 4.232. Defecation sites, Results from this research

Current Defecation Practices
Sickness - Severe 1
Sickness - Mild
11
Jungle near w ater source
Jungle not near w ater source
2 1 2
Children > 3
21
Children < 3 1
Adult Night
Street or near house

5
Cattle shed
7
Adult Day
16
11
Fields
1 2
3
15
10
15
In the house/ anyw here

3
20
25
30
Container
35
Latrine
Number of respondents
Open defecation is prevalent, with a low coverage, and even lower usage, of latrines. The results consistently
show the practice of adults to visit the jungle by day, and through interviews it was clear that if there was a
source of water near the village, they would choose this area. The jungle generally refers to public land on
the periphery of the village. Common reasons for choosing the jungle were; the fact there is often water
sources for washing; vegetation provides privacy; the land is public, therefore they are not defecating on their
own, or others land. Being caught defecating on others land was shameful, and mentioned to be a fairly
common source of dispute within the communities. People may also defecate whilst out of the village working
the fields during the day. The adult respondents who claimed to defecate in the village by day were relatively
elderly citizens, reasoning impaired mobility and vision and incontinence prevented them travelling far from
the house.
During night time, locations differed, with 61% of respondents claiming to defecate on the street or close to
the house. Reasons for this included; fear of animals (such as bears) or spirits in the jungle or paths; lack of
light, and distance to the jungle. In addition to this, at night they are not seen defecating in the village, and
therefore not shamed. Women claimed to be generally more afraid to travel to the jungle at these times, and
almost invariably go in the street or garden near the house at these times. Those who owned and claimed to
use latrines, used them during night time.
45
Figure 4.233. Collection & Disposal of Faeces
Collection & Disposal of Faeces
Pick up w ith hands/leaves

Basket and husks
Sickness faeces disposal
Sickness faeces collection
Child faeces disposal
Child faeces collection
Multi purpose pan
Street
10
12
Bushes in village
8
0
Bushes outside village
14
16
18
Latrine
Eaten by Dog
For children, location for defecation was related to age. Respondents claimed that less than around 3 years
of age (exact aging challenging in the research), children were stated to defecate anywhere, including in the
house. In this case, the mother normally collects and discards it, or the dog eats it. Potties are generally not
used. When the child is older than around 3 years, up until around 8, they commonly defecate in the street or
near to the house, after which they start to visit the jungle. When a family member is sick, and not able to
leave the house, faeces is commonly collected in a domestic container, which is used for other food-related
purposes, and discarded either indiscriminately in the street, or hidden in a bush in, or on the edge of the
village, where others would not see it.
Anal Cleansing
The KAP survey stated that almost all the respondents (99%) used water for anal cleansing. However, this
research yielded different results.
Figure 4.234. Methods of Anal Cleansing (Adults)
Method of Anal Cleansing

Take w ater w ith them
4
Day
Night
14
0
5
1 2
10
Wash w here defecate (e.g

stream, spring)
Wash after at home
15
4
20
25
30
Wipe then w ash
Wipe only
There was variability with night time and daytime practices. In daytime, the practice by adults was dependent
on the availability or proximity to water, with 5 out of 25 respondents claiming to use stones, twigs and leaves
to wipe, then washing after if close to water, and 9 out of 25 only wiping. By night, many more respondents
claimed to take water from the house, as suggested in the KAP survey, as they were normally not travelling
far from the house. One interviewee stated they did not take water with them by day, as everyone would
know where he was going.
Children often defecate in the street, then return to the house to wash themselves or a family member
washes them, often using water from the drinking water container. Those interviewed who claimed to take
water did not normally have a designated container, and said they used between 0.5-1.5l per time.
46
Perceived Issues with Current Practices

A number of issues with the defecation practices were mentioned by interviewees. Commonly mentioned
problems are presented in Figure 4.235.
Other issues mentioned included the fact children get scolded by adults when they go in the street, and it is a
common source of dispute between households. In Natharpu village, two female interviewees stated that the
jungle area generally used as the village defecation area was a mans place, but there was no womens
place, hence they had no choice to defecate in the street of nearby fields.
Figure 4.235. Issues with current defecation practices, as perceived by interviewees
Issues with Current Defecation Practices, as Percieved by

Interviewees
Animal attacks/bites
Distance/time to defecation area
No w ater w here they defecate
Thorns in feet
Privacy
Rain/cold
Defecation area is 'dirty'
Hassle of finding a new location
No torch for nighttime defecation
Smell/makes village 'dirty'
Fear of visiting the jungle at night
Step on faeces and bring into the
Health impacts
0
10
12
Number o f Respo ndents Who M entio ned the Issue
4.2.4
Experiences of Latrine Ownership and Usage
Reason for Construction

Open defecation is the norm in the study area, and the use of latrines limited, estimated by the author to
range between 0-15% of the population of the communities visited. The KAP Survey suggested less than
10% usage from respondents. Latrines do exist in the communities, but are generally derelict, dismantled, or
used for storage. The dominant reason for the existence of these latrines is due to previous Maoist
campaigns, which, among other initiatives, violently forced inhabitants to construct latrines. Figure 4.241
shows the reasons for latrine construction given by 56 respondents:
Figures 4.241, 4.242. Reasons for building a latrine in the past, and the location of the latrine.
Reason for Building a Latrine in the Past
(56 Respondents)
Pre-Maoist selfinitiative
Location of Previous or Current

Latrine (56 Respondents)
Side of the
house/under
balcony
Public land
Due to Maoist
pressure
Garden next to
the house
Pre-Maoist
Development
Project
Mothers group
pressure (for
child latrines)
Land w ithin the

village
Land ow ned
outside the
village
47
A small number of respondents built latrines before the Maoist pressure, generally following exposure and
experience of latrines in the district towns, or in India during economic migrancy. At the time of field research,
a growing number of basic latrines were being constructed, or derelict latrines recommissioned for childrens
toilets, following advocacy and social pressure by active mothers groups in Nerah and Taza villages (see Box
4.15)
Design
A wide range of designs were observed in the study area, showing local level innovation, with a range of local
products, and limited input of external materials.
Designs seen that were being used included:
Pit Latrines
Pits were generally, but not exclusively, shallow and unlined. Squatting areas were constructed by laying logs
and stone slabs, and finished by covering with packed soil. Few direct pits had fly control measures, or
plugs/lids for the squatting hole.
Offset Pour-Flush Latrines
This design type was the most common in the area. Pits seen were both cubic and cylindrical, generally lined,
with logs, and/or stone slab lids, covered with soil. All designs were single pit type, and the distance of offset
ranged from 30cm (just outside the superstructure) to 2m. In two instances, the chute discharged to the land
surface, as the pits were full. A variety of materials were innovatively used for the chute and pan. Chutes
were often HDP pipes salvaged from derelict GFS, in original form, or opened up and beaten to shape to
combine pan and chute. In other instances, there was simply a sloping stone slab or wooden plank to
defecate on, and pour/push the excreta with a designated stick into the pit. Carved basic wooden pans,
folded plastic from broken jerry cans and rolled tin sheets were also used for pans. In a village subject to a
pre-Maoist government project (Lower Rhimi), designs included HDP pipes, and graduated cement pan
structures (Figure 4.255). No household latrines visited utilised ubend water seal designs.
Figure 4.243, 4.244, 4.245, 4.246. Examples of pan designs and water containers in local latrines
Water Storage and Maintenance Materials in the Latrine

In some instances, no water was stored within the latrine, with the user carrying it from the house. However,
most functional latrines had designated water containers. These ranged from glass bottles, to buckets, screw
lid containers and even broken jerry cans, laid on their side and opened up for access (see Figure 4.246).
One latrine owner was even utilising rainwater harvesting to augment the toilet water supply. In addition to
water, many latrines contained a designated pushing stick, to dislodge stools from the pan and chute, and
one owner kept ash, to aid handwashing, and for periodic application into the latrine pit to mitigate odours.
Superstructure
The superstructures were often small and cramped, built with local stone, and roofed with wooden planks
covered with soil. Some were constructed using wood planks. Ingenuity was observed with the doors, using
tin sheeting, grain sacks, and more commonly, wooden planks on basic hinges. Many included a small,
glassless window, and the stones were generally unmortered, allowing natural ventilation. Figure 4.248
shows the common occurrence of cramped superstructures built to minimal standards for compliance to
Maoist pressures.
48
Figures 4.247, 4.248, 4.249, 4.2410. Examples of local functional, child and derelict latrines.
Location of Latrines
Figure 4.242 shows the different locations of latrines that have been built in the villages. This was variable,
often upon population density, and land ownership. Where communities were relatively dispersed, latrines
were placed close to the houses, and in more dense settlements, on the periphery of the village, and on
areas of land owned within the village itself. In villages where Maoist pressure for latrines was particularly
focussed, such as Pumeru, latrines were built on public land on the roads leading into the villages.
Access to, and ownership of land to build the latrines was stated by inner-village households to be a major
reason for not constructing latrines during the Maoist pressure.
Pre-Maoist governmental initiatives had been undertaken in two communities (Rati and Lower Rhimi) leading
to coverage of around 50%, many of which were still being used. Innovation was seen on the part of technical
low-cost design, and latrine location. Locations included; under the balcony, with offset pit under the village
path, and on the side of the house.
Out of 56 interviewees questioned on the topic, only 4 claimed to have previously shared a latrine with
another household.
Usage Trends
This was difficult to effectively evaluate, as many interviewees claimed to use their latrine daily, but upon
inspection, the toilet obviously had not been used for months, or years. Many interviewees stated that their
whole family use(d) the latrine at all times.
However, the following points regarding usage were discovered in different interviews;
Toilets may be reserved for use only at night or in emergencies by adults, choosing to go to the
jungle by day, as they do not want the pit to fill too quickly.
The toilets are for use only by children, as adults can go to the jungle.
Conversely, children may be prevented from using them for fear of them making it dirty.
Use may be restricted to the father, or males of the family.
Experiences of Latrine Ownership, Use and Maintenance
Positive experiences and perceived benefits of the latrine use mentioned by interviewees included;
convenience through proximity to the house; and hence time saved not visiting the jungle; ease and safety of
use for nigh time defecation; privacy; improved environment and reduced pollution on the village paths;
shelter from the rains and less distance to walk in the snow; they do not have to send their children far from
the house to defecate; children are not scolded by adults for defecating in the street; they can take water with
them, or keep it in the latrine, for anal cleansing.
Despite the benefits mentioned by former users, most had reverted back to open defecation, and the latrines
had become derelict. This was stated to be linked to many reasons. Common issues presented in Figure
4.2411.
49
When the Maoists undertook their forced latrine programme, they provided no financial, material, and limitedno technical support to the communities. Because of this, latrines constructed were generally of poor
technical standard, with inadequate materials. The community were also, in many instances, building for
compliance, not because they perceived a benefit, and hence in some circumstances, did not build it with the
thought of actually using it. Little investment was made in the latrines, building to minimum standards, and the
designs were temporary in most instances.
Figures 4.2411, 4.2412. Issues with, and reasons for stopping using the latrine. Findings from this research and
the KAP Survey.
Issues w ith, and Reasons for Stopping Using Old Latrine
Smell
Pit Collapse
Temporary' design
Lacked w ater storage in the latrine
Village w ater shortages
Decame dirty w ith improper use
Difficult to clean
Not habituated to use
Pit filled rapidly
Leaking roof
Latrine w as used publicly
Cramped superstructure
Superstructure collapsed
Insects/flies
Why did you stop using

(KAP Survey)
3
1-Pit was full
28
2-Damaged
38
3-No habit to
use
4-Forced
to build
31
10
15
20
Number of Respondents Who Mentioned the Issue
The designs were generally made from local materials, such as wood and unpolished stone, with rough,
difficult to clean surfaces, and as it was many users first time to use a latrine, often became fouled and
malodorous. This was a particular issue where the latrines were located within the village, but did not have a
padlock, as the latrine would be used as a public toilet.
Latrines that were shared by more than one household complained of other familys children fouling the toilet,
and their parents not cleaning after them, causing inter-house disputes.
The fact they utilised rough surfaced materials for pan and chutes required relatively large volumes of water
to flush and clean. This was stated to be an issue due to annual water shortages in the area (and domestic
priorities for the water) and distances to collect, and the lack of adequate and available storage containers for
the latrine.
Smell was the most commonly stated issue, understandable, as few pits were ventilated, and the users
previous experience in the fresh mountain air. Interestingly, flies were not mentioned to be a problem.
Pits were commonly shallow and unlined, and interviewees stated that in many cases they collapsed, or
overflowed in the rainy season. Logs laid to support the squatting area rotted and failed.
Four current users of latrines of offset pit latrines stated that they intended to revert back to defecating in the
jungle when the pit becomes full, for 2 years, by which time they could empty the pit, or it would have settled
sufficiently for reuse. They could not dig another pit as they had no more space for a new one, or the pipe
was not long enough to allow switching to a new pit.
50
4.2.5
Future Aspirations for Latrines
Permanent Latrines
Although many interviewees mentioned that they perceived benefits of formerly using latrines, they were
reluctant to build another temporary latrine. The latrines they previously built had issues, were now broken,
and the users were not keen to invest their limited time or resources on another latrine using only local
materials that would become rapidly filled, soiled, or collapse. Interviewees stated that they were unable (or
unwilling) to access or finance permanent materials such as cement, pipe and pan to build a permanent
latrine. This may well also be linked to the previous promises made to them by ACF and other NGOs in the
area about material provision, so households are holding out for assistance until they construct a new latrine.
Design Type & Previous Promises

When questioned on the type of latrine they would like to build, answers generally described offset pour flush
designs, incorporating a pan, cement and pipe. It should be noted that this is what ACF staff promised in 5 of
the visited communities in Focus Group Discussions (FGDs) 6 months prior to this research, and many
interviewees in these communities perceived this question as a memory test of what they were promised.
It was found that this preference for offset pour-flush pits was for a number of reasons;
The offset pour flush with pan design is the commonly used improved design in the district towns
and constructed by other locally operating NGOs, and therefore they have had experience and
exposure to this design type, and perceive it as modern, and desirable.
Pit latrines were a common design of Maoist temporary latrines, and were found to be malodorous.
There is a general desire to have the pit as far away from the point of defecation to limit odours in the
latrine. The functionality of a waterseal is not readily grasped; therefore an offset pit is more desirable
than a latrine set above the pit, regardless of a waterseal.
When questioned regarding the ability of the interviewees to sustain such external materials as a pan if it
became broken, interviewees initially stated they would request external assistance from an NGO. When
reasoned that this may not be viable, most respondents conceded a design less reliant on external materials
may be more appropriate. Regardless of the exact materials or designs, the following features of a toilet
were identified as important to the interviewees;
Easy to clean, without requiring large volumes of water
Water source or storage within the latrine
Not too odorous
It must have a lockable entrance, to stop public use.
4.2.6
Locations of Latrines
When questioned on potential locations for the latrines, interviewees stated they would be keen to build the
latrines closer to their houses than the former Maoist latrines, as the permanent designs would not be so
odorous. In many of the communities visited, land access appeared, and was stated to be a potential barrier
to certain households accessing their own latrine.
The main households with this potential problem are those located within a terrace inside the villages. When
questioned about latrine location, much of the mid-higher caste interviewees stated they had land close to the
village which they could use, or that they could probably exchange or purchase land from others for the
purpose.
Many households stated that for land acquisition, land price is according to area, and lower-caste households
will commonly build the maximum size house on their limited plot size, seldom leaving much free, unused
space. These households often only own land far from the village, and have the lowest financial resources
available to acquire land.
51
Community Suggestions and Perceptions of Options Available for Latrine Location

Suggestions for the issue of land access included land exchange and purchase at a household to household
level, and that a committee should be formed to push the process forward, and to apply pressure on the
owners of the land surrounding the village to be willing to sell, even to low castes, at favourable, or at least
non profiteering rates. Many interviewees warned that ACF should not interfere in the process of land
acquisition, which should be organised within the village itself.
A number of options were suggested by the author to interviewees for potential solutions for the issue of land
availability. Responses were as follows;
The idea of all households contributing to a central fund, to enable the village to gain total sanitation
type status, where the funds were accessible for land acquisition, was unpopular. Respondents noted
that not all would contribute, and many would try to access the funds, potentially leading to disputes.
The concept of sharing latrines was unacceptable to 32 out of 35 interviewees. This was reasoned
by; other familys children would soil it, and there would be disputes regarding cleaning and
maintenance, and those with large families anticipated long waiting times and rapid pit filling.
Interestingly, those who found the idea most unacceptable were Dalits. This was explained to be due
to the fact that they have very limited physical resources, and generally inherited and shared
between brothers. The concept of sharing and joint ownership of a latrine was expected to pose
potential for family feuds and conflict. Those few who conceded that they could share latrines stated
that it would only be under specific circumstances, generally a direct blood relative and their family.
Findings from the KAP Survey suggested that just over 10% of respondents were willing to share
latrines, with common concerns of sharing presented in Figure 4.26.
Figure 4.26. Perceived Issues of Sharing a Latrine, from the KAP Survey.
Problem of sharing latrine
1-No
12%
2%
12%
2-Intimacy
3-Cast
24%
4-Cleaning problem
37%
5-Not my family
13%
6-Other
However, when suggested with using a latrine block, where each household had a separate cubicle,
but utilising the same pit, interviewees did not perceive a problem, as long as all doors were lockable
to prevent public use. The sharing of a block with between higher castes and Dalits was generally
deemed unacceptable.
The possibility of locating a latrine within the cattle shed took persuasion. Initially respondents
claimed that they feared that it would be odorous for the house, and that they did not think that there
was sufficient space. However upon inspection, they agreed that in many instances it would be
feasible, as long as it was permanent and therefore easy to clean and non-odorous, and robust to
avoid damage from cattle. An interview with a local priest revealed that, as cows are deemed as
gods, locating a latrine within the cow shed was completely unacceptable, and any project that
promoted this, he would actively advocate against. However, locating it within the buffalo
compartment was deemed as acceptable, as long as it was not in the direct domain of the cows.
Similar initial responses for cattle sheds were received upon the proposition of locating latrines
underneath the first floor balcony. It was not thought that there was sufficient space, and there were
also doubts about where they would then discharge their domestic greywater, and the fact that it may
encroach onto public land or block pathways, but in theory it was stated to be acceptable.
52
4.2.7
Institutional Sanitary Facilities
3 out of 4 secondary schools had latrines, although one was under construction, which had been left for over
1 year since initial construction of the superstructure, as the cement for the overall school rehabilitation was
not sufficient, and was not prioritised for the toilets. Out of the 6 primary schools, two had latrines, both were
visibly derelict. With the two health posts, one had facilities that were also under construction since over 6
months, the other had none.
None of the schools or health posts visited had reliable or adequate yielding water supplies, and half of them
had no supply at all.
Latrines built recently were generally relatively high standard offset pour flush, with waterseal, fibreglass pan
and cement finish, built in a block style arrangement. These were either constructed by NGOs Saapros or
Deppros on behalf of UNICEFs Quick Impact Project (QIP), or by the DDC/District Education Office.
Without a proximal or adequate water supply, the latrines were commonly blocked due to insufficient water to
flush with a waterseal, and rapidly became derelict. At one secondary school, 4 latrines were being
constructed, one per gender for teachers and students. This meant 2 latrines for 270 students; 1 latrine for
140 male students.
At 3 schools, latrines were locked, for the exclusive use of teachers and visitors, leaving no facilities for the
students. This was reasoned by caretakers and teachers as the students do not take care of the latrines, and
they become rapidly dirty, particularly as there are so many students to potentially use the latrines and water
shortages.
4.3
Environmental Sanitation
In addition to defecation habits, poor practices of solid waste, greywater and livestock excreta management
create environmental conditions within settlements that pose high risk for disease transmission, particularly in
the denser, nucleated villages.
4.3.1
Solid waste disposal
The production of domestic solid waste was explained to be seasonal both in terms of volumes and type of
waste produced. Interviewees estimates of volumes ranged from 1 or more baskets per week (approximately
35 l baskets) in the harvest periods, mainly consisting of waste from grain processing, to quarter of a bucket
or less in the winter. Outside of harvest periods, solid waste generally consists of small volumes of organic
waste, such as vegetable peelings and corn cobs. Inorganic waste is produced, but in very small quantities.
Current domestic waste disposal practices are presented in Figure 4.31.
Figures 4.311, 4.312. Solid Waste Management Practices from this research, and the KAP Survey, respectively.
Dom estic Waste Disposal Practices (32
respondents)
Indiscriminate/
onto street
How does the family manage the refuse
Inorganic 03
97
Compost
Feed to cattle
1-Dumping
Vegetale 01 6
2-Pits
93
3-Compost
4-Anyw here
Burn
Throw onto
garden directly
Animal 01
59
20
41
40
60
80
100
The results from both researches show that indiscriminate disposal, generally by throwing waste onto the
street or garden from the balcony is the most common method of disposal. Few respondents remarked that
the practices were a major issue (See Figure 4.22), and generally only when pushed did they mention issues,
such as smell, rats and the fact it made the street dirty.
53
When suggested with digging a pit for refuse disposal, respondents were generally not enthusiastic, and
commented that the volumes of waste were low, and their constraints in terms of time and available land.
Mixing with composting was not commonly practiced, and respondents stated that they were not aware of the
true benefits, but saw potential, with some mentioning the lack of an available container as a potential barrier.
4.3.2
Roof and Greywater disposal
No settlement visited outside the district towns had community level drainage systems, and domestic
drainage caused village paths to become slippery, with areas of stagnant greywater and mud encouraging
flies and vermin. Water drains from the roof onto the street paths, and tapstand drainage is an issue.
Figures 4.321, 4.322. Domestic greywater management practice findings from this research, and the KAP Survey,
respectively.
Gre yw at er Dis pos al Practice s ( 32

re spondents) Indisc riminate
dis posal/ drains to
str eet
Onto garden
(drainage pipe or
tos s)
Designated pit
How does the family manage the waste

water
3%
0%
1-Kitchen garden
2-Emptied near
the house
97%
3-Drained
anyw here
At the domestic level, greywater was predominantly drained onto the street from a designated dishwashing
area on the balcony, causing localised areas of stagnant water. In less dense areas, or houses with direct
frontage to cultivated land (or just the other side of the path), some households have incorporated a basic
kitchen-garden irrigation system, using pipes salvaged from derelict GFS.
One of the activities of the aforementioned Mothers Groups of Nerah and Taza villages was to promote the
construction of basic greywater pits, to contain the extent of saturation, shown on Figure 4.325
Roofwater from households is often drained to one or two corners of the roof, and drained by a long HDP
pipe or traditional carved wood chute to offset the drainage to fall in the same location as the greywater, or to
a neighbouring field or garden plot. No integrated grey and roofwater domestic drainage systems were
observed.
Again, drainage was not widely stated as a major issue in the village, but when probed, interviewees
mentioned problems of; paths becoming slippery to walk on (often causing disputed between households);
the quagmire situation that results from poor drainage, solid waste, excreta and livestock trampling; and
occasional odours.
Options suggested to interviewees such as building improved, gravel filled soakaway pits, or extending
coverage of kitchen gardening were received well, but mentioning potential barriers of time availability and
HDP pipe access. Community level initiatives such as village drainage channels were suggested by 3
interviewees, but they conceded that ongoing maintenance may be difficult, and channels were likely to
become blocked, or damaged by livestock.
54
Figures 4.323, 4.324, 4.325, 4.326. Pictures of the environmental sanitation situation in the villages
4.3.3
Livestock and composting practices
The communitys livelihoods are intricately connected with agriculture, to the point that they share their
homes with their cattle. Generally, buffalos and cows are taken to the highlands to graze in the summer and
brought increasingly closer to graze in the colder months, and are kept largely within the cattle shed in the
winter. During the times the livestock are in the settlements, by night they are almost invariably kept in the
ground floor of dwellings (in 97% of cases according to the KAP Survey), and by day often kept in front of the
house, or tethered to designated posts within the village. Livestock excreta within the shed is commonly
composted in-situ; mixed with leaves and pine needles brought from the jungle, but it is not a common
practice to frequently collect the faeces from in front of the house or on the street. One interviewee mentioned
that one reason for this was a lack of a shovel. The manure in the shed is brought out once or twice per year,
and heaped outside the shed, or on the street, to mature for one month, before being taken to the fields. The
responsibility of composting and mucking out the cattle sheds is generally that of the daughter in law, or
children.
Issues with the current livestock and composting practices were not commonly mentioned by interviewees
unless probed. Regarding animals in the village, the main problem was that of them trampling and churning
up the paths, and that the compost heaps can take up space and block pathways. When pushed, some
interviewees conceded that the; dirtiness caused by the animals in the village can be a problem, as children
play in the street, then walk in the house, bringing dung with them; and that, mixed with stagnated greywater,
dung can omit a gas that can cause fevers. Answers were, in some instances defensive, with one interviewee
stating that it (composting and livestock practices) may be an issue, but it is the compost that keeps us with
food, and alive.
The knowledge or perception that livestock excreta had the potential to cause ill health was not widely
understood. Indeed, livestock (cow) excreta was found to have a wide number of applications, presented in
Box 4.33.
Suggestions regarding alternative practices were not forthcoming, but 2 interviewees stated that a committee
could be formed, and equipped with shovels to clean the livestock excreta from streets, on rotation.
The suggestion that the animals could be kept outside of the village was overwhelmingly unpopular, with
respondents defensively stating that the cold conditions would kill the animals, and that keeping them on the
ground floor in the winter was a source of household heating. Besides this, interviewees stated that land
acquisition, the costs of building another cattle shed, and the requirement for constant monitoring, even in
winter months, made the proposition difficult as well as unpopular.
The concept of composting the manure outside the village, or far from the house was also unpopular, as it
would require daily transport to the field, which was laborious, and deemed to the interviewees as
unnecessary.
55
Box. 4.33. Perceptions of, and Uses for Cow Excreta
Cows are believed to be gods, and therefore pure. In this logic, cow excreta is also deemed to be
pure, and used for a wide range of applications. However, buffalo or other animal excreta is
understood to be impure and therefore not used for practices aside from manure. A list of the
applications for cow dung in the study area is presented below:
Mixed with leaves and used to wash hands, body and face for exfoliation properties
Mixed with water and used to wash dishes
Mixed with red mud and used to clean the floors of the house
Mixed with water and a lower quantity of mud and water and applied to the roof to create a
hard surface upon which to dry/process grains
Used as a cement-like 'filler' to fill holes in the house walls or roof
Mixed with leaves or pine needles and used as compost
Mixed with water, and smeared on general purpose transport/storage baskets to reinforce them
Used in the plastering and mortar to bind stones in wall construction
Handwashing is not perceived to be a high priority after handling the dung, and fresh dung is
often collected, transported and stored in plates or bowls used for eating from by family
members.
4.3.4
Road Paving
In addition to latrine building, another forced Maoist initiative in 4 of the communities visited was weekly street
clean-ups and path paving with local stone slabs. Although most interviewees stated that the communities
were cleaner at this time, they also mention that now no-one is currently willing to work on these types of
projects for free.
4.4
Personal Hygiene
Due to a number of factors, the personal hygiene of inhabitants of the study area was generally extremely
poor, particularly that of the children. This section outlines current practices, perceived issues, barriers and
future aspirations of interviewees regarding their own, and familys personal hygiene.
4.4.1
Personal washing
The frequency of personal bathing varied between interviewee, and was stated to be influenced by the
season and temperature, water availability, and access to washing materials. It was observed that there were
trends within the village, often with lower castes having a lower state of personal hygiene, and between
villages, thought to be related to the remoteness of the village and number of visitors, relative level of
education of inhabitants, and proximity/yield of the water supply.
The major reason for the seasonal difference in washing frequency was the temperature of the air and water
in the winter, and, to a lesser extent the reduced source yields at these times. Women generally claimed to
wash at least monthly, regardless of the season, believed to be related to menstrual cycles, and
corresponding rituals of purity. There was a broad trend amongst the answers to indicate that the older
56
generations spend longer periods without washing, with one 50 year old male respondent claiming not to
wash at all during winter; a period of at least 2.5 months.
Figures 4.411, 4.412. Frequency of Personal Washing Results from this Research, and the KAP Survey,
Respectively.
How often family members are taking shower
Frequency of Personal Washing
Children 1
Once per week

Winter
Frequency Winter Child
Once per fortnight

Frequency Winter Adult
Father 0
41
57
26
73
Mother 2 19
1-Never
79
Once per month
Frequency Summer Child
2-Weekly
Summer
Children 1
Once per two

months
Frequency Summer Adult

0
10
15
Less than once per

two months
20
86
Father 0
78
Mother 0
0%
13
23
68
20%
40%
3-Monthly
32
60%
80%
100%
A wide range of washing agents were used by interviewees. Soap use was desirable, but generally only
infrequently used, when it was brought back from a family members visit district towns or India, or when the
household had spare financial resources. However, the more affluent households used soap at all times.
Natural cleaning products were also used, including ground-up (locally available) Senu and Utenu roots,
ground walnut shells, mustard seed fibres, kumeru (leached white mud), and even fresh cow dung mixed
with leaves. Aside from the cow dung, the materials were only generally used only for washing hair, and
normally only used by women. The use of these materials was seasonal, and subject to the user having
sufficient time to collect and prepare them.
Figure 4.413. Issues with personal washing, as perceived by interviewees
Issues with Personal Washing
Privacy/ not able to w ash fully
Soap access
Village w ater shortages
Cold w ater or w eather
Only ow n 1 pair of clothes
Dirty conditions of village
Tap stand crow ding
Smoke in homes
Distance to w ater source
0
10
12
Issues mentioned by the respondents regarding their current bathing practices are presented in Figure 4.413.
Privacy was mentioned as a major barrier for adults and children of both genders, but seemed to be a bigger
issue for the women. Women complained of having to cover at least their lower halves with a sarong whilst
washing, limiting the effectiveness and extent of bathing the whole body. The fact that many interviewees
only had one pair of clothes meant that they had to put on dirty clothes after washing themselves, and some
also reasoned that the benefit of washing frequently was limited, as the village environment, smoke in the
57
house, and agricultural activities make them rapidly dirty again. Water supply yield and proximity was also a
common problem, mentioning that in times of scarcity, personal hygiene is less of a priority than water for
drinking or cooking purposes. Scarcity of time to wash was also commonly identified.
Interviewees, particularly women, were very enthusiastic about the concept of some form of privacy structure
next to water points, such as public bathrooms, stating that with this, they would be likely to wash more
frequently. They felt that they could be managed by some form of village committee. Interviewees generally
stated that they could share facilities between genders (with use at different times), but certain interviewees
said they would not be willing to share facilities with Dalits, and feared waiting times and potential misuse
without effective monitoring.
5 Interviewees who either never, or intermittently used soap claimed that if it was made more affordable in
the village shop, between 12-16 rupees per bar (normal price 20-25 at village stores) they would use it at all
times. Female interviewees were also enthusiastic about the potential to produce improved washing products
at the domestic level.
4.4.2
Clothes Washing
Clothes washing was commonly mentioned to be the responsibility of the mother, although many children
were observed to wash their own clothes. Frequencies generally ranged from fortnightly in the summer
months, to less than once per month in the winter. However, women cleaned their own clothes monthly, likely
to be related to the menstrual cycle, particularly as sanitary towels or other products are not widely used in
the area. More affluent families may use laundry soap, but the predominant washing agent for clothes in use
is ash. Often, clothes are boiled in large cooking pots in an ash-water mix, helping to remove ingrained dirt,
lice and fleas.
4.4.3
Hand Washing
Handwashing was a strong focus of investigation in the KAP Survey, and therefore not a particular focus of
this research. Findings from the KAP Survey are presented below:
Figure 4.43. Box Y. Findings from the KAP Survey Regarding Hand Washing
Key findings
from the KAP
Survey regarding
handwashing:
When do you usually wash your hands
8-Af ter w orking
7-Af ter touching animals
6-Af ter cleaning a child
11
5-Af ter def ecate
28
4-Af ter eating
17
66% use only

water to wash,
18% ash, and only
6% use soap
16
3-Bef ore eating

2-Af ter cooking
11
1-Bef ore cooking
9
0
10
15
%
53% of
respondents wash
their hands after
defecating to
remove smell,
21% to prevent
disease
20
25
30
85% stated they

did not use soap as
it was either too
expensive or
unavailable.
It was found in this research that the use of ash was unpopular as it caused the hands to dry and become
cracked, and that for ingrained dirt, leaves, mud and cow dung was may be used to aid cleaning. As with
personal washing, in times of water scarcity, handwashing is placed at a lower priority than water for drinking
and cooking.
58
4.5
Child Hygiene & Sanitation
The status of the children's hygiene in the study area is generally extremely poor. It was found to be variable
between families, and villages, and expected to deteriorate during the winter months for reasons previously
mentioned for adult hygiene.
This section presents findings from interviews with children, parents, teachers, District Education Officers
(DEO) and District Health Officers (DHO), regarding current practices, responsibilities, barriers and
opportunities for child hygiene and sanitation.
4.5.1
Parenting, Responsibilities and Care Practices
The supervision of the children is related to the age of the child, time constraints of the mother, and
availability and willingness of another family member to supervise. Young children are often left to be taken
care of in the house or village by the mother in-law, and to a lesser extent father in-law (the grandparents of
the child), an elder sibling, or the father. In the case of the elder sibling taking responsibility, it is
predominantly the responsibility of the older sister, and not the elder brothers. This was rationalised by
interviewees as the boys are more careless, and less attentive to their siblings well being. The extent to
which the fathers were observed to be involved with supervision varied between families, with no clear trends
in caste group. Father's supervision could range from constant play and contact, to passive supervision whilst
sat discussing or smoking with other males. Many fathers, particularly from lower caste households work in
India for up to 6 months per year, and are therefore unable to supervise.
Regardless of responsibility, the sight and sound of a child screaming alone in the street, or filthy and
covered in flies is common throughout the study area.
Figures 4.511, 4.512, 4.513, 4.514, 4.516. 12 day-old baby given birth, and kept in the cattle shed; a child left alone
unsupervised at home; a child covered in flies in Humla district; baby washing with cold water; elder sister
taking care of younger sibling whilst mother works the fields.
The upkeep of the cleanliness of the child was generally mentioned by interviewees (most of which were
parents) to be responsibility of the mother, and, to a lesser extent, both parents. 92% of KAP Survey
respondents said it was the mother. However, from observation, it is clear that elder siblings, invariably
females, are often the people taking the children to bathe. It is traditionally the role of the women to wash the
child, and 2 fathers who were interviewed whilst supervising their child commented on the deplorable state of
the child's cleanliness, but were not themselves motivated to wash them.
Before the children can walk, they are normally cleaned by pouring cold water from a jug or held under the
tapstand in many instances using soap, and sometimes following washing with rubbing mustard oil or ghee
into their skin. Children of this age do not seem to enjoy the experience of washing, possibly due to the water
temperature, commonly screaming and kicking in the air.
Once the child is old enough to walk, it is sent to the tapstand to wash themselves at the order of a parent,
occasionally accompanied by siblings or parents, but often alone. Indeed, the interviewees perception of
being 'responsible for the upkeep of the child's hygiene' was often limited to the person who tells the child to
wash.
59
With defecation practices; the children who cannot walk defecate anywhere, or are held by a family member
over the balcony. Potties are seldom used in the area. When the child is old enough to walk, he or she is told
to go a bit far from the house, and later to the jungle. Younger children often do not wear clothes on their
lower half, or the seat is cut out of them to allow them to defecate at any time without (in theory) soiling their
clothes. In very few circumstances did the concept of teaching the child about how and where to defecate or
wash extend beyond verbal instructions and commands. Few interviewees stated that they accompanied
their child to teach them practically about defecation or washing.
Nethertheless, many interviewees (parents) stated that it is their responsibility to teach their child, and
generally that of the mother. However when children were asked where they learned how to wash or other
hygiene and sanitation activities, they would commonly say that they learned more at school, from elder
siblings, or merely from observation at tapstands. Figure 4.517 presents results from both parents and
children.
Children in the study area are deemed by parents to be largely autonomous for their own cleanliness and
defecation practices from a very early age. The age mentioned by parents ranged from 7-8 years down to
when they can walk. One Dalit family interviewed stated that once the child can crawl it looks after itself.
The exact ages of children was difficult to determine in the field, due to limited accuracy of the researchers
estimations, and vague estimates parents had for their own children.
Figure 4.517. Issues and barriers in child hygiene perceived by interviewees
Issues and Barriers in Child Hygiene as
Percieved by Interview ees (Parents)
Soap access
No time to supervise
No time to teach
Dirty environment
Water supply shortages
Not enough clothes
0
10
12
14
The major reason for this early age of autonomy was blamed on the time availability of the mother. Many
interviewees also remarked that (due to poor family planning) once the child is at walking age, another child
has been born that requires the mothers attention. One Dalit mother explained that she stops washing the
children when they begin to crawl, rationalising that after this age, it is up to chance, stating 'if they survive
they survive, if not they die'. This women and her mother had experienced particularly high infant mortality
rates.
From observation, many of the children in the study area aged approximately between 2-10 years are
particularly unclean. Before this age the parents generally take more responsibility, and after around 10
years, the children seem to be more aware or responsible for their own cleanliness. When asked if their
children were as clean as they would like them to be, 14 out of 30 respondents stated their current status was
sufficient, not perceiving it as a big problem. However, the other 16 stated that they were unable to bring their
children to the desired cleanliness for a number of reasons, presented in Figure 4.517.
The lack of access to enabling factors such as soap, spare clothes and adequate water supply, along with the
mothers lack of time were the most common problems. 6 respondents also noted that the children play in the
streets which are dirty, and that it is impossible to constantly supervise them, so they soon become dirty after
being washed.
60
4.5.2
The Role of the School
Although many of the schools were closed for festival holiday at the time of research, interviews were carried
out with students, parents, local teachers and the DEOs from Humla and Mugu. The schools, like health
posts and local governance, are suffering from low functionality, poor staffing, under resources, in addition to
poor monitoring and accountability of teachers.
Although there is little in the way of formalised hygiene promotion campaigns in the schools, topics are taught
at both primary and secondary level which include messages on personal hygiene and environmental
sanitation. These are, however, only lessons based, with no practical exercises, and little-no visual materials.
Indeed, many of the schools do not have water or functional/accessible toilet facilities with which to undertake
these activities.
At 5 of the schools, the teachers actively and routinely monitored the hygiene status of the students (normally
checking nails, hands and face), telling dirty children to wash before they next come back to school. In 3
schools, there was an annual prize for the cleanest student, the winner receiving hygiene products like soap,
in addition to stationary and books. Both the monitoring and competitions are the initiative of the schools, and
are not part of a government education strategy.
The teachers remark that the students hygiene generally improves due to the monitoring and competitions,
and students remark that there is a certain degree of peer pressure not to be too dirty at school.
Student interviewees mentioned that the messages about improved hygiene practices from the teacher, such
as wearing slippers when going to defecate, using a latrine and washing daily with soap were generally
unattainable due to a lack of enabling factors. Parents of the students stated that their children bring the
messages such as to construct latrines back to the home, but do not follow their requests, due to lack of time
and money.
All teachers interviewed agreed there was a general trend for students to be particularly unclean until the
latter years of primary school, and, in general, Dalit children tended to have relatively worse hygienic
conditions.
School attendance varies seasonally, depending on labour demands in the home and fields, with harvest time
being particularly quiet, and girls are often removed from school to help in the home during the fathers
absence in India. In areas where there are seasonal settlements, children may only visit the school for half of
the year. Along with sickness absences, another key problem for attendance in the area is the presence of
the teacher, whom may be absent over long periods, and even have alternative jobs.
Figure 4.52. School Enrolment Trends in Mugu District 2006-7. Created from data obtained in 'District Education
Office Gamghadee, Mugu. Schools, Students, Teachers, Students of Mugu District 2064-65
School Enrolment Trends in Mugu District 2006-07
Gross Enrolment Rate

(%)
100
80
60
Boys %
Girls %
40
20
0
61
According to local government statistics for Mugu District, attendance is relatively good for primary level, but
drops significantly for lower secondary (10-12 years) and secondary (12 plus), with the proportion of girls
falling from 43% in primary, to 25% and 20% for lower secondary and secondary respectively. A similar story
is seen for total Dalit attendance, with Dalit girls accounting for 15% and 11% for total Dalit lower secondary
and secondary attendance.
The Karnali Zone has various governmental strategies to boost school attendance, which, according to the
Mugu DEO includes payment for primary school attendance of 350 NPR per year for Dalit boys, and 100
NPR per month for all girls, regardless of caste. These payments increase for lower secondary and
secondary, and the scheme is applied in all schools within the zone. Other initiatives include a pilot food-for
education in 70 schools, and free textbook distributions. It remains to be seen whether this will significantly
boost attendance, particularly for girls above primary level.
62
Discussion
This section discusses appropriate approaches for sanitation and hygiene, in light of the context, findings of
the filed research, and meetings with over 40 sector workers.
The discussion refers to the current ACF approach, but focuses more on appropriate strategies for future,
longer term development projects in the area.
5.1
Overall Approach
Previous assessments of ACFs intervention strategies have suggested a weakness in community orientation
and mobilisation (ACF 2007c, Ockelford 2007). This mirrors to some extent other actors activities in the area,
where due to multiple factors, particularly security and field access, projects have taken a more hardware or
construction focus, with limited software activities.
The area is challenging in which to undertake WASH activities; where supply chains are long and costly, local
and district governance and services impaired, field access challenging, and communities may be
demobilised, relatively uncohesive, with alternative priorities and high demands for external assistance.
It is suggested that these challenges, through appropriate, effective, long-term coordinated activities, could
be worked around, to sustainably improve hygiene and sanitation conditions, and to empower the
communities to develop their own situations. Section 5.1 discusses important overall components for future
projects in the area, before entering into detail on sanitation and hygiene in subsequent sections.
5.1.1
Community Approach
Many NGOs acting in other areas of Nepal operate projects that include up to one year dedicated to initial
social preparation or community mobilisation. In this phase the community is sensitised, and through
participatory activities, demand is built for the services and infrastructure that will follow. The community may
be actively involved in developing community action plans, and Water and Sanitation Users Committees
(WSUCs) are trained. In this, it is argued that an appropriate approach for the area would be to sequence
activities to begin with software activities, followed by technical interventions and hardware activities.
Following an initial needs assessment, broad sensitisation of communities in the area can be undertaken to
inform beneficiary communities as to the mandate and services available from the NGO. This should be
followed by a transparent and if necessary, assisted application process to the NGO for support. This would
help to gauge community motivation, but also, as a pre-requisite, requiring the communities to mobilise
themselves to some degree to develop community plans for the application. This approach would also build
on the sense of ownership the community has on the process. This demand-responsive approach is in
contrast to the commonly practiced pro-active selection, where NGOs may be seen as rich outsiders coming
into the villages and pushing their ideas onto the village. This is of particular relevance in this situation, where
communities may see projects as a mode of material or financial gain, not necessarily so bothered about the
end product of the project (such as the example of the community dismantling the GFS for CFW employment,
Box 4.18).
The high expectations and, in some instances, dependency mentality observed in the area may be, in part,
related to strong pro-active approaches with limited community orientation or participation. It is recognised
that long term development approaches incorporating participatory techniques, has been challenging to
implement in the area, especially due to the conflict, reducing many projects to more rapid quick impact
project approaches, with a hardware, infrastructural focus. However, as the security situation in the area
seems to be progressively improving, there is an opportunity to build up the capacity, and empower the
communities to help themselves.
63
Initial impressions are important and strong facilitation and rapport building is essential in the early stages of
the project, to gain the communitys trust, and develop their ownership and active involvement in the
project.
Expectations for material or financial gain from projects can be high in the area, and experience has shown
that demands can increase through time, with some community members bargaining with the NGOs for the
best deal. To mitigate this, roles, responsibilities and even budgets should be made clear, and if
necessary publicly displayed, and Memorandums of Understanding (MoUs) should be signed by the NGO
and community in the early stages of the project.
The context of the area is essentially post-conflict, and many communities have suffered from a breakdown of
social cohesion and leadership. In such circumstances, individuals may have a depleted sense of self-worth
(WaterAid 2007, pers comms), and not feel able to change their situation. This may be confounded by some
individuals previous unsuccessful attempts at social mobilisation, through previous, poorly planned and
supported NGO or Government projects.
A clear potential exists, with good capacity building and regular support, to empower the community, and
build up social capital, initiative and leadership through community projects such as WASH interventions.
5.1.2
Community Based Organisations
Many of the communities have pre-existing Community Based Organisations (CBOs), such as mothers
groups. In two communities they have been observed to have capacity to drive significant change in the
villages, whereas in others CBOs have been formed but lack direction. These groups hold strong potential for
agents of change in the village, and are essentially pre-mobilised units within the community which NGOs
could utilise in their projects. Experience in 3 communities visited showed that initial failures of CBOs to
mobilise the community, and the absence or inadequacy of follow-up support from the NGO that created
the CBO, can lead to the CBO members feeling they are unable to drive change, and a sense of fatalism can
prevail. In this, mobilisation and failure may be worse than no mobilisation. Any activity in the area using
CBOs should dedicate sufficient time and resources for adequate training in areas such as conflict resolution
and decision making, and, most importantly, periodic follow-up support visits, to assist them to overcome
barriers faced, and refresh and re-motivate the members. This is especially important, as communities may
be weak, with challenges managing projects or activities especially in the post conflict scenario. Seeing is
believing, and to help communities and CBOs realise that change is achievable, CBO visits to success
villages should be encouraged.
Due to the sensitive political situation in the area, NGOs should be careful not to inadvertently support CBOs
that may have ulterior political intentions or bias. In addition, to increase accountability and transparency, and
potentially gain future support, CBOs should be encouraged to legally register at the district level. This latter
point is a requirement for all WSUC created according to national RWSS policy (GoN 2004).
5.1.3
Coordination of Activities
The active involvement and coordinated selection of projects with the DDC and VDCs is not only a
mandatory requirement for RWSS projects (GoN 2004), but essential to avoid overlapping projects or
conflicting approaches (offering communities differing levels of incentives and subsidies) in the
implementation area. This involvement allows the project to be coherent with district, regional and national
development strategies.
Regarding decisions on subsidy to be provided, salaries for local staff, incentives for involvement in project
activities, and porterage rates, it should be borne in mind that all activities undertaken set a precedent for
future activities in the area, for future ACF operations, other implementing NGOs and local government.
64
5.1.4
Developing Local Capacity
Projects should, where possible, utilise and involve local government and institutions (teachers, health
workers) staff. This would have the benefit of; bringing district officials to the field; reaffirming or empowering
their positions; strengthening links with more remote VDCs; benefit from their local knowledge and
understanding, and develop the capacity of local services. The involvement of local institutions from the
beginning holds potential for post-project sustainability by linking the project and CBOs to more permanent
structures and support networks. The involvement of local staff, in addition to local recruitment and training
for posts within the NGO is more sustainable long term, and could mitigate the high turnover of national staff,
many of whom are sourced from Kathmandu and may not be accustomed to the living conditions of the area.
It is recognised, however, that working with local government can be a slow, bureaucratic process, and the
current low-functionality of local governmental departments and services make this approach uncertain in the
current political climate. In addition, available human resources in the area for recruitment are limited in terms
of capacity. However, the investment of training local staff is a more sustainable option than continual
external sourcing, and maximises the potential economic benefits the project has on the area.
The project should involve the local private sector and supply chains wherever possible, especially for
procurement of materials, to strengthen supply chains, ensure the ongoing availability of materials and skills,
and to maximise the local economic benefit of the project.
Many of the National NGOs have developed their own strategies and approaches based on their
experiences. INGOs could benefit from their local knowledge and experience, whilst developing the capacity
of the partner through its international experience. In this, the INGO could strive to move away from using the
local partner as an implementing contractor, towards a win-win partnership.
A move towards more participatory development, with the community taking control of the process, and
empowering the local partner to have autonomy for decision making, would require the NGO to vanquish
control, and be less prescriptive over its activities, and move towards the role of the facilitator.
5.1.5
Timescales and Donor Funding
A Key constraint of ACF Nepals past and present activities is the fact it has been trying to work in an
essentially development context, within humanitarian timeframes (Ockelford 2007).
If the type of development approach outlined in section 5.1 was to be undertaken, it is argued that multi-year
development projects, with corresponding donors should be approached.
This would allow the community to drive change at a pace that may be more appropriate to their time and
resource constraints, and to allow flexibility for potential delays involved in local material procurement, and
the involvement of local authorities. The sustained presence of the NGO would aid ongoing follow-up support,
in the realisation that behavioural change in the community may take time.
5.2
Options Available for Environmental Sanitation and Hygiene Approaches
This section discusses the current ACF approach, and possible future, long term approaches to improving
sanitation and hygiene in the area.
5.2.1
Sanitation
The Current Approach

The approach to sanitation currently employed by ACF in Mugu/Humla is that of a flat rate subsidy, with the
additional provision of skilled labour. Although the design standards, and volume of external materials
65
provided for the latrines have reduced significantly since the Bajhang project, per household costs remain
very high, at around 67 Euros (external materials and skilled labour).
Without transport, the material subsidy and skilled labour costs are not excessively high by Nepali standards.
However, current procurement and transportation systems involve procurement of all materials in Nepalgunj
(in the Terai), followed by road, and then helicopter transportation, and finally local porterage to ACF field
stores. Transportation accounts for 64% of total financial input from ACF, of which 95% is on helicopter
transport. Transportation costs are based on weight, and 75% (around 31 Euros) of transport costs are spent
on the 25kgs of cement provided to each household.
Table 5.211. A breakdown of current costs, materials and contributions for household latrine construction in ACF
A1D project. Data from ACF Procurement Lists, Logistics and WASH PM estimates.
Component
Quantity
Unit
Unit Cost
(Procurement
in NPG)
Materials (Procurement Costs)

Cement (25kgs)
Bag
0.5
500
HDPE pipe 110 mm (4Kg/cm2), dark coloured, 2,5 metre length
Piece
1
860
Latrine pan with footrests
Piece
1
600
Siphon
Piece
1
60
Elbow Pipe
Piece
1
70
Local Materials (sand, stones, wood - No cost to procure) Subtotal
Labour*
Skilled Labour
Days
0.5
700
Dayssuperstructure)
Unskilled Labour (Pit digging/lining, collecting local materials,
12 building
180
Subtotal
Transport of Materials
Local Materials (cost covered in unskilled labour days)
External Materials (NPG-Field Store)
kgs
33.5
116
Total Costs (NPR)
Total Costs (Euros)
Relative Contributions (%)
Cost
ACF
Community
250
860
600
60
70
1,840
350
350
2,160
2,160
3,886
6,076
67
74
2,160
24
26
Two clear potentials for cost reducing this system exist:
The first is to reduce the total weight of external materials provided to the beneficiaries, with the
biggest cost reduction potential being on reducing the quantity of cement. For example, reducing the
quantity of cement to 12.5kgs per household would reduce costs by 27%, from 67 to 49 Euros.
The second would be to alter the transportation system, using local supply chains, procuring
materials from district outlets and retailers, who could porter or mule-transport materials overland to
their stores, and then ACF or the community themselves could organise porterage to the
communities. This option has the advantage of strengthening the potential of ongoing availability of
sanitation materials in the area post project, and maximises the potential economic impact of the
project in the area. The drawback of this approach is that ACF would be in less control of the
procurement and more important, delivery dates, potentially delaying project activities.
Table 5.212 shows that per capita costs borne by ACF for latrine construction, using current design
standards, could be reduced by 15% through local procurement and porterage of materials.
66
Table 5.212. Comparison for procurement and transport costs for latrines
Component
Quantity
Unit
Procurement in
NPG and Air
Transport
Local
Procurement**
and Porterage
250
860
600
60
70
1,840
1,500
1,288
875
80
80
3,823
350
350
3,886
6,076
67
1,020
5,193
57
Materials (Procurement Costs)

Cement (25kgs)
Bag
0.5
Piece
HDPE pipe 110 mm (4Kg/cm2), dark coloured, 2,5 metre length
1
Latrine pan with footrests
Piece
1
Siphon
Piece
1
Elbow Pipe
Piece
1
Subtotal
Skilled Labour
Skilled Labour
Days
0.5
Transport of Materials*
External Materials
kgs
33.5
Total Costs (NPR)
Total Costs (Euros)
* Transport from point of purchase to Mugu field store (Nerah)
** Procurement in Mugu district town stores
Research undertaken by WaterAid (2007b) found that approaches in Nepal undertaking flat rate, hardware
subsidies up to pan level, as ACF is utilising, leads to far higher per capita costs than other approaches,
particularly software approaches such as CLTS. Based purely on costs, an approach that provides very
little, or no material subsidy, such as CLTS would bring the highest coverage of household sanitation with
minimal external financing. However, following negative experiences with temporary latrines made only of
local materials, and promises of external material support for latrines made to the communities either by ACF
or other organisations in the past, many interviewees stated they would be unwilling to construct latrines
without some form of hardware subsidy.
Cost of the programme (NRs)
Figure 5.21. Cost of sanitation financing modalities in a typical Nepali community of 99 households (33 ultra
poor, 33 poor and 33 medium). Source: WaterAid 2007.
400000
350000
300000
250000
200000
150000
100000
50000
0
Subsidy up
to pan level
Graded
subsidy
Minimum
subsidy
Subsidy +
Revolving
loan
Revolving
loan
SLTS
CLTS
As various other projects exist in the area, supplying communities with hardware subsidies, it is likely, even
with strong facilitation, that communities would reject projects without subsidies, and choose to wait, instead
for assistance from another organisation.
In the long term, these conflicting approaches may be addressed through proper coordination by the NGOs
and local government to delimit geographical areas of implementation, and the national government enforcing
thresholds on what organisations can provide. However, in the shorter term, it is argued that due to
community expectations and past experiences, a project may not engage or interest beneficiaries without the
provision of some form of permanent materials.
An appropriate approach should therefore seek to provide the minimum materials necessary for the
community to be satisfied they have received support, whilst at the same time minimising costs, and avoiding
undermining ownership by giving too much.
67
5.2.2
Hardware Approach & Appropriate Technologies
There are no national or international minimum design standards that are relevant to rural sanitation
technologies in Nepal. National policy does however state that 100% of ongoing operation and maintenance
costs of latrines should be bourn by the household, meaning that materials used for construction should be
realistically replaceable by the household, or highly durable.
An assessment of the Bajhang programme recommended offering a range of latrine designs, from which the
user can choose which is most appropriate to their circumstances (Ockelford 2007).
Table 5.221 (overleaf) evaluates the range of technology options for the context. The offset pour flush design
is the most popular with the users, and is appropriate as the vast majority of the users will be anal washers.
Using twin pits means the structures can be permanent, and there is a strategy for continual emptying and
reuse. There is another advantage that the waste can be safely removed from the pit after around 2 years,
and used as a productive soil additive, contributing to food security of the area. However, there are two main
drawbacks of a conventional designed twin-pit pour flush:
1. Pour flush toilets commonly utilise a waterseal ubend or siphon to act as a barrier to odours and flies
between the pit and defecation point. This structure is reliant on sufficient quantities being available for
flushing; otherwise it can become blocked, and subsequently disused. In an area with unreliable water
supplies, it may not be wise to promote water-dependent toilets. Many basic offset pour-flush toilets in the
area however simply do not use the waterseal, using instead simply a straight pipe at an inclined angle from
pan to pit.
68
Table 5.221. Appropriate sanitation technology options for the context
Technology Option
Shallow pit (cat
defecation)
Bucket latrines and
Nightsoil
Potties
Basic pit latrine
Ventilated Improved
Pit (VIP) latrine
Double pit latrine
Pour flush direct pit
latrine
Pour flush offset

double pit latrine
Composting toilet
Strengths in context
Weakness in context
Comments
To be promoted for daytime defecation whilst
in the fields. Soil helmiths mitigated by
promoting using stone foot slabs.
No cost
Fly nuisance
Can be used as fertiliser
Transmission of soil helmiths
Low initial cost

Low space option
Malodorous and fly nuisance

Dander to health of collection and disposal
Likely indiscriminate/irregular disposal
If poorly maintained, bigger health risk than

open defecation. To be avoided.
Low cost (if local design)
May be used for other purposes
To be promoted for child and sickness

disposal. Provide 20l Jerry cans to be cut in
half- half used for latrine water storage, half
for potty. Potties could be made in practical
HP sessions by users.
Low cost
Low demand for water for operation or maintenance
Simple, replicable technology
Low-moderate cost
Control of flies and odour
Previous negative experiences in the area

Fly nuisance and malodorous
No option for when pit is full
Needs certain conditions (prevailing winds, dark interior,
sunlight on vent)
Low demand for water for operation or maintenance
Permanent structure
Contents of pit can be emptied and used as fertiliser
Space saving where not space for twin pit
Bigger demand for concrete for 2 slabs/pans

Bigger demand on space for pits and superstructure
Requires waterseal - dependent on reliable water supply
Generally anal washers in area
Desired and understood by beneficiaries

Low cost (if local design)
Permanent- strategy for pit emptying
Contents of pit can be used as fertiliser
Generally anal washers in area
Without waterseal- moderately low water demand
Improves food security with fertiliser
Integrated solution for solid waste disposal
Bulking agents (ash and organic waste) readily available
Requires space for two pits

With waterseal- requires reliable water supply
Without waterseal- potential malodorous and flies
If providing all HDP pipe, better to promote

basic VIPs where space and water is limited.
To be promoted as an option where water
supply is unreliable, and no space for pit
switching. Can ventilate pit using basic
subsidy package.
Can promote as an option where sufficient
space but unreliable water supply.
Can promote as an option where space is
limited but unreliable water supply. Without
waterseal better to opt for basic VIP.
To be recommended as standard design.
Need fly/odour control if no waterseal - Use
pan 'plug' or 'stopper' and periodically add
ash. Needs provision of water storage within
latrine.
High capita costs

Labour intensive and require significant behavioural change
Twin-pit option provides fertiliser with minimal
Technically complex with urine diversion
effort and lower per-capita costs.
Anal cleansing (washers) - disturb moisture balance
Low demand for additional manure if high maintenance
69
Fly and odour control can be improved by the periodic additive of ash into the pit (also improving the
productivity of the sludge for fertiliser), and placing a plug over the hole. This is less hygienic than using a
waterseal, but arguably more appropriate. Users should therefore not be given waterseals in a standard
package, but advised of the benefits and drawbacks of waterseals, for them to make their own decision on
what is most relevant to them, and purchase one if desired.
The availability of water (stored) within the latrine was seen as a high priority by interviewees for anal
cleansing and flushing. Without this, users may be reluctant to use it, or use household containers, such as
jugs also used for drinking purposes.
2. Where available space is an issue, twin-pits may not be possible. In these circumstances, direct pits may
be more appropriate, although their design life is limited to the size of pit. Where users are anal cleansers,
and have a reliable and adequate supply of water, a direct pour-flush latrine with waterseal may be promoted.
However, given water supplies may fail, a pit latrine with basic pit ventilation may be a better option.
Basic Package and Technical Design

In light of the appropriate technology options suggested, the following basic subsidy package is suggested,
which allows flexibility between a basic ventilated pit latrine and pour-flush.
Table 5.222. Recommended basic subsidy for household latrines
Material
Cement (12.5kgs)
HDPE pipe 110 mm dark
coloured, 2,5 metre
length
Elbow Pipe OR Fly
netting for vent pipe
20l Jerry can
Use (Pour-flush design)
Forming basic latrine 'pan' and

hygienic surface
Use (Basic ventilated pit

design)
Forming hygienic surface for

squatting area, and fixing
vent pipe**
Costs (current
Costs
procurement (procurement
and air transort)
locally)
Procur Portera
Procure Transpor
ement ge to
ment
t
GGD* field
125
1,450
625
Drainage pipe and incorporated

Ventilation pipe
into pan
860
812
1,288
Elbow pipe for pit switching

without physical works on pan
Fly net for vent pipe
60
58
80
Latrine water supply and potty
Latrine water supply and potty
120
29
160
Sub total (NPR)

Total (NPR)
Total (Euros)
* GGD stands for Gamghadee, the district town of Mugu
1165
2349
3,514
38.6
950
2,153 950
3,103
34.1
** This volume of cement is not sufficient for a solid concrete squatting slab, but to cover laid stone slab arrangement
The basic subsidy omits a pan from its design. This is because fibreglass pans are less durable than cement
and HDP pipe, and as 100% maintenance costs would be bourn by the households, it is deemed more
appropriate to state the benefits of using pans, and those who can afford, desire, and feel they can replace
them, may purchase them.
Many functional latrines were observed in the field that used innovative techniques in the absence of purpose
built pans, to achieve smooth, easy to clean surfaces for improvised pan structures.
70
Figure 5.223. Improvised, pan structures integrating cement pan with pipe. Lower Rhimi village, Humla.
This basic subsidy package provides the minimum amount of materials to attain permanent and moderately
hygienic, easy to clean attributes, and encourages innovative designs. The reduced volume and weight
enables easier field transportation, reducing costs and making collection, particularly by vulnerable
households, more achievable. With current procurement practices, the package reduces costs of material
provision by 42% of current costs, down to 38 Euros per household. These costs could be further reduced to
34 Euros (49% less) by procuring materials through district outlets and portering to the field. During
sensitisation, households should be given sufficient information regarding the advantages, drawbacks,
maintenance requirements and costs for a range of latrine designs and standards, for them to be empowered
to make informed decisions based on their own priorities and circumstances.
Sanimart
As there may be households wishing to attain higher standards for their latrines, such as the addition of pans,
siphons and use more concrete, a Sanimart system should be developed to make these materials as
accessible and affordable as possible. Due to economies of scale, and the high capital required, it is
unrealistic to supply such materials through the informal shops in each village. A realistic option could be to
work with retailers in the district towns to help them to obtain and supply materials at the minimal price.
WSUCs could organise bulk purchases and porterage from retailers to the community, and the NGO could
even subsidise materials, by providing the WSUCs with discount vouchers, and paying the retailers the
difference. To make Sanimart a viable option, there has to be sufficient consumer demand. Therefore ACF
should coordinate with other sanitation actors in the area (DDC/DTO, DWSS, and other NGOs) and try to get
them to support and promote this local supply chain in their activities.
Construction and Skills Base

Current ACF latrine construction activities comprise of an NGO overseer based in the communities to
supervise and assist in construction. These overseers theoretically remain in the community until all latrines
are built, but then leave. A more sustainable approach could be to train local masons sufficiently to be able
to construct the latrines, so that the skills base remains in the community, and also reducing the human
resource demands on the NGO. If the skills remain within the community, users are not rushed to build
latrines under the NGOs timeframes.
Masons could be incentivised to participate in the project by providing them a higher subsidy package, such
as more cement and a pan. Practical training could be provided to him through the construction of initial
model latrines in the community. The community can then use these well constructed latrine models as
reference points for their own construction, and to aid decision making over which design is most appropriate
to them.
71
Subsidy
It is unclear, given the social dynamics and general high expectations of support from individuals, regardless
of socio-economic status in the communities, whether graduated subsidy would be appropriate. Rather, what
is suggested here is that basic latrine packages should be available to all, with the more affluent encouraged
to upgrade their latrines themselves. National policy states that the ultra poor should be supported in
sanitation projects through targeted grants (GoN 2004). If, following strong community sensitisation and
mobilisation, vulnerable households are not assisted by neighbours or relatives for construction and
porterage, grants could be made available to assist them. This should be used only as a last resort, as it may
cause conflict or be abused, and the vulnerability classification should follow national guidelines (see GoN
2004).
5.2.3
Software Approach
Evaluations of ACF programmes in Bajhang and Mugu/Humla have criticised the relatively low focus on
software and social mobilisation (Ockelford 2007, ACF 2007c). As the vast majority of the population have
defecated outside most of their life, as generations did before them, successful sanitation programmes need
to have a strong software component, to drive for significant behavioural change. This software approach
should be undertaken at the beginning of projects, to sensitise the communities, and build demand for
sanitation, before any construction activities begin.
The current approach to sanitation used by ACF in Mugu/Humla is targeting and supporting individual
households, and is not likely to achieve 100% coverage. This means that although latrines have been built,
the full public health benefits are limited, as open defecation will still be practiced by some households.
A total sanitation approach would be more effective at attaining full coverage as the issue of sanitation
would be taken from an individual to community initiative and responsibility. By working at the community
level, pressure can be placed on those who continue to defecate openly, and barriers faced by certain
households (such as land availability or inability to construct) can be worked through as a community.
Interviewees suggested that committees and CBOs could be empowered and supported to help manage this
process.
Table 5.23. An assessment of various approaches to sanitation for the context of the area.
Approach
CLTS
SLTS
Flat rate subsidy
Graduated
subsidy
Strengths in context
Weaknesses/barriers in context
Community initiative
Strong community mobilisation techniques
Low social cohesion

Needs good facilitators (may not be available locally)
Communities expect material support
Communities do not want another temporary latrine
Incorporation and focus on children
Low functionality and potential capacity of schools
All members of the community expect material
Potentially high per captia costs
support
No specific poverty focus (in line with RWSS Policy)
Potential hijacking by richer households
Poverty focus and supporting mechanism for poor
Potentially socially unpopular option
Challenges in monitoring, and potential misuse of funds
Revolving fund
Potential for greater costs borne by households
Sanitation a low priority for limited household cash

Slow payback as cash flows are limited and seasonal
Ensure ongoing material availability

Sanimart
Maximise local economic benefit from project
Limited purchasing power of households in the area

Economies of scale and challenges of bringing outlets
closer than district towns
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Relevant Latrine Promotion

Past programmes such as the Maoist forced latrine building has shown that if the users do not readily
perceive a benefit for themselves of using the latrine, the usage will not be sustained. Due to the traditional
beliefs about cause-effect of disease, an approach using predominantly health based messages for
promoting latrine usage may not be so effective. However, the interviewees mentioned a number of issues
that they perceive with their current defecation habits (see Figure 4.235), which should be drawn upon in
promotion and group discussions, so that they see benefits of latrines that are relevant to their lives.
Ignition PRA
The ignition PRA tools utilised in CLTS use an approach based on shame, self-respect and disgust as drivers
and motivators for sanitation, justified as health based messages may not be sufficient to drum-up initial
momentum for community-level action. Rather the health benefits are realised following the usage of latrines,
which is an ongoing motivator for sustained usage.
The application of community approach iPRA tools in the area may be hindered by a number of points:
The currently weak social cohesion and lack of leadership in many communities
The low motivation for self-help community initiatives without incentive in some communities
Low numbers of visitors to the communities and the relevance of shame and self respect approach
The need for strong facilitation skills of the social mobiliser, and the reality of the limited human
resource capacity available locally, and high national staff turnover.
This third point could be addressed by local recruitment and strong capacity building, and/or working with
partners with proven track record in successful iPRA, such as NEWAH.
Ignition PRA tools should be piloted in the area as means of initial community mobilisation, and successes
should be scaled up. The piloting would need strong initial facilitation, along with regular, sustained follow-up
support.
Children have strong potential to drive social change within the village, and schools should be included in
sanitation promotion when they are within the catchment of intervention. However, relying on schools as the
main entry point into the communities (as in SLTS) may not be appropriate in the area, due to the low
functionality and staffing issues of the schools. Schools should be assisted to have access to latrines and
water supplies, and teachers should encouraged students to use them. This topic is discussed further in
section 5.5.
The aim of total sanitation is to stop open defecation. This takes significant effort, and should be recognised.
The involvement of the local health posts can provide feedback to the communities on improving health
status, and the DDC or VDCs should be involved in the official recognition, ceremony, and even in the
provision of community rewards, for the attainment of open defecation free status. In the ceremonies,
representatives from surrounding villages should be invited, to disseminate the message, and show other
communities what is possible.
5.2.4
Replicability and Future Sustainability
To maximise on public health benefits, communities could be encouraged, and supported to attain 100%
coverage of latrines, rather than the NGO trying to spread its activities thinly between communities, gaining,
say, 60% in each. However, as the sanitation approach suggested in this report involves the subsidy of
external materials, it may be difficult for neighbouring communities to replicate the latrines without external
assistance, limiting the potential for a multiplier effect in the area from the NGOs activities.
To maximise the effectiveness and impact from a community intervention in the area, the role of the VDCs
and DDCs are arguably critical to support subsequent community-driven sanitation in the area, and for
ongoing sustainability of sanitation projects in general.
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Funding and Continual Support
Each VDC in Mugu should receive an annual budget of 1 million NPR (around 11,000 Euros) per annum
(DDC Mugu staff, 2007 pers comms). This must be divided between the administrative wards and
communities of the VDC, but still represents a considerable budget for the area. The funds are channelled
from the DDC, and are to be spent on community/VDC infrastructure and services. The VDCs have moderate
autonomy of what to spend the funds on, but need to account for the use through annual reporting. With the
remoteness of the communities, and subsequent poor monitoring, there is a real danger of corruption and
embezzlement. The DDC also has an annual budget from DoLIDAR to fund rural water and sanitation
projects. It is suggested that these funds provided to the VDCs from the DDCs could be used for communities
wishing to obtain the same the basic subsidy provided by the NGO in the neighbouring implementing
communities.
This approach would need the VDCs and DDC on board from the inception of the project, with both parties
sensitised as to the importance of sanitation in their working areas, and willing to support communities
wishing to improve their access to sanitation. Although the VDC funds have the mandate of addressing
community, not household issues, the point could be advocated that total sanitation is a community project,
with community benefits. Funding provided could cover the procurement costs (at the district level) of basic
subsidy materials, and the activities of a social mobiliser/facilitator. Funds could also be made available from
the VDC for total sanitation rewards to the communities, and the DDC could provide rewards for VDCs, as
an incentive for their participation in sanitation development.
This is not to suggest that the NGO provides funds to the local government, but that local government funds
are made available for communities outside the NGOs implementation area to gain support for sanitation.
Local Skills Base
For sustainability and ongoing accessibility of skills, the NGO should invest in local skill development and
capacity building. Using and training local masons in the intervention communities would leave construction
skills in the VDCs, and the use (and training) of local government or local NGO staff in community
mobilisation and facilitation in the intervention communities, would potentially leave these skills at the district
level. Key skills for the local mobiliser should include community mobilisation and iPRA, community proposal
writing, and capacity building WSUCs.
Additional advantages of utilising local government staff or using local partner NGOs include; maximising the
employment and economic gain of the project in the area; benefiting from their local knowledge; and
potentially reducing national staff turnover, as staff recruited in Kathmandu often find it difficult to adjust to
local lifestyle. Costs for staff transport would also be greatly reduced.
Indeed, partner NGOs need not be national-level NGOs. INGOs could see their potential role of developing
the capacity of local (district or regional) NGOs. Skills could be brought from reputable national-level NGOs
such as NEWAH, by contracting them to train the local partners in key skills.
Igniting Local Demand for Sanitation
ACF experience of assisting sanitation in communities in the area, through provision of materials, has seen
many other communities outside the intervention area calling for similar assistance.
This local demand could be further increased through inviting members of neighbouring communities to
observe the process in the intervention communities, particularly at reward ceremonies. Members of the
health posts and CBOs of the intervention community could undertake exchange visits to other communities
to disseminate their experiences, and public display boards could be placed in the area. The social mobilisers
could be paid by the DDC or VDCs to visit communities, to mobilise them, and help them to develop
community action plans and proposals for VDC/DDC assistance for materials and ongoing software
assistance. This improved link between community and local government may aid the transparency and
accountability of the use of VDC funds. In this respect, further activities in the area would be demand driven,
by mobilised communities who know what is, and is not available for their assistance.
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Economies of Scale
Working at the VDC, and even DDC level would help to increase the economies of scale for bulk
procurement and transport of sanitary materials by district retailers, and increases the potential viability of
Sanimart outlets at the VDC level. It would also help to standardise the approach and subsidy level across
the VDC, helping to mitigate conflictory approaches or high community expectations for assistance in
sanitation.
5.2.5
Latrine Locations
The lack of free land available for households to build latrines close to the house may be a barrier for some
for building latrines. However, it is likely that if there is sufficient community demand and pressure for total
sanitation, with pressure groups and good social facilitation, it is likely that the community would overcome
these barriers themselves. At the household level, if there is sufficient demand for latrines, innovative
solutions to locations and space saving designs will be found. The total sanitation approach should drive the
importance as a community responsibility. NGOs should avoid becoming involved in land acquisition for
latrines, and leave the process to the community. However, the NGOs role can be that of a facilitator,
suggesting technical and social solutions, and ensuring the process is inclusive, where the vulnerable,
landless households are addressed. Below are potential options for those without obvious access to land:
Space saving latrines. Design models with small squatting areas and superstructures that can be
located beneath the balcony. Pits could be placed in front of the house underneath public paths.
Locate within the cattle shed. This could involve structural work on the houses, and must not be in
the cow compartment.
The use of public land for individual or multi-household latrine blocks. This should be through formal
consent of the VDC.
The support and training for saving and credit groups for land acquisition
Establish a committee to act as a pressure group for land owners to set aside/sell land for landless
Advocate sharing latrines between households. If users see benefits of the latrines, and the pans are
easy to clean, this may be an acceptable option.
5.3
5.3.1
Promotion of Hygiene and Environmental Sanitation

Prioritising Interventions
In communities with such a wide number of environmental health risk conditions and practices, it unrealistic
to expect that an intervention can cover all issues at once. It is necessary therefore to prioritise activities and
health promotion on key-high risk issues, ideally those which have knock on impacts on other issues.
However, the key issues highlighted by a WASH professional may not correlate with the risks or issues
perceived by the community. For maximum impact and effectiveness, a balance must be made between the
environmental health and beneficiary priorities, with the biggest potential for impact and change in focussing
on issues that involve a minimal amount of behavioural change or technical input. In this, strategies and
approaches to improving environmental health should follow the path of least resistance. This is not to say
that certain issues should be avoided, as participatory hygiene sensitisation can help to develop or modify
community perceptions of risks. There may be differences between the priorities perceived by different
members of the community, or within the family, highlighting the need for the identification and discussion of
issues at the community level with representative participation from all ages and genders. In the absence of
sufficient epidemiological, health or water quality (particularly at point of consumption) data, the relative
prioritisation of the various environmental health issues is unavoidably subjective, as is the assessment
between issue (cause) and health problems (effect). More research is clearly required on this topic in the
area. Table 5.31 identifies key issues in environmental health in the intervention area, and interventions that
could address them.
75
Table 5.31. Environmental health priorities and potential physical interventions
Relative
Issue
Community Priority Potential Hardware/Physical Interventions
Cost*Benefit**
Low
Latrine construction
Open defecation in the village
High
High
Low
Potty construction
Low
Latrine construction
High
Child/sickness excreta disposal
Low
Low
Potty construction
Low
Handwashing facilities
Lack of handwashing at key times (with or without soap)
High
Low
Low
Soap distribution or production
High
Remove animals from inside village/house
Presence of livestock excreta in human habitat (fresh)
Moderate/unclear
Very low
High
Process manure in fields
Moderate
Regular collection and containment of dung
Low (only 3 weeks per
High
Process manure in fields
Very low
Composting manure outside the houses
year)
Moderate
Regular collection and containment of dung
Moderate
Waste Pits
Low-moderate
Indescriminate solid waste disposal
Low (variable)
Moderate
Compost, potentially with Manure
Low
Feed to animals
Low
Soakaways
Grey/storm/roof water stagnation
Moderate
Moderate
Low
Kitchen Garden Irrigation
High
Drainage Trenches
Low
Construct bathing/privacy facilities
Low-moderate
Soap distribution or production
Poor personal hygiene
Moderate-high
Moderate-high (variable) Hygiene kit production or distrubition
Moderate
Low-moderate
Improve access/yield of water supply
Low-moderate
Improve environmental sanitation
Low-moderate
Source water quality
Low-high (variable) Low
Catchment/system management.
Low-moderate
Develop multiple/alternative sources.
Source water quantity
Moderate
High
Low-moderate
Improve system efficiency
Low-moderate
Vectors (flies)
Moderate
Low
Low-moderate
Vectors (rodents and pests)
Low
Low
* Cost in terms of capital economic cost, and labour to sustain
** These relative cost benefits are the authors estimates only, and are highly dependent on context
EH Priority in the
Area
76
Hygiene promotion is limited without access to enabling factors. There were various barriers identified during
the field research which may limit the beneficiaries ability to achieve improved health or hygiene conditions.
These are discussed in the following sections.
5.3.2
Enabling Factors
Environmental Sanitation
Hygiene and environmental sanitation are inherently interlinked. With a dirty environment, inhabitants are
more reluctant to wash themselves, their clothes or their children frequently, as they will rapidly become dirty
again. In addition, if all villages or people are of a similar standard of hygiene or sanitation, there is no clean
reference point upon which to compare ones own standards. Therefore a more holistic approach to
environmental sanitation and hygiene is needed.
Greywater disposal, solid waste management and livestock excreta interventions have a clear potential to be
integrated with food security activities. Kitchen-garden irrigation can be promoted and supported for
greywater disposal, and as domestic solid waste is dominantly organic, it can be combined with manure in a
drive for improved composting. Sweepings from house cleaning can be put in a sweepings pit yielding high
quantities of potatoes.
Excellent booklets covering basic techniques for composting, livestock excreta management, greywater
irrigation, sweepings pits, and improved farming and environmental management have been produced in
western Nepal by an INGO called Appropriate Technology Asia. Their contact details are presented in
Appendix 1.
The presence of livestock excreta in the villages and around the homes was not generally perceived by
interviewees as a major issue, and alternatives to keeping the animals in the ground floor were complex,
potentially expensive and overwhelmingly unpopular. However, attempts to manage and contain the excreta
could be promoted by providing or locally producing shovels to aid mucking out excreta from in front of the
house and inner village areas. The heaping and/or containment of the manure could be incorporated with
messages of improved composting.
Greywater drainage in inner-village areas where kitchen-garden solutions is not possible could be greatly
improved by advising communities on constructing gravel filled soakaways.
Street paving was attempted by the Maoists, bringing significant improvements in street conditions, but were
not maintained. Communities agree that path paving would improve the state of the villages but are unwilling
to work on such a project without payment. The government has a strategy of one household one
employment, which the community or WSUC could be linked to for financing such a project. Communities
could also be linked with local organisations that provide or subsidise improved ventilated stoves.
Personal Hygiene and Handwashing

In addition to the dirtiness of the village, major barriers interviewees mentioned for improved hygiene were
insufficient water supply, issues of privacy for bathing, and access to soap.
Whilst addressing shortfalls in water supply should be standard interventions in WASH projects, privacy for
personal bathing is not often addressed. Many interviewees of all ages and genders stated that they were
likely to wash themselves more frequently, and, particularly for women, more effectively, if they had privacy
whilst washing. As a low cost intervention, semi-public wooden shelters (bathrooms) could be piloted in
communities, to be managed at the tapstand-cluster level. Walls could be built near the tapstands to act as
basic privacy screens for the same purpose.
The affordability and accessibility of soap is another factor. Soap is sold in the village stores at a 20-25%
mark-up price to that which is available in district town stores. A small-scale pilot of cost reducing, or
77
subsidising supply chains for soap (at the village shop level) could be worked on, as could workshops to
improve the domestic production of soap using local ingredients.
Current ACF strategy includes providing the beneficiary households with 4 bars of soap each. Although this is
arguably unsustainable (particularly taking into account the procurement and transportation methods), it could
help to ignite demand for soap in the communities. Males generally hold control over the families purchasing
habits, and if they can perceive the benefits of soap, they are more likely to prioritise family expenditure on it.
The procurement of soap for distribution should, where possible be undertaken through the village shop
owners, to strengthen the supply chain of soap and other hygiene consumables to the village level.
Handwashing at key times, particularly after defecating and child/sickness stool disposal, is argued to be the
second biggest priority for hygiene promotion after safe excreta disposal.
The construction of basic handwashing units such as tippy taps for use in the latrine or in the household are
low cost, low tech interventions that could prevent individuals washing with the family drinking water jug.
Another major barrier to improved hygiene, particularly that of child hygiene, is the lack of time availability of
the mothers. An integrated approach that reduces mothers daily workload, through interventions such as
hydro grain grinding mills may also indirectly benefit hygiene conditions.
5.4
5.4.1
Hygiene Promotion
Current Approach
Hygiene Promotion (HP) in the ACF Bajhang project was criticised as very weak, with short training sessions
covering too many topics, resulting in limited improvements in hygiene behaviour (Ockelford 2007).
HP activities were not undertaken in Bajhang or Mugu/Humla until the late stages of the projects, with water
supply construction taking precedent over initial WASH activities.
The current HP approach currently used by ACF is predominantly health-based lesson sessions, using IEC
materials, to community groups (mothers, children and general community) by hygiene promoters of the
implementing partner NGO. This is due to be followed by individual household visits by the external hygiene
promoters, and the training of community hygiene promoters towards the end of the project.
5.4.2
Future Approach
As mentioned in Section 5.31, with so many issues of hygiene and sanitation to address in the communities,
key risk issues and practices should be addressed as a priority. These priorities may vary between
communities and groups, and should be tailored accordingly. One or two topics should be addressed per
session to avoid saturating the audience.
The IRC (2005) state HP should priorities messages addressing issues of:
1. The highest risk
2. The greatest ease of successful change
3. The greatest possibility of successful change
4. The most interest on the part of the community
As with sanitation promotion, given the commonly held traditional beliefs regarding causes of disease, purely
health based messages may not be appropriate. Messages should therefore contain a balance of health
messages and education, and highlighting the issues that they currently perceive with their situation, to make
beneficiaries perceive the relevance of the HP to their lives and situations. An approach that facilitates the
communities to realise the problems of their environment by themselves, and barriers to overcome, rather
than being told by an outsider, may be more effective at driving change. Therefore a participatory approach
to HP such as the PHAST technique should be used. It is recognised, however, that as with ignition PRA for
sanitation promotion, the effectiveness of PRA tools is determined by the strength of the facilitator.
78
Experience of HP during the A1D project has shown that there is a reluctance to attend sessions without
incentives, and those who attend sessions, may leave half way through, thought to be because of other
commitments, or boredom. HP sessions should be as engaging and participatory as possible to sustain the
interest of the audience, and lessons should include practical exercises wherever possible. Incentivising
attendance should be well thought through, and coordinated with other development actors in the area.
Potential incentives could be providing basic materials for use in practical hygiene promotion sessions, where
attendees may be taught to construct enabling facilities such as hand washing facilities (tippy taps), basic
child/sickness potties and latrine water containers, and locally produced soap. Attendees would then have to
attend the full sessions to gain the materials, and keep the end product, at the end of the session. Other
practical exercises could be in the construction of improved soakaways, or enhancement of kitchen garden
irrigation. The latter may be taken on through food security interventions.
Experience from locally operating NGOs has shown that running competitions between children, households
and even villages for the best hygiene standards has been successful. However, these competitions should
be linked to, or run by more permanent structures such as the VDCs, DEOs/schools and health posts, to
enhance post-project sustainability.
The skills base within the community and local institutions (FCHVs, health post workers, teachers and
community members) to undertake HP should be developed and invested in, as they will be there long after
the project finishes. This training should commence at the beginning of HP activities, to maximise the on the
job training, rather than bolted on at the end.
The inclusion and participation of local health posts has proved to be effective in the area, as they can
enhance/accredit the authority of external or community hygiene promoters, and provide the community
feedback on their improving health status.
Conversely, it is important not to exclude traditional healers and priests from the process. If they feel that their
authority is not being acknowledged, or is being undermined, they may try to demobilise HP activities, or
discredit the hygiene promoters. The department of health approaches this issue by formally acknowledging
the existence and services offered by the healers, and telling them that f they can solve the issue, try, but if
they are unsuccessful or unable to cure it, to refer patients to conventional health services immediately.
Whilst many hygiene promotion activities in WASH projects focus on women or mothers groups, at the
relevant demography responsible for household and family hygiene and sanitation, it is important in this
context not to exclude males. It is the males who have dominant power over financial resources and decision
making in the household and community, and also the males who are likely to build new infrastructure,
therefore their participation in the process is essential. Research has shown that domestic violence towards
women is widely justified in the implementation area (more so than anywhere else in Nepal) (MoH&P 2006).
Although important, and a component of ACF-IN strategy, gender empowerment should be sensitive not to
over-empower women to such an extent that may cause domestic violence and subordination.
5.5
Child Hygiene Improvement
The improvement of the childrens hygiene status could be addressed through 3 broad approaches;
improvement of environmental sanitation conditions and enabling factors; promoting parent-child care
practices; and direct HP to children.
Different interventions will benefit different ages of children, where child-care approaches focus more on
children less than 5 years, direct HP to children would benefit around 3 years plus, and environmental
sanitation improvements would potentially benefit all.
5.5.1
Environmental Sanitation and Enabling Factors
Due to cultural, social and livelihood factors, it is unrealistic to expect that children will be constantly
supervised. Children will continue to play in the paths and around the village, and not always wash their
79
hands. It is therefore pertinent to improve the general hygiene status (excreta disposal, greywater drainage,
and domestic waste and manure practices) of the villages. Cleaning up the environment should de-facto
improve childrens hygiene and health.
Interviewees mentioned a number of barriers to attaining improved child hygiene status. These included; the
lack of soap; lack of mothers time to supervise/wash or teach children; shortfalls in water supplies; and the
dirtiness of the village. Therefore, any intervention that helps to overcome these barriers, such as cost
reducing, distributing or locally producing soap; reducing the daily workload of women; and improving water
supply and environmental sanitation would potentially improve child hygiene.
5.5.2
Parent to Child Care Practices
The extent of parent to child teaching, supervision and upkeep regarding hygiene and sanitation is limited in
the area, due to a number of social, cultural and economic constraints. Whilst parents interviewed perceive
that it is their responsibility to teach the children about washing and defecating, children stated they learn
more on these topics at school or simply from observation of others.
Interventions should build on parental ability and sense of responsibility, to improve and maintain the hygiene
of their children. This concept of responsibility is especially pertinent for males (fathers and grandfathers) who
generally have more time available than mothers.
Infant mortality rates are high in the area, and parents should be made to feel empowered about the fact that
they can improve the potential for survival of their children; and that it is not simply up to chance.
Key opportunities exist with the presence of mothers groups and Female Community Health Volunteers
(FCHVs) in many of the communities. Group activities could be held to develop and promote basic care
practices, whilst building on the parent-child relationship through quality or play time. These sessions
should include practical exercises where possible. An example of such an exercise is baby bath sessions,
which could turn bathing from an unpleasant chore to an enjoyable experience for both child and parent (ACF
2006b).
These sessions should be open and accessible to all who partake in childcare in the communities, and could
be an ideal opportunity to involve the males in the hygiene upkeep of their children.
FCHVs could be trained to undertake such sessions in the communities, and follow-up household visits. The
involvement and training of FCHVs in HP programmes is coherent with national RWSS policy (GoN 2004),
although their potential limitations in terms of capacity to educate, credibility, and actual amount of activity in
the communities should be taken into account.
There is a clear potential to integrate activities in child care practices for hygiene promotion with future
preventative malnutrition programmes. Current ACF strategies involve the training of FCHVs in malnutrition
detection, but do not yet include preventative care for malnutrition. A potentially effective mode of future
malnutrition preventative care in the communities would be education through mothers groups.
If FCHVs are to be trained, and nutrition messages communicated through mothers groups, it should be fully
coordinated by both WASH and Nutrition programmes. A potential issue of this is that there are so many
messages to be communicated on both child hygiene and malnutrition prevention; there is a true danger of
trying to cram too much in.
Given constraints on parental time, the relatively low priority that some households place on child care and
teaching, and poor hygiene practices of the parents themselves, parent to child approaches should not be
relied upon as the sole method to communicate hygiene and sanitation messages to children.
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5.5.3
Hygiene Promotion Directly to Children
Children are potential agents of change in the communities, and are often charged with the supervision of
younger siblings whilst the mother is working. Once educated, children may actively teach other children
(child-child approach), or passively teach, by becoming models for other children to watch and learn
improved practices through observation.
Two opportunities for direct hygiene promotion to children are; in schools; and through child groups.
School Hygiene Promotion

Hygiene education through the schools should be undertaken through coordination with the DEO and other
NGOs, particularly UNICEF, who are active in schools in the area. The broad experience of UNICEF in
school HP should be capitalised on, and they could also be approached for training and IEC materials. The
DEO should be involved to aid sustainability, and to facilitate the scaling up of successes to other schools
outside the area of intervention. As with community HP, for messages to be implemented, users must be able
to access enabling factors. Therefore all schools within the catchment of project intervention should be
provided with water supply and sanitation facilities. Many latrines constructed for schools in the area rapidly
became disused in the absence of a water supply for cleaning and flushing. A water supply to the institution
would also facilitate hand and personal washing. Soap could be made accessible throughout the project
duration, financed either by the NGO, or more sustainably, the school management committee (SMC).
Mirrors could be built into tapstands to aid washing, and potentially develop students sense of self respect.
The active participation of teachers is essential. Teachers and the SMC should be sensitised to perceive the
importance and benefits of the project, and feel a sense of control, ownership, and pride over it. The school
could be promoted as a model of best practice within the community, and the programme could reaffirm the
teachers sense of job satisfaction by feeling they are driving change in the area. A sustainable approach
would be to train the teachers in HP for students, rather than NGO staff undertaking HP sessions in the
schools. Teachers and caretakers should be encouraged to have patience with students using and dirtying
the latrines, recognising the fact that they may be using them for the first time.
HP activities should be made practical wherever possible, with teachers taking charge of activities such as
showing how to wash the body and hands effectively, as students may not learn this at home. Students
should play an active role in managing the environmental sanitation of the school, and competitions could be
undertaken for the cleanest schools in the area. Teachers could be encouraged to take an active role in
monitoring the hygiene status of the children, acknowledging good practices, and condemn bad ones, such
as open defecation whilst at schools. Some schools in the area hold annual award ceremonies for students,
with a prize for the cleanest child, which they found to be successful, as it can install healthy competition and
peer pressure for cleanliness amongst students.
Students should be encouraged to teach other children not present in the school about their improved
practices, particularly younger siblings and friends/family that do not attend school.
Out-of-School Child Education

An approach working in schools may not address all children, particularly lower caste (Dalit) children and
females over around 10 years, for whom school attendance is limited. Whilst child-child education can be
encouraged to the students, out of school hygiene promotion sessions through childrens groups could also
be useful. This would be particularly relevant where the local school is experiencing regular closures and
staffing issues. These could include sessions with girls who supervise younger siblings on care practices and
child washing, and action groups could be promoted to undertake household visits, village clean-ups, and
monitor against open defecation. Experience of other NGOs in the country has found that children can
become highly active in HP and environmental sanitation improvement within the communities (UNICEF
2006, Plan 2007 pers comms), proud to be involved in driving forward development. Whether in or out of
school, child HP should be made as practical, participatory, and fun as possible, incorporating mediums such
as song, drama, puppetry and competitions.
81
Conclusions & Recommendations
The Importance of Hygiene and Sanitation in the Area

Mugu and Humla are among the least developed of the 75 districts of Nepal; which itself is one of the poorest
countries in the world (Ockelford 2007). The districts are remote and drought prone, and the prolonged
conflict in the area has impaired local governance, social organisation and cohesion, and community based
services.
Sanitation coverage in the area is among the lowest in Nepal (CBS & ICIMOD 2003), and was calculated at
less than 10% in the area of this study (ACF 2007). Hygiene practices are poor, with key risks identified as;
open defecation, indiscriminate stool disposal, and low incidence of handwashing, particularly with soap.
Solid waste, greywater and livestock excreta management practices create poor environmental sanitation
conditions, particularly in the dense, nucleated communities. Personal and clothes washing is infrequent, and
child hygiene is an area of particular concern.
Diarrhoea is the biggest cause of mortality in the area, and there is a widespread prevalence of intestinal
worms and skin infections (DHO Mugu & Humla 2007 pers comms), in addition to a high incidence of child
malnutrition (ACF 2007e). Whilst this research cannot quantify the impacts of the hygiene and environmental
sanitation conditions on disease and malnutrition incidence, it seems clear that they bear a strong influence.
Although hygiene and sanitation may be the priority in the eyes of the outsider, they are lower priorities to the
communities, particularly in light of uncertainties of food and water supplies.
Whilst progress has been made in the area, opportunities certainly exist to develop approaches to hygiene
and sanitation, particularly relating to relevance, effectiveness, impact, replicability and sustainability.
Overall community approach

Given the improving security and field access in the area, approaches could shift towards a more community
orientated software approach, focussing on sensitisation, mobilisation and demand building for the WASH
services and infrastructure that will follow. Pro-active project selection and planning, limited community
participation, high levels of subsidy, and a focus on hardware activities may limit the sustainability and impact
of projects, and reinforce the communitys feelings of dependency on external assistance.
Many of the post-conflict communities visited were experiencing weaknesses in social cohesion, leadership
and initiative. Interventions could take the opportunity to build up social capital, and empower the
communities, particularly the CBOs to be able to manage and drive change. Any attempts at mobilisation
should be complemented with frequent, and sustained follow-up support, as a community trying to mobilise
and failing, may install a sense of fatalism, inhibiting future self-help initiatives. Beliefs and practices are deep
rooted, and change needs time, support and encouragement.
For ongoing sustainability, projects should be linked wherever possible with more permanent structures, such
as local schools, health posts, VDCs and district authorities, and procurement of materials should endeavour
to reinforce local supply chains.
The local skills base should be developed, and left within the area after the project finishes. These skills
include community based masons and hygiene promoters, and district level social mobilisers and facilitators.
Sanitation Approaches
Although much research and piloting of sanitation approaches has been undertaken in other areas of Nepal,
little research has been done in the Karnali zone. Previous sanitation initiatives, such as the Maoist latrine
82
construction programme and other NGO projects in the area show that whilst latrines may be constructed,
usage may not be sustained. These past experiences should be capitalised on when developing future
approaches in the area.
The approach suggested should have a strong software focus, where the community is mobilised with
participatory techniques such as iPRA tools, and demand is built for sanitation at the community level.
Sanitation should be promoted with messages in line with users perceptions of issues, in combination with
health based messages.
A total sanitation approach is suggested to maximise public health benefits. Also, by making sanitation a
community initiative, barriers faced by individual households such as land access may be worked through,
and CBOs could be encouraged to act as community pressure groups to strive for 100% coverage and
usage.
Due to the remoteness of the area, and material costs, conventional designs for latrines incur high percapita costs, and pose challenges for replicability, and the users ability to sustain them. Given the low
presence of other sanitation actors in the districts, particularly in the remote VDCs, national financing
resource gaps for sanitation, and optimistic national coverage targets; there is a clear need for more low-cost,
replicable approaches.
Past experiences of temporary latrines, previous promises, high community expectations, limited household
resources and ulterior household priorities are all local factors that make purely software approaches such
as CLTS or revolving funds potentially limited in terms of effectiveness or impact in the area.
It is argued that, in the case of the study area, communities need to be provided with some form of material
subsidy, if the majority of the households are to build latrines.
A minimal basic subsidy is suggested, to provide households with sufficient materials to build permanent
latrines and satisfy them that they are receiving material support from the intervention, however minimising
per capita material procurement and transport costs, and encouraging innovative design.
The basic subsidy suggested provides flexibility in design, to accommodate users preferences and
constraints, and could be augmented with a Sanimart system for those aspiring for higher standards of
latrines.
To maximise impact and local replicability outside the NGOs intervention communities, and to harness local
demand ignited for sanitation, communities should be able to access support from their VDCs or DDC in the
form of community mobilisers, training and financing for basic subsidies. VDCs and DDCs could also provide
rewards and incentives for achievements in sanitation at the community, and VDC level.
Poor coordination and overlapping projects, with varying policies of community incentives and subsidies in
the area is leading to high community expectations for assistance, and bargaining for the best deal. This
inhibits self help initiatives and the community acceptance of projects offering limited or no subsidies for
latrines.
District level coordination of activities is essential to mitigate conflicting approaches, and a standardised
approach at the VDC (or multi-VDC) would also build on economies of scale, making decentralised Sanimart
outlets more viable. Standardised material procurement practices would strengthen the district level supply
chains and reduce costs through bulk purchase.
A tight partnership is necessary between the implementing NGO and local government, to coordinate
activities, build up the local skills base, and to advocate for their active involvement in supporting communitydriven sanitation projects.
Central government could facilitate the process by channelling funds mandated for sanitation, providing
training, and advocating the importance of sanitation to the DDCs, and incentivising and rewarding districtlevel achievements.
83
Hygiene and Environmental Sanitation

This research identified that community priorities or perceptions of issues do not necessarily correspond to
that of the environmental health issues. With such a range of environmental health issues, there is a danger
of trying to address too many problems, potentially cramming HP sessions, to an audience with strong
constraints on time availability. Interventions and messages should be prioritised to; address the key high-risk
practices; practices with the most community interest; and those with potential for knock-on effects on other
issues.
As with sanitation, HP should be initially undertaken through community-level participatory mobilisation,
providing a platform for issues to be highlighted by all castes, ages and genders, and addressed by the
community. The total sanitation concept could be further extended to community clean-up initiatives,
coordinated by supported CBOs such as mothers groups or the WSUCs, and VDCs/DDCs could reward
achievements. Initial community mobilisation should be followed by more targeted HP sessions.
HP sessions should be as participatory, relevant, and enjoyable as possible, and incentives for attendance
could be through attendees keeping the end product of practical sessions. The local skills base should be
developed for HP capacity, including those of FCHVs, health post staff and teachers, for post project
sustainability.
Low-cost technical solutions exist for environmental sanitation issues in the communities, and some have a
strong potential for integration with food security activities. CBOs could be linked with other organisations
potentially supporting improved stoves or village path paving, to facilitate holistic improvements in community
and household cleanliness. Other barriers identified by interviewees to improved hygiene practices, such as
privacy whilst washing, soap access should be addressed.
Child hygiene is a serious and complex issue in the area. Children are often left autonomous for their hygiene
at an early age, and parental teaching on hygiene and sanitation issues appears to be limited in many
households.
A multiple approach is suggested to address the issue; including improving the environmental sanitation
conditions of the communities, addressing barriers mentioned, such as water and soap access, and the time
availability of mothers, along with targeted hygiene promotion.
Child-care practices could be developed in group sessions; an activity that potentially overlaps with
preventative malnutrition activities. However, given that not all households would be interested, or able to
significantly improve practices, direct child hygiene promotion is recommended. The local schools could be
equipped with facilities, and developed as centres of best practices, where students learn defecation,
washing and environmental sanitation practices, and encouraged to teach others. The active involvement of
teachers is critical in this approach, and the DEO could support inter-school competitions and reward
achievements.
However, given the issues of functionality faced by local schools, and trends of attendance, out-of school
child clubs would also be useful to communicate the messages to all.
Operational Recommendations
Regarding the NGOs current and future operations in the area, the following points are highlighted:
Working in a limited number of VDCs across two districts boundaries does not seem to be efficient.
From the authors perspective, from the villages visited in this research, Mugu has higher needs in
terms of WASH interventions.
If child hygiene is to be taken on as a key component for future activities, a multiple approach is
needed, to include direct child hygiene education, improving the environmental sanitation conditions,
84
addressing enabling factors, and developing child-care practices. This latter intervention has clear
overlap with preventative malnutrition initiatives.
An integrated approach between nutrition, food security and WASH programmes would maximise the
impact of the interventions, and the interest from the side of the community.
The NGO should develop a win-win partnership with local partnership, moving away from somewhat
contractual relationships. Local (district-regional-level) NGOs could be used for partners, and
reputable NGOs such as NEWAH could be contracted to provide their training.
The NGO should move towards a longer-term (multi-year) developmental approach, with
corresponding donor support.
Regarding the conclusions from the KAP Survey (ACF June 2007); in light of this research, the following
points are highlighted:
The topics to be covered in HP are important, but there is a danger of trying to cram too many
messages. Key risks, such as safe excreta disposal (including child hygiene) and handwashing
should be prioritised, as should treatment of diarrhoea. This prioritising should be based, to a
maximum extent, on objective, scientific datasets.
HP messages should be in line with the users perceptions of their realities, not solely health based.
Advocating for changes in community practices through HP need to be achievable for the audience,
therefore enabling factors should be addressed.
Summary
Implementing sanitation and hygiene projects in the area is likely to remain challenging, particularly as
individuals and households give relatively low priority to change, incomes are low, local government and
community leadership remains weak, and supply chains are long and costly.
However, change can occur, albeit with time, and should be driven by the communities themselves.
In light of national targets and financial constraints, approaches to hygiene and sanitation in the area need to
be coordinated, low-cost, replicable, and sustainable.
A holistic and integrated approach should be taken to work towards the common goal of reducing mortality
and morbidity through malnutrition and sanitary related diseases.
Recommendations for Further Research

The following areas of further research are suggested in the area;
The appropriateness and modality of implementing graduated subsidies in the context of postconflict, potentially egalitarian communities.
The potential application of CLTS iPRA tools in communities where social cohesion and leadership
structures are weak, and expectations on external assistance are high.
The potential, viability and needs of Sanitation Marketing at the VDC level in remote mountainous
areas.
Objective methodologies and criteria for identifying key environmental health risks, and prioritising
interventions in communities.
85
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88
Appendix
1. Interviewee and Contacts List

2. Questions for Communities (Field Research Question List)
3. Sphere Standards for Excreta Disposal
4. Map Showing Geographical Distribution of Sanitation Actors in Nepal
5. Comparison of RWSS Policy and Strategy and ACF-IN WASH Policy (from ACF 2007)
6. Annual Cropping and Social Calendar for Communities in the Study Area
7. List of Schools and Health posts Visited During Field research
89
Appendix 1. Interviewee and Contacts List
Agricultural Development Office (Humla)

Agricultural Development Office (Mugu)
Appropriate Technology Asia
ATA
Care Nepal
CBWSSP
CCDC
CESI
Concern
DDC (Humla)
DDC (Humla) DACAW Project
Deepros
District Education Office (Humla)
District Education Office (Mugu)
District Health Office (Humla)
District Health Office (Mugu)
District Land Office
District Livestock Office
District Technical Office (Humla)
District Technical Office (Mugu)
District WatSan Sub Office
District WatSan Sub Office
DOLIDAR
DOLIDAR
Domestic & Small Industries Department
DWSS
DWSS
DWSS
DWSS
Helvetas
INF
Jay Nepal Youth Club
KIRDAC
Malica
NEWAH
NEWAH
OXFAM
Plan Nepal
RRN
RVWRMP (FINIDA)
RWSS FB
Saapros
SNV
UMN
UNICEF
UNICEF
UNICEF
UNICEF
WaterAid
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Name
?
Durga Rajal
1
1
1
1
1
organisation
Nat. Govt
Donor/Fund
Local Govt.
INGO
NGO
Organisation
Local/National
Organisation Type
Chris Evans
Nirmala Sharma
1 Kishora Sskya
?
Hari Har Sapkota
Pradeep Shrestra
Tilak Paudel
?
?
Namsum Bhistra
Kul Bhadur Pardera
Dr. Sarbesh Sharma
Chakra Bar Mulla
Topbhadur Rawl
Binde Shaaray
Rajesh Kumar Yadab
Shoviyat Khadka
Shiva Kumar Shrestra
Dhurba Deb Khumar
J. Sherma
Kamal Jaishi
Hirlal Shrestra
Kamal Ashikari
Mr. Nawal Mishtra
Khum Subdedi
Khamal Adigari
Adhir Sharma
?
?
Madoc Neoparney
?
Umesh Pandey
Laxmi Paudel
Narbikram Thapa
Nabin Pradhan
Mr. Ratna
1 Ram Bahadur Thapa
1 Chandra Bista
?
Hendrik Visser
Kari Mitchell
Larry Robertson
Radhika Thumbahangphey
Pursotum Achari
Surindra Rana/ Mr Amir
Oliver Jones
Location
Phone
Email
SMK
680011
GGD
87460086
KTM
15549774 nepal@arasia.org.uk
KTM
15549774 cevans@gn.apc.org
KTM
15522800 nirmala@carenepal.org
KTM
14430948 cwssp@wlink.com.np
GGD
4414430/4419412
harihars@ceci.org.np
Surkhet
NPG
81520704 pradeep.shrestha@concern.net
SMK
680016
SMK
SMK
SMK
GGD
SMK
GGD
87460161
GGD
87460083
SMK
680010
SMK
GGD
87460137
GGD
87460130
SMK
87680057
KTM
15521021
KTM
15546355 kjaishi@gmail.com
SMK
KTM
9841435467
KTM
9841628139
KTM
14413670/9851059946
khumsubedi@gmail.com
KTM
9841435467
KTM
15524925 po.helvetasnepal.org.np
GGD (Jamaldara)
GGD
NPG
81524013
GGD
KTM
14377107
KTM
14377107 laxmipaudyal@newah.org.np
KTM
1536075 nthapa@oxfam.org.uk
KTM
15535580 nabin.pradhan@plan-international.org
KTM
14422153
SMK
87680144 ramthapanp@yahoo.com
KTM
14410761 chandra@rwss.org
GGD
KTM
hvisser@snv.np
GGD
460043
KTM
15524991
NPG
81550008
KTM
15523000
NPG
81550008
KTM
15552765 oliverjones@wateraidnepal.org.np
90
Appendix 2
Questions for Communities (Field Research Question List)
Village ..
....
VDC ...
District
Date
Stats: Age.
Sex. Caste.. Vulnerable Group? .
Location of house
Size/Structure of Family:
Total.. , <5 , 5teen , Teen.., Adult.
Environmental Hygiene/Sanitation Situation (Open ended/broad to gauge perceptions and priorities)
Major perceived issues in the village relating to hygiene and sanitation? Order of importance/priority?
What can be done about them?
Defecation Practices
Where do you/your child defecate (variability seasonally/time availability/sickness/night)
What do you use for anal cleansing? If water where collect, where are water sources in village?
How transport etc.
What are the problems with your/child defecation practices/locations?
What do they do with child faeces? Where/do children learn where to defecate, anal cleansing -018,18-24, >24months
Latrines
Have you ever built a latrine? If yes;
Did they use it? Design? How long? Why? Why stop (if applicable)?
Any problems with it?
Where was it located? Why? Issues with location? Shared?
Plan to build another latrine (replacement of temporary, one of ACF planned intervention areas)
Plan/aspire to (demand)? Barriers?

Where locate it? How acquire land? Financial methods/practicalities/timescales/barriers? Perceptions
of location within the house/balcony/cowshed- women/animals space? Realistically enough space
for 1/2 pits? Put pits under paths?
How close need to be to be used at night and by the children/elderly/dispose child/sickness faeces?
Achievable?
Perceptions of sharing latrine/latrine block for cost reductions? Who possible to share with?
What to do when it is full? Nightsoil collection/disposal methods/realities-whose responsibility? Space
available to switch pits? Perceptions of Ecosan? Demand for high grade/additional compost,
willingness for upkeep/bulking agents available through year/moisture control?
Cultural/spiritual beliefs about faeces?
What kind of design? External materials how feel they could sustain? Where can they access them
logistics/costs..
How can they finance all this? Land acquisition and materials/labour/construction/porterage?
Contributions and subsidies realities of graduated subsidy?
When would they construct it? Barriers to construction?
Are there the skills within the community to construct it?
Who would be responsible for cleaning it? How ensure it remains clean? What use to clean it?
What do for anal cleansing in the latrine? What if water not available/bucket lost/broken use of solid
wiping material?
How ensure latrines were being used? Usage by the adults instead of going to the jungle? Individual
or community?
What would they do when away from latrines/seasonal migration replicability?
What can be done about child/sick/elderly/night defecation? Potties?
Village Cleanliness
What do/could they do with their domestic/ food processing refuse? What type of refuse/volume
variability /year?
91
What is done with rooftop drainage/greywater? Issues? Roof space to drain away from street?
Space for soakaways?
Where are the animals kept through the year? Why? Length of time in village length of time shit in
street?
What is done with their faeces? Clean up or left there? Composting?
Any issues regarding animal waste/composting practices (erosion/health/cleanliness)?
What could be done about this? How could the village be cleaner?
Perceptions of keeping animals/processing compost outside village/communal area?
Perceptions of bunding/isolating compost design ideas to address issues mentioned?
space/resources available?
Personal Hygiene
Personal washing
Are there any issues with your/family personal hygiene in the village? Health problems associated to
these? Causes?
How frequently do they/family wash themselves? Seasonal variation? Why?
Issues of washing where/the way they do? Are they/family as clean as they want to be?
What use? Use/see benefits of soap? Access/costs?
Handwashing
(When) do they/family wash their hands? Restrictions? Why do they wash them? Perceived
benefits?
What do they use to wash them Different materials at key times? Perceptions of using ash?
Where do they wash them (facilities) using what?
Clothes washing
How often do they wash their/families clothes? Why? Annual variability? Who is responsible for
clothes washing?
What do they use for washing?
Schools/Child Hygiene
How do they/their children learn about hygiene/sanitation practices? Gender? How to wash
themselves/clothes?
How/do they teach the child to use the latrine?
Rites/coming of age and significance of stopping looking after child? Different for boys/girls?
Who washes the childrens hands/teaches? When do they wash/with what? Where?
Who is responsible for the childrens hygiene/sanitation/bathing upkeep/supervision seasonal
variation?
Who looks after the kids when the parents are absent?
Do they/their children go to school? What prevents them?
What facilities exist at school for hygiene/sanitation? Do they use them?
Do they learn about hygiene/sanitation in lessons? Interested? Fun? Memorable?
Recommendations?
Village or community approach/CBOs
What do they think would be/is the most powerful medium of change in the village? Who respected?
Any CBOs/ever created in village?
Would people listen more to an NGO/external (e.g. KIRDAC) representative or member of own
community?
Would an approach based on community monitoring, vigilance and shame be effective?
What do people learn best/enjoy most/participate most in; visual aids, community exercises, lessons,
drama, songs?
92
Appendix 3.
Sphere Standards for Excreta Disposal. Source: Sphere (2004, Revised Ed.)
Excreta disposal standard 1: access to, and numbers of, toilets
People have adequate numbers of toilets, sufficiently close to their dwellings, to allow them rapid, safe and
acceptable access at all times of the day and night.
Key Indicators:
A maximum of 20 people use each toilet
Use of toilets is arranged by household(s) and/or segregated by sex.
Separate toilets for women and men are available in public places (markets, distribution centres, health centres,
etc.).
Toilets are no more than 50 metres from dwellings.
Toilets are used in the most hygienic way and children's faeces are disposed of immediately and hygienically.
Excreta disposal standard 2: design, construction and use of toilets

Toilets are sited, designed, constructed and maintained in such a way as to be comfortable, hygienic and safe
to use.
Key Indicators relevant to the research situation include;
Users (especially women) have been consulted and approve of the siting and design of the toilet.
Toilets are designed, built and located to have the following features:
- they can be used by all sections of the population, including children, older people, pregnant women and
physically and mentally disabled people;
- they are sited to minimise threats to users, especially women and girls, throughout the day and night;
- they are sufficiently easy to keep clean to invite use and do not present a health hazard;
- they provide a degree of privacy in line with the norms of the users;
- they minimise fly and mosquito breeding.
All toilets constructed that use water for flushing and/or a hygienic seal have an adequate and regular supply of
water.
Pit latrines and soakaways (for most soils) are at least 30 metres from any groundwater source and the bottom of
any latrine is at least 1.5 metres above the water table. Drainage or spillage from defecation systems must not run
towards any surface water source or shallow groundwater source.
People are provided with tools and materials for constructing, maintaining and cleaning their own toilets if
appropriate.
93
Appendix 4.
Source: WaterAid 2007
94
Appendix 5. Adequacy between the RWSS Policy (2004) and the ACF-IN policy. Source: ACF (2007c)
Criteria
MDGs
Integrated management of
the resource
General criteria
ACF-IN policy
Nepal policy
Principles of intervention
MDG 1, 3, 4, 5, 6, 7, 8
Compromise between environment,
resource & social
MDG 1, 3, 7
Measures will be taken to reduce
environmental impacts & water
resource development
Criteria of intervention
Survival threatened, deficiency local
100% population will get water supply
structures, recurrent crises, general state of facility & sanitation services by 2017
under-development
Specific criteria (WS)
Sanitation = health hazard, insufficient

quantities of water, distance from WP is a
socio-economic limiting factor
Target beneficiaries
IDPs or refugees, lost of livelihoods due to

crisis, ethnic minorities victims of
discriminatory behaviour, remote
communities, communities unable to
maintain min. standards, risk of acute
malnutrition
Vulnerable people, better to cover the entire
targeted pop., average quantity of average
quality, breaking faecal-contamination, key
places (health centres, schools)
Definition of intervention
priorities (WS)
Intervention modalities
Impact
- Greatest measurable
impact
- Integrated approaches
- HH focused approach
Appropriateness & relevance
Bajhang Evaluation
X
X
Reduce water borne diseases & its

victims in the nation.
Utilise in productive works the time &
labour of women, men & children saved
from carrying water
On priority basis, backward people and
ethnic groups
ACF-IN policy
KAP surveys 1 & 2
Nut, FS, WS, health, advocacy
Monitoring & evaluation tools
Maximum impact of project if the needs of the pop are
covered in priority at the HH level
Context, population, environment
Multidisciplinary team
Conflict-affected population, IDPs, stress

on coping mechanisms, increased
vulnerability of the poorest parts of the
population (Dalits)
Not really defined either in the first
assessment and concept paper in 01/05
conflict-affected population, ethnic

minorities victims of discriminatory
behaviour, remote communities, pop at
risk of acute malnutrition
Long list of activities with target indicators,

assumption that short assessment (2
weeks) found all the problems and
solutions, partners knowledge &
experience of working was not used
Nepal policy
Public awareness & health education = integral part. Basic
sanitation package of UNICEF/DWSS through the Hygiene
Improvement Framework
Participatory approach (leadership of the local community)
95
Needs analysis driven

response
- Multidisciplinary analysis
- Direct approach to
populations
- Understanding,
respecting & integrating
local factors
- Response adapted to the
capacities & willingness
of the communities
- Involvement &
participation of affected
communities & local
actors
- Feasibility study
- Appropriate, tested,
replicable & sustainable
techniques
Coherence
- Coordinating activities
-
Standards & guidelines
Good targeting (participation of the pop., fit prog. with

existing social dynamics, monitor prog. impact, handling
over activities, work with local institutional capacity)
Beliefs, knowledge & management = respect
Technical decisions with social & cultural aspects
(willingness, management capacity, respect beliefs & taboos
& hierarchy, resources available)
Participatory approach, community involvement, grass-roots
approach, local staff promotion
Hydrological validation & hydro-chemical suitability
Low cost technologies, maintenance mechanisms,
replicability
Project consistent with the mission strategy, guidelines of

ministry of WS, donor strategy. All stakeholders
(communities, authorities, NGOs, UN, private sector)
International & national standards mainly WHO guidelines

and Sphere standards
Coverage
Need to reach major population groups facing lifethreatening suffering wherever they are and focusing on
most vulnerable ones
Efficiency
Quantitative & qualitative outputs of the project, costeffectiveness shall be demonstrated through proper budget
follow-up, procurement rules
Effectiveness
Extent to which an activity achieves its purpose (respect of

the timeframe, monitoring, PCM, LFA indicators reached)
Reinforce social organisation and cohesion through a
communal approach to water management
Sustainability
- Community, civil society
Optimum utilisation of locally available know-how, skill &

resources. The type and level of service will be according to
the capacity as well as the willingness to pay by the
consumers, for which they will have to contribute to capital
investment for such facility
Human resource development programme will be developed &
extended from central level to the community level. VDCs will
play the lead role in involving WUCs in the construction and to
mobilise their contributions in cash and kind.
Given their stability and infrequent mobility in community life,
preference will be given to married women while selecting
Village Maintenance Workers for each schemes
Appropriate technology that is affordable to and manageable
by the users committees. A consumer-oriented catalogue
include affordable, appropriate and environmental friendly
technologies and estimation of construction, O&M costs
National Water Supply and Sanitation Coordination Committee
to coordinate the activities. Overlapping or inconsistent
policies and regulations will be made more efficient, effective
and consistent. DDC/VDC will coordinate and monitor the
international NGOs
Necessary standards will be set and implemented for the
material & equipment, system design & construction to
maintain the quality of work. The standard service level will be
defined according the water QARQ*
Participation of gender, caste & disadvantaged ethnic groups.
Poor communities will be targeted. Proper methodology and
norms will be developed in identifying the poorest households
within the community and such households will be provided
with specified target grants
Proper budget allocation will be ensured to meet the
scheduled target for the construction of new water supply
projects as well as O&M of the completed projects. O&M fund
and rehabilitation fund will be created at DDC and VDC level
to support rehabilitation financing
X
NGOs will train the community level female health workers on
the promotion of sanitation issues. Appropriate guidelines for
96
& institutions
strengthening
Transfer of knowledge &
handover
Capitalising on
experience & analysis
Gradual withdrawal of aid with total at the end, official

handover, technical training & maintenance groups,
community ownership, availability of and access to spare
parts and transparency in the management
Sharing of essential information is invariably an objective of
any programme
Operational research, link

with Universities
Operational research projects and short term studies
Gender
Ensure that the programmes implemented could benefit

equally men & women according to their specific needs and
with equal collaboration and participation of both sexes
People living with HIV/AIDS
Access to safe water and sanitation is indispensable for

people living with HIV/AIDS
Restricted mobility so special consideration should be given
to ensuring that they receive an equitable service
Routinely excluded by WS but should always be considered
in infrastructure projects
Particularly measures must be taken to ensure their
equitable access to basic services
WS facilities should be made as safe and accessible as
possible taking into account security situation
Assess the environmental risks and minimise impact (overexploitation
Elderly people
Disabled people
Children
Protection
Respect for the environment
Public/private sector
participation
Can provide essential products and practical solutions faster

or more cost-effectively than relief agencies
WUSC management will be developed (O&M, water tariffs,

social sanctions for illegal connections, O&M fund)
The consumers themselves will own, operate and have
responsibility to maintain water supply projects. DWSS will
hand over ownership and responsibility for O&M of all
schemes to local bodies (DDCs, VDCs, Municipalities or
WUCs). Technical assistants of the VDCs will be trained in
O&M as a back-up support to enhance internal capacity of
WUCs
A Water Users and Sanitation Federation may be established
for independent monitoring and social auditing
Research & development included in the policy
Plans of the VDCs and the DDCs will be formulated by
ensuring proper representation of disadvantaged people on
the basis of gender, caste and ethnicity. Such groups should
include at least 30% representation of women
X
X
X
X
X
Environmental impact should be included in the indicators. An
environmental screening appraisal will be included in all
projects to identify environmental concerns.
Service delivery mechanism of water supply & sanitation by
users committees, CBOs, NGOs & private sector in
partnership with each other will be established
97
Appendix 6 Annual Cropping and Social Calendar for Communities in the Study Area. Accessed from Food Security Team, ACF Nepal.
Activities
Harvest
Mustard
Harvest
Ploughing
Sowing /
Planting
Harvest
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Sowing
Paddy
(Irrigated)
Ploughing
Paddy (Rain
fed)
Sowing
Harvest
Ploughing
Sowing
Harvest
Ploughing
Common
Specific
India
February
2 3 4
March
2 3 4
April
2 3
May
2 3
June
2 3 4
July
2 3
August
2 3 4
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Ploughing
Millet /
Kaguno
January
2 3 4
Agriculture
Upper Village
Ploughing Lower Village
Upper Village
Sowing
Lower Village
Wheat /
Barley
Vegetables
Sowing
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Upper Village
Lower Village
Harvest
Festivals
Dashain
Diwali
Maghi
Anante Purni
Bich-chhati
Saune Sankranti
Chaite Astami
Dashahara (Jaira VDC)
Taga (Darma VDC)
Migration
Leaving village
Return back to village
Wedding Season
Wood / NTFP Collection

AVAILABILITY
98
September
1 2 3 4
October
2 3 4
November
1 2 3 4
December
1 2 3 4
Appendix 7
List of Schools and Health posts Visited During Field research
Mahadev Primary School (Nerah)
Kalika Primary School (Libru)
Health Post (Dhupi)
Dhupi Primary/Secondary School
Jamaldara Alternative School
Nachara School
Pumeru Secondary School
Jima Primary School
Melcham Health Post
Melcham Secondary School
Mahadev Secondary School (Dharma)
99

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Appropriate Approaches to Hygiene and

Environmental Sanitation in Remote

Will Tillett, 01-2008

Will Tillett, 01-2008

Will Tillett, 01-2008

Will Tillett, 01-2008

Presenting ACF-IN Approaches and Programmes

In natural or man-made crises which threaten food security or result in famine,

In situations where survival depends on humanitarian aid.

Will Tillett, 01-2008

Will Tillett, 01-2008

Will Tillett, 01-2008

Will Tillett, 01-2008

Will Tillett, 01-2008

Action Contre la Faim

Will Tillett, 01-2008

Humla and Mugu Districts

Human Development Rankings (Out of 75 Districts in Nepal)**

Will Tillett, 01-2008

Will Tillett, 01-2008

Will Tillett, 01-2008

Aims and Objectives

Specific Focus of the Research

Promotion, design, financing, logistics, location and management of household latrines

Improved personal hygiene of children

Will Tillett, 01-2008

The Importance of Hygiene and Sanitation

Will Tillett, 01-2008

The Provision of Sanitation in Nepal

Will Tillett, 01-2008

Funds and technical

Will Tillett, 01-2008

Strategies and Policy in Rural Sanitation and Hygiene Promotion

Hygiene promotion standard 1: program me design and implementation

Water supply standard 3: water use facilities and goods

Will Tillett, 01-2008

Excreta disposal standard 1: access to, and numbers of, toilets

Action Contre La Faim International Network WASH Policy

Covering the minimum requirements necessary for life

Overall RWSS Policy and Strategy

Will Tillett, 01-2008

Will Tillett, 01-2008

Subsidy or Self Respect: Community Approaches

CLTS differs from traditional approaches in that:

Will Tillett, 01-2008

Community Led Basic Sanitation for All (CLBSA)

Revolving Funds and Loans

The Model Approach

Will Tillett, 01-2008

Will Tillett, 01-2008

Table 3. Activity schedule for research project

Will Tillett, 01-2008

Figs 3.121 & 3.122. Demographic and caste divisions of 87 interviews.

Table 3.11. Community selection for field research

Rationale for Selection

Received a GFS from ACF in

Planned for a GFS and

Will Tillett, 01-2008

Style and Topics for the Interviews

Will Tillett, 01-2008

For a full list of questions, see Appendix 2.

Structured and Non-Structured Observation

Coordination with Other Sector Workers