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Water, Sanitation, & Hygiene in Central America and the Carribean: Depth Over Breadth for Sustainable Interventions
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Date (dcterms:date)
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2017
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Creator (dcterms:creator)
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Burgess, Joey
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Environmental Studies
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extracted text (extracttext:extracted_text)
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WATER, SANITATION, & HYGIENE
IN CENTRAL AMERICA AND THE CARIBBEAN:
DEPTH OVER BREADTH FOR SUSTAINABLE INTERVENTIONS
by
Joey Burgess
A Thesis
Submitted in partial fulfillment
of the requirements for the degree
Master of Environmental Studies
The Evergreen State College
June 2017
©2017 by Joey Burgess. All rights reserved.
This Thesis for the Master of Environmental Studies Degree
by
Joey Burgess
has been approved for
The Evergreen State College
by
________________________
Kathleen Saul
Member of the Faculty
________________________
Date
ABSTRACT
Water, Sanitation, & Hygiene
in Central America and the Caribbean:
Depth Over Breadth for Sustainable Interventions
Joey Burgess
Water, Sanitation, and Hygiene (WASH) resources are often scarce in developing
communities around the world. Although countless organizations from small non-profits
to large international government agencies are working to improve conditions, their
actions, known as interventions, often do not lead to lasting results. Interventions are
limited by the tendency in the WASH sector toward a practical approach, without a
sufficient theoretical base of knowledge for effective planning and design. There is a
need for theoretical tools that can guide organizations through designing interventions
that are sustainable. This study is a comparative analysis of twelve WASH interventions
throughout one of the regions with the least access to WASH – Central America and the
Caribbean. For this study, I use two frameworks from the limited WASH literature to
identify key strategies for sustainable interventions. The analysis also sheds light on the
utility of the limited WASH literature by evaluating the two frameworks for designing
and evaluating WASH interventions. Through the analysis, I determined the two
frameworks are effective for design and evaluation, however, they are both limited by
redundancies and unclear definitions. The most effective strategies for sustainable
interventions fell into two general categories – taking a Holistic Approach to intervention
and establishing strong External Support systems. Both strategies transcend simply
providing a technology or inciting behavior change by transcending the direct service of
the intervention by enhancing systems that are connected to WASH.
Table of Contents
Introduction .......................................................................................................................................... 1
Background ..................................................................................................................................... 1
Significance ..................................................................................................................................... 4
Practical & Theoretical Approaches in WASH ....................................................................... 6
Study Design ........................................................................................................................................ 9
Criteria for Including Interventions .......................................................................................... 11
Frameworks Used for Comparative Analysis ........................................................................ 12
USAID – WASHplus Improvement Framework (WIF).................................................. 13
WaterAid – Wash Sustainability Framework (WSF) ....................................................... 16
Analysis .......................................................................................................................................... 20
Findings .............................................................................................................................................. 21
Standards ........................................................................................................................................ 22
Commonalities Amongst High Scores ..................................................................................... 23
Associations .................................................................................................................................. 32
Discussion & Recommendations ................................................................................................... 34
Dominant Themes ........................................................................................................................ 35
Holistic Approach .................................................................................................................... 35
External Involvement .............................................................................................................. 36
Functionality & Dynamics of Frameworks – WASHplus Improvement Framework ... 38
Advantages .............................................................................................................................. 38
Limitations ............................................................................................................................... 40
Functionality & Dynamics of Frameworks – WaterAid Sustainability Framework ...... 42
Advantages .............................................................................................................................. 42
Limitations ............................................................................................................................... 43
Current Limitations to Collecting/Analyzing WASH Data................................................. 45
Hard to Compare................................................................................................................... 45
Hard to Measure .................................................................................................................... 46
Addressing Limitations ............................................................................................................... 47
Recommended Framework ........................................................................................................ 48
iv
Conclusion ..........................................................................................................................................49
References ..........................................................................................................................................51
v
List of Figures
FIGURE 1. Schematic of study design………………………………………………..…17
FIGURE 2. USAID's WASHplus Improvement Framework (WIF)…………….............22
FIGURE 3. WaterAid’s WASH Sustainability Framework (WSF)……………..........…26
FIGURE 4: Educational material at well-site at a local school in Camoapa, Nicaragua...48
FIGURE 5: New Framework - The Evergreen WASH Sustainability Framework……...57
List of Tables
TABLE 1. Definition of sustainability by German NGO Welt Hunger Hilfe……...……12
TABLE 2. Measurable outcomes from interventions included in the study……………..19
TABLE 3. Criteria for scoring high in each scoring group ……………………………..28
TABLE 4. Results – Combined Intervention………………………………………...…..31
TABLE 5. Results – Capacity Building…………………………………………..……...32
TABLE 6. Results – Technology Chosen by User…………………………....................33
TABLE 7. Results – Environmental Aspects………………………………..…………..34
TABLE 8. Results – Both Water & Sanitation…………………………………………..35
TABLE 9. Results – Water Use Committees (WUCs)…………………………………..36
TABLE 10. Results – Capital Contribution……………………………………………...36
TABLE 11. Results – Monitoring System……………………………………………….37
TABLE 12. Results – Support System for Local Management………………………….38
TABLE 13. Results – Support System for Local Management………………………….39
TABLE 14: Limiting Categories………………………………………………………...48
TABLE 15: Problems with outcomes……………………………………………………55
vi
Acknowledgements
Kathleen Saul – The most dedicated, patient, and hardworking professor that I know. I
appreciate all of your guidance and am honored having you as Reader.
Eric Martin (Bucknell University) – Helped throughout the entire process from the initial
idea throughout study design. Your guidance is invaluable.
Larry Geri (MPA Program) – Catalyzed the project by teaching me the survey process
and program evaluation methods. Your guidance is invaluable.
El Porvenir Staff – Allowed me to assist with household survey project and gain
experience in the field. ¡Muchísimo gracias!
Project Hearts – Allowed me to enter the community as an outsider and pilot a program,
gaining invaluable experience. ¡Muchísimo gracias!
Sustainability in Prisons Project Staff – Creates a supportive environment that enabled
me to fully dedicate to work and this project.
Evergreen Faculty – Encouraged systems thinking, trained on thorough research methods,
and changed the lens through which I see the world. Thank you for being here.
Jennica – Supported me through the entire process, my loving partner.
vii
Introduction
Background
Within the global population, one group of people, the global north, rarely
consider where their drinking water comes from or where their human waste goes.
Technological capability in the global north is so great that water and sanitation are a
non-issue for most of the population. Meanwhile, billions of people in another group, the
global south or “the developing world,” do not have access to basic human needs in terms
of water and sanitation (UNICEF & WHO, 2015). Despite safe water and sanitation
being designated as basic human rights by the United Nations General Assembly in 2010
and other global movements like the Millennium Development Goals, an imbalance of
resource-access remains between the global north and south (UNICEF & WHO, 2015).
In terms of access to safe drinking water, 9% of the global population (663
million people) do not have access to an improved water source – meaning that the
source is protected by a barrier from fecal contamination (UNICEF & WHO, 2015).
Access to adequate sanitation is much less widespread with 32% (2.4 billion people) of
the global population without access to improved sanitation – meaning that excreta is
hygienically separated from human contact (UNICEF & WHO, 2015). Perhaps the
statistic with the worst result in terms of human and environmental health is that 13% of
the global population resorting to open defecation – meaning they do not use any
designated toilet and excreta is not contained from the environment (UNICEF & WHO,
2015). A global movement called, “Water, Sanitation, & Hygiene (WASH)” initiated by
UNICEF promotes the enhancement of local systems to “improve water supplies and
1
sanitation facilities in schools and communities.” UNICEF recognizes that each field
requires its own independent work, however, WASH was grouped to highlight the
interdependent nature of the three fields and the importance of collaboration for progress
(UNICEF, 2016).
Many developing nations are locked into systems where basic human needs like
WASH are limiting factors to upward mobility. Inadequate safe water and sanitation
permeates nearly all aspects of daily life in rural areas and severely limits achievement of
other development activities like “adequate nutrition, gender equality, education and the
eradication of poverty” (UNICEF & WHO, 2015). Since women in developing
communities tend to hold the water management responsibilities, inadequate water and
sanitation conditions disproportionally affect women and severely limits their upward
mobility in terms of alleviating poverty for themselves and their families (UNICEF &
WHO, 2015). Collecting water is time consuming and the responsibility limits time for
things like educating themselves or their children – not to mention that collecting water
can be dangerous and often leads to women frequently placing themselves in vulnerable
positions (Water and Sanitation Programme, 2010). The disproportionate burden felt by
women is just one example of how inadequate WASH conditions limits many aspects of
life in developing communities.
Inadequate WASH conditions restricts economic opportunity in the developing
world because most resources must be spent on surviving through the results of poor
health. I repeatedly witnessed the economic restriction scenario while managing a
household WASH survey project in rural Nicaragua in 2015. The purpose of the survey
was to inform a non-profit organization, El Porvenir, on the performance of its aid
2
programs as well as on the health and WASH conditions of the local communities. Most
of the households I visited were on small dairy farms that depend on the sale of a few
jugs of milk per day for income. The households report frequent visits to health posts
which require an average four hours of travel and if the medication they seek is available,
it is often too expensive for the farming households to afford (Burgess, 2015). Frequent
illness is also reported which is most likely due to residents using the same surface water
points for washing clothes, washing dishes, and personal hygiene. Since 22% of the
households in the region resort to open defecation, many of these water points are
contaminated vectors for water-borne disease transmission (Burgess, 2015). The rural
families in this area of Nicaragua are locked into a system; the households are forced to
spend their income on medicine that does not treat the underlying problem – inadequate
water and sanitation.
Although subject to varying conditions of poverty, I also witnessed similar
mechanisms in the Dominican Republic that keep rural communities locked in the same
perpetual state of immobility due to the foundational problem of inadequate access to
safe water and sanitation. In a rural area of the country I worked with a non-profit
organization, Project Hearts, gathering baseline data on the needs of the community and
piloting a program that provides access to safe water storage, filtration treatment, and
incites behavior change. Globally, there are countless organizations and agencies doing
work like El Porvenir and Project Hearts, attempting to assist communities with WASH
development. These organizations include local and international non-profits like El
Porvenir or Water for People, governmental agencies like the United States Agency for
International Development (USAID), and international agencies like the World Health
3
Organization (WHO). The aid activities are in the form of “interventions” that occur at
household, community, municipal, regional, or national levels. Interventions have highly
varied approaches, scopes, and goals – resulting in a sector with no standard of practice.
Significance
Countless organizations and agencies worldwide spend an average of US $220
billion annually on investments and human resources for WASH interventions (Hutton,
2012). However, their efforts are often limited by strategies that do not lead to lasting
improvements on WASH conditions. For example, the Caribbean coastal region of
Central America has been host to many humanitarian efforts to improve WASH systems,
but the approaches of international non-profits and government agencies have been
largely unsuccessful due to cultural differences that go unacknowledged by intervening
organizations. In an article from 2014, Tinoco et al. cite “quick fix solutions” as one of
the major contributions to the failures of interventions. Quick fix solutions fail because
they do not assess the capabilities of the communities in which they are implemented,
they clash with cultural preferences, they ignore relevant local knowledge, or the
installations often remain incomplete due to incapacity to control or monitor them after
implementation (Tinoco, Cortobius, Grajales, & Kjellénd, 2014). Another downfall of the
quick fix solution is that interventions do not include sufficient user training or WASH
education.
While there are plenty of studies on the efficacy or limitations of interventions,
there are not sufficient resources on identifying the most effective and sustainable
approaches to WASH intervention in specific regions (Aiken, Stauber, Ortiz, & Sobsey,
4
2011). Community WASH access depends on countless variables that are beyond control
such as regional climate, proximity to centralized cities or towns, economic stability, and
geography which make a uniform approach to designing interventions problematic.
However, honing in on the most effective strategies for improving WASH conditions will
make efforts more efficient and will make investments into WASH programming more
worthwhile. Further, honing in on the most sustainable strategies for improving WASH
conditions will enable beneficiaries of the intervention to use the system in longevity and
potentially achieve upward mobilization through meeting basic needs.
The notion of “sustainability” is highly debated in terms of a definition, so for this
study I use the definition set by the German humanitarian aid organization, Welt Hunger
Hilfe. To be considered sustainable in this study, the service had to fit the criteria
outlined in Table 1.
TABLE 1: Definition of sustainability by German NGO Welt Hunger Hilfe
Sub-Saharan Africa, South and East Asia, and Latin America are identified as
having the least WASH coverage in the world (UNICEF & WHO, 2015). My experience
5
in the WASH sector has been focused in Central America and the Caribbean which are
host to some of the poorest nations in Latin America – Haiti, Honduras, and Nicaragua.
Many other nations in Central America and the Caribbean are plagued by political unrest
such as El Salvador and Honduras. Central America and the Caribbean have a tropical
climate pattern with two main seasons – wet and drought. The region also experiences
frequent extreme storm events. Climate change will intensify pressure on rural access to
WASH in Central America and the Caribbean in two primary ways, which are connected
and influence one another: altered precipitation patterns and increased
intensity/frequency of natural disasters (Mendoza & Barmen, 2006; Hidalgo, Amador,
Alfar, & Quesada, 2013; Rivera & Wamsler, 2014). Altered precipitation patterns are
already seen in the Caribbean through extended drought periods (Intergovernmental
Panel on Climate Change, 2014). The current economic conditions, expected climate
pressures, and my participatory experience are what led to my focusing on Central
America and the Caribbean region in this study.
Practical & Theoretical Approaches in WASH
Currently, a main issue in global WASH aid is that organizations often implement
practical approaches that initially seem impactful such as, “We installed 234 bio-sand
filters in the Posoltega community.” (Vanderzwaag, Atwater, Bartlett, & Baker, 2009).
However, the question of the community’s knowledge about microbes and how waterborne diseases are transmitted is often overlooked. Posoltega residents may not have seen
the need for bio-sand filters and decide not to use them, as seen in the under 10% rate of
continued use (Vanderzwaag, 2009). The focus on practicality in WASH partly stems
6
from most organization’s evaluation structures being results-based. To ensure continued
funding organizations must regularly show funders results, so most organizations
consider interventions “finished” at given stage. Organizations then proceed to the next
community in need to produce more results and receive continued funding – which is the
mechanism that leads to unsustainable “quick-fix” approaches (Easterley, 2006; Tinoco
et al. 2014).
While working the in the Dominican Republic with Project Hearts, I piloted a
program that is designed to provide affordable ceramic water filters and rain catchment
systems with storage tanks to households. During the planning stage, I collected baseline
data through household surveys, discussions with Community Health Leaders, and local
medical records from hospitals, clinics, and health-posts in the area. The data shows that
about 40% of the population was consuming untreated water on a daily basis as well as a
high prevalence of water borne diseases, especially in children under five years of age
(Machado, 2015). With these data, it was clear to the organization and I that the best
course of action was to prioritize dispersing ceramic filters and training the households
on their proper usage, with the hope of supplying a few families with rain catchment
systems and storage tanks. However, at the end of the first quarter of the program I found
that the number of filters provided was far below our goal and the number of rain
catchment systems with storage tanks provided exceeded 300% of the target (Adea,
2016). Our baseline data collection and analysis missed a vital aspect – the community’s
priority on reliable water storage. Community members prioritized being able to store
water reliably and safely before considering the content or quality of the water itself.
Although the baseline data shows problematic statistics related to health, the most
7
problematic statistic to the community itself was not shown. The program was then
altered to reflect the community’s priority on storage and to increase education on
transmitting water borne diseases and health related to WASH.
Errors in intervention design are not uncommon in the WASH sector. The “quickfix” focus stems from a practical approach taken by WASH organizations that hinders the
sustainability of interventions. The WASH literature does not have a sufficient theoretical
base of knowledge that organizations can rely on during the design stage of WASH
interventions, as there are few frameworks that guide organizations on how to approach
interventions sustainably. In this thesis I first explore the threshold between practical and
theoretical strategies by examining WASH interventions through two available WASH
frameworks. The research questions addressed are:
“Are the WASHplus Improvement Framework and the WaterAid Sustainability
Framework effective for designing sustainable WASH interventions in Central America
& the Caribbean?”
and from these two frameworks,
“What are they key strategies that lead to more sustainable interventions?”
The need for increased investment in planning strategies stems from the nature of
the WASH sector being directed by outsiders of the communities being intervened
(Tinoco et al., 2014). As seen in my story of error in the Dominican Republic, an
organization can have the most benevolent intentions but the position in the community
as outsiders can severely limit their affect. The outsider position is key to keep in mind
8
not only for reading this thesis but also for understanding the foreign aid sector in
general. Building a strong theoretical knowledge base can reduce the limitations of the
outsider position and lead to more effective and sustainable WASH interventions.
Study Design
This section includes an explanation of the criteria for the case studies included,
followed by an exploration of each case study and the methods used to evaluate the
interventions. Two frameworks were selected for analyzing interventions, the WASH
Plus Improvement Framework created by USAID and the WASH Sustainability
Framework created by WaterAid. I explain both frameworks’ structures as well as the
specific characteristics that led me to use them in this study. Finally, the methods used to
discuss the interventions through the two frameworks are explained. Figure 1 shows the
study design.
9
FIGURE 1: Schematic of study design
I use the frameworks to analyze the interventions to highlight the need for a
stronger theoretical base of knowledge in the WASH sector. The WSF and the WIF are
examples drawn from a limited pool of theoretical frameworks, and their ability to
measure performance and ensure sustainability of WASH interventions is assessed
through the analysis.
10
Criteria for Including Interventions
Interventions included in this study needed to fit a set of pre-established criteria.
First, the intervention had to take place in either Central America or the Caribbean region
because of the relative continuity of climate and economic conditions throughout the
region. Confining the study to Central America and the Caribbean also contributes to
filling a current gap in the WASH literature — an analysis specific to a region (Burgess,
2015).
Next, the intervention had to provide a technology or incite behavior change
concerning water supply, treatment, sanitation systems, handwashing stations,
soap/storage containers/consumables, or fecal sludge management (as according to the
WASH Plus framework). For example, the intervention could include the provision of
bio-sand filters, or a hand-washing education campaign, or both. The intervention also
fits the criteria if it is focused on managing latrines that have filled, or building new
latrines. In addition, the intervention had to have measurable outcomes reported in the
literature or reference materials that would enable comparative analysis. Often,
organizations will report what they do, which are Outputs, instead of reporting the results
that are produced by what they do, which are Outcomes (Poister, 2003). For example, an
output is constructing 50 latrines for a community; the outcome is that rates of diarrhea in
children under five years old decreased by 20% due to cleaner water from less open
defecation. Outcomes are always measurable; otherwise results of interventions can be
reported ambiguously or incomparably. To see how the interventions included in this
study met the criteria, see Table 2.
11
TABLE 2: Measurable outcomes of interventions included in the study.
Intervention
WASH Technology or Behavior Change
Mesita Azul Ultraviolet
Treatment - Mexico
Both
Caritas & Catholic Relief
Services - Guatemala
Behavior
American Red Cross - El
Salvador, Guatemala,
Honduras, Nicaragua
Both
Bio-Sand Filters - Nicaragua
Technology
USAID PROSALUD - El
Salvador
USAID - Dominican Republic
Both
Both
FEMSA - Mexico
Technology
FEMSA - Nicaragua
Technology
Water for People - Honduras
Both
Water for People Guatemala
Both
El Porvenir - Nicaragua
Both
Project Hearts - Dominican
Republic
Both
Measurable Outcome Reported
Reduced % of households with
contaminated water by a risk
difference (RD) of -19%
12% more households self reported
treating water than control
households (risk difference)
No difference in access to improved
sanitation facility; Found 15%
decrease in use & maintenance of
latrines
24/234 BSFs still in use (10% rate of
sustained use)
40% reduction of childhood diarrhea
under 5 years old
33% water systems still functioning
160 individuals "benefited with access
to quality water"
60 families gained access to improved
sanitation
97% households have access to
sanitation facility
61% people over five years old use
sanitation facility
540 people have adequate sanitation
resources
% reduction in monthly income spent
on potable water
Frameworks Used for Comparative Analysis
The two frameworks chosen for analyzing WASH Interventions are USAID’s
WASH Plus Improvement Framework (WIF) and WaterAid’s WASH Sustainability
Framework (WSF). Both frameworks focus on the sustainability of interventions and
although there is overlapping information between them, thee frameworks were created
by organizations with highly varying capacities and different strategies for intervention.
12
Each framework is composed of three dominant fields that are sub-divided by individual
categories which are explained in detail in the following sections. The frameworks were
not chosen purely for analysis, but also to identify and evaluate the potential for their
application in designing other interventions and measuring performance.
USAID – WASHplus Improvement Framework (WIF)
The WASHplus Improvement Framework (WIF) was created to support a project
that started in 2010 and finished mid-2016. The primary goal of the WASHplus project
was, “creating and delivering interventions that lead to significant improvements in
access, practices, and health outcomes related to water supply, sanitation, and hygiene
(WASH) and household air pollution” (USAID, 2014). All interventions performed
during the WASHplus project used evidence-based approaches aiming to reduce rates of
diarrhea and respiratory infections, particularly in children. The organization also placed
a priority on “promoting and exploring innovation” in WASH strategies and technologies
(USAID, 2014). The WASHplus model was designed to integrate into existing
HIV/AIDS prevention programs, as well as those addressing neglected tropical diseases,
nutrition, and related education. Partnerships for the project included large scale
international organizations such as CARE and Winrock International as well as a large
network of on-the-ground NGOs, universities, and private sector agents (USAID, 2014).
WASHplus focused its efforts on six countries: Bangladesh, Benin, Burkina Faso,
Mali, Nepal, and Zambia. This geographic restriction provided the opportunity to assess
the applicability of a framework created for the eastern hemisphere in Central America
and the Caribbean. The WASHplus framework is structured on three dominant fields that
13
are related to, “improvement for reduced diarrhea and improved health.” (USAID, 2014).
The three fields are:
“Access to Hardware and Services”: involving the direct provision of technologies and
behavior change aspects connected to water supply, sanitation systems, and handwashing
stations. This component is the direct service component of the intervention; it does not
include training, education, monitoring, or external support system. For this study, I have
collapsed one category, “Fecal Sludge Management” into another, “Sanitation Systems”
to avoid redundant scoring. Likewise, “Soap, containers, water treatment, and other
consumables for household water treatment, menstrual hygiene management, and anal
cleansing” was changed to exclude “water treatment.”
“Promotions”: catalyzing the acceptance and continued use of the intervention by the
beneficiaries. Education and training are critical for success of this component, but
promotions also involves household outreach, various types of media use including social
media and radio, Community Led Total Sanitation (CLTS), and School Led Total
Sanitation (SLTS). For this study, I merged collapsed “Social Marketing” into “Mass
Media” to avoid redundant scoring. I also changed SLTS to “School Involved” due to the
limited implementation of the SLTS strategy in Central America and the Caribbean.
Likewise, CLTS was excluded from the study because it is also not implemented widely
in the study region and essentially the same data is encompassed in another category,
“Community Participation.”
14
“Enabling Environment”: implementing strategies that allow the beneficiaries to fully
support the intervention to ensure positive outcomes and longevity. These strategies
include a supportive policy and tariff structure, institutional strengthening, capacity
building, and partnerships. Figure 2 displays the WIF in its entirety.
FIGURE 2: USAID's WASHplus Improvement Framework (WIF)
I chose the WIF because it was created by a governmental aid organization — the
United States Agency for International Development (USAID). USAID operates on a
$27.2 billion USD annual budget and performs large scale global interventions to support
15
“Global Health, Education, and Economic Growth & Trade” (USAID, 2015). Since
USAID is a U.S. government agency, using this framework for analyzing interventions
will be valuable to determine if extensive resources and a “two-fold purpose of furthering
America’s interests while improving lives in the developing world” yields an effective
measure of intervention performance (USAID, 2015). Although the other framework
used in this study was produced by an organization with extensive resources available, it
differs from USAID because it is an international charity and does not nearly have the
reach of a governmental organization – providing ideal conditions for comparison.
WaterAid – Wash Sustainability Framework (WSF)
WaterAid was established in 1981 and by 1986 the organization had programs in
Ethiopia, Tanzania, Nepal, and India (WaterAid, 2017). Starting with basic WASH
interventions, the organization has evolved and is now involved in local and international
advocacy and policy change based on “WASH’s vital role in reducing poverty”
(WaterAid, 2017). The WaterAid model mandates hygiene education with every
intervention because the organization believes that interventions are ineffective in its
absence (WaterAid, 2017). As a charity, WaterAid depends on funding from both public
and private sectors. Increasingly larger scale donors (including USAID) have enabled the
organization to expand its capacity greatly. For example, in 2003 the United Kingdom
Department for International Development gave WaterAid £15.5 million for its
Bangladesh project (WaterAid, 2017). Although these large allocations enhance the
potential capability and scale of interventions, it also makes WaterAid subject to the
16
United Kingdom Department for International Development’s oversight throughout the
use of the funding.
WaterAid works in thirty-two developing countries across the Central America,
South America, Asia & Pacific Islands, and East, West, & South Africa. The programs
are solely focused on WASH; however, WaterAid also incorporates issues the
organization considers connected to WASH such as time poverty (meaning that women
devote significant hours to collecting water, and thus have less time to spend on other
things like education), menstrual health, violence, social exclusion, and urbanization
(WaterAid, 2017). The framework is structured around three dominant fields. The outer
fields “Design and Implementation” and “External Support” are key elements that flank
the central field, “Community based, externally supported Operation & Maintenance
(O&M) system in place” — which supports the entire intervention (Carter, Casey, &
Harvey, 2011). One section outside of the three fields precedes the intervention itself:
“Establish need, demand and service level” (WaterAid, 2017). For this study, due the
difficulty of obtaining data on “relevant service levels” I consider need, demand, and
relevant service level as established prior to implementation and did not use this category
for scoring.
“Design and Implementation”: crafting a plan that covers aspects that could limit
effectiveness of interventions. These aspects appear in the initiation phase of the project
and include full beneficiary participation, capital contribution by beneficiary,
environmental aspects addressed, and a monitoring system in place (Carter et al., 2011).
For this study, I issue requirements for one category, “High Quality Implementation” for
17
which if the intervention meets at least one, it receives a positive score. These
requirements are derived from the WaterAid Framework definition document that
explains criteria for each category (Carter et al., 2011). The intervention meets “high
quality” by scaling-up from previous interventions, having systems in place to correct for
malfunctioned or broken technologies, or using enduring materials that can be sourced
and constructed locally (Carter et al., 2011, pp. 13-19).
“Community based, externally supported O&M system in place”: creating systems
that ensure the required operations and maintenance of the technologies and behavior
changes occur post-intervention. According to the framework, a sustainable O&M system
has its water use committee still functioning, maintenance tasks undertaken, strong links
between beneficiary and support systems, and environmental monitoring (Carter et al.,
2011).
“External Support”: the intervening organization continuing dialogue and actions with
the beneficiary after the intervention takes place. According to WaterAid, key aspects of
external support are technical assistance to beneficiaries and committees (if established),
recurrent cost sharing, and support to supply chains and service providers (Carter et al.,
2011). Figure 3 displays the WSF in its entirety.
18
FIGURE 3: WaterAid's WASH Sustainability Framework
The primary reason I use the WSF is because it is highly detailed in defining each
section, therefore it provides the ability to assess if rigidity is a limiting factor in
determining if a framework is proficient at measuring intervention performance. I also
chose the WSF because it was created by an international NGO that is widely mentioned
in WASH literature and current publications This provides an ideal opportunity to
compare a framework created by an NGO against a governmental organization’s
framework and find out which is a stronger theoretical framework for WASH
interventions in Central America and the Caribbean.
19
Analysis
Once the data from each case study is in the two frameworks, the interventions
are scored in terms of five different scoring groups. The scoring groups and the criteria
for earning high scores are explained in Table 3.
TABLE 3: Criteria for scoring high in each scoring group
Scoring Group
Criteria for High Score
Highest scoring interventions
achieved outcomes with highest
Achieved Outcomes
rates of success
Highest scoring interventions are
assessed as reporting outcomes
Most Effective Measurable Outcome
that are both measurable and
comparable
Highest scoring interventions have
Highest WASHplus (WIF) Score
the most positive entries in the
WIF.
Highest scoring interventions have
Highest WaterAid (WSF) Score
the most positive entries in the
WSF.
Highest Scoring interventions have
Highest Combined Framework Score the most positive entries in both
frameworks combined.
The four highest scores in each scoring group are then compared in terms of
commonalities that emerge from analyzing the two frameworks. The common
characteristics will emerge as categories or themes that are shared amongst the highest
scoring interventions. After the highest scoring interventions for each scoring group are
identified, they are also analyzed in terms of associations. For an association to exist, the
following criteria is met:
20
1) The four interventions with the most entries in the given field are represented by
at least one of the five scoring groups
OR
2) The four overall highest scoring interventions (USAID – Dominican Republic,
Water for People – Honduras, Water for People – Guatemala, El Porvenir Nicaragua) are represented with the highest number of entries in that field.
The results of the “Scores” and “Associations” analyses are the main data sources for
identifying the most sustainable strategies, which provides the opportunity to assess if
these frameworks are useful for designing future interventions and measuring
performance. The categories and themes of WASH strategies that emerge as the most
sustainable are also supported by field notes taken during participant observation.
Merging these categories results in a recommended framework that adds to the theoretical
WASH knowledge base.
Findings
In the next few pages, I explain the findings from the analysis of twelve
interventions under two WASH sustainability frameworks. The categories for the final
recommended framework are composed of these results because they point to the most
sustainable intervention strategies. In the “Standards” section, I explain the categories
that are incorporated by at least 75% of the entire group of interventions. Since these
categories are so prolific, they are considered “Standard” practice for WASH intervention
and are not discussed in detail beyond this section.
21
In the second section, “Commonalities Amongst High Scores,” I discuss the
findings from analyzing the common characteristics of interventions with high scores in
each of the five scoring groups. Finally, I conclude the “Findings” section with the results
of the “Associations” analysis.
Standards
The following categories are incorporated by nearly all interventions and are
therefore considered standards for sustainable WASH interventions – which means they
are placed on the recommended framework in some form. To be considered standard, at
least 83.3% of the interventions must be incorporated.
The first categories to be considered standard are “Full user participation” from
WASHplus and “Community participation” by WaterAid. They are incorporated by 88%
of the entire group and represent the same strategy – including beneficiary input in the
intervention. With this high percentage, it is safe to assume that community buy-in is
crucial for the sustainability of WASH interventions.
The next category that is considered standard is the “Training” category found in
the WASHplus framework. It is safe to assume that there is some element of training
necessary for all interventions, which is reflected in 96% of intervention incorporating
training (the remaining 4% is due to a report of “insufficient training”) (Vanderzwaag,
2009).
The final category that is considered standard is WaterAid’s “Established need,
demand, and relevant service level.” Although establishing need, demand, and service
22
level is vital, for this study I have assumed that each organization made this step before
intervening in the communities. There is strong evidence that all interventions included in
this study established need, demand and relevant service level, however two
interventions, “Caritas & Catholic Relief Services – Guatemala” and “USAID
PROSALUD – El Salvador” do not provide a concrete explanation of a need or demand
recognized prior to intervention. Due to this constraint, I am unable to score this category
with validity and therefore chose to consider “Established need, demand, and relevant
service level” as a standard approach in the WASH sector.
Commonalities Amongst High Scores
Each table displays the percentage of highest scoring interventions that
incorporate the category in each of the five scoring groups as well as the score for the
entire group of twelve interventions. The tables below are explanations of each finding as
well as supportive participant observation when available.
TABLE 4: Combined Interventions
Scoring Group
Combined Intervention (Technology,
Behavior Change, Community Development)
Achieved Outcomes
75.0%
Most Effective Measured Outcome
75.0%
WASHplus Framework High Score
100.0%
WaterAid Framework High Score
100.0%
Overall Framework High Score
100.0%
Entire Group
50.0%
23
A dominant theme that emerges from the data is that the highest scoring
interventions implemented a combination of providing technology, inciting behavior
change (training and education), and community development in the intervention
approach. Community development is defined by starting or supporting WUCs,
collaboration with government entities, creating networks, or other cross-sectoral
coordination. There were three associations with high scores and implementing the
combination of technology, inciting behavior change, and community development:
1. WASHplus framework high score
2. WaterAid framework high scores
3. Combined framework high scores
TABLE 5. Results – Capacity Building
Scoring Group
Achieved Outcomes
Capacity
Building
Most Effective Measured Outcome
100.0%
100.0%
WASHplus Framework High Score
100.0%
WaterAid Framework High Score
100.0%
Overall Framework High Score
100.0%
Entire Group
66.7%
Capacity building is a key factor for effective interventions; all highest scoring
interventions incorporate capacity building in some form, compared to 66.7% of the
entire group of interventions. For these interventions, capacity building takes the form of
establishing WUCs, creating training and promotions programs, as well as involving
local and national governments in WASH activities. For Project Hearts, the organization I
worked with in the Dominican Republic, the WASH Days program depends on
24
incorporating and expanding another program, the Community Health Leader program.
Since most of the communities are small, the Community Health Leaders are well known
women who are known as a resource for basic health and first aid knowledge and are
frequently used resources for basic health and first aid. Most of the participants in the
WASH Days program attribute their participation in the program to Community Health
Leaders who encourage them to participate (Burgess, 2015). Without the capacity
building aspect of the WASH Days program, the program scope is severely limited.
TABLE 6. Results – Technology chosen by user
Scoring Group
Technology Chosen by User
Achieved Outcomes
Most Effective Measured Outcome
25.0%
25.0%
WASHplus Framework High Score
50.0%
WaterAid Framework High Score
83.0%
Overall Framework High Score
50.0%
Entire Group
29.0%
In three out of five of the scoring criteria, the highest scoring interventions do not
incorporate a “technology chosen by user.” This result is counterintuitive, as user
participation being a key factor (see “Standards” section above) implies that increased
beneficiary decision-power leads to a more sustainable intervention. Also, the fact that
WaterAid includes “Technology fit for purpose & chosen by user” in the framework
implies that beneficiary choosing power is important for the sustainability of
interventions. However, the analysis of these twelve interventions through these two
frameworks yields the opposite effect, as seen in Table 6, most of the highest scoring
interventions do not supply technologies that are chosen by the beneficiary. This does not
25
mean that the beneficiaries were not involved in deciding the direction of the
intervention, but it does mean that there is some influence that comes from the
intervening organization regarding which specific technology is most appropriate.
TABLE 7. Results – Environmental Aspects
Scoring Group
Achieved Outcomes
Environmental Aspects Addressed
Properly
Most Effective Measured Outcome
100.0%
75.0%
WASHplus Framework High Score
75.0%
WaterAid Framework High Score
100.0%
Overall Framework High Score
100.0%
Entire Group
66.7%
Addressing environmental aspects properly was a factor for all scoring criteria.
Although only 67% of the interventions in this study address environmental aspects
properly, it is addressed by most of the highest scoring interventions. WaterAid defines
“properly addressed” as focusing on both the security of the water source and enhancing
the concept of sanitation for the beneficiary (Carter et al., 2011). In rural Nicaragua,
working with El Porvenir, I saw in the evaluation results that WASH education based on
watersheds and promoting the separation of washing locations, drinking water collection,
and sanitation was highly effective (Burgess, 2015). Households that we visited were
often eager to show us their reforestation projects, promoted by El Porvenir for water
retention on the rural landscape that has mostly been turned to farm and pastureland with
little concern for the environment.
26
TABLE 8. Results – Both Water & Sanitation
Scoring Group
Incorporated Both Water & Sanitation
Technology
Achieved Outcomes
Most Effective Measured Outcome
50.0%
100.0%
WASHplus Framework High Score
75.0%
WaterAid Framework High Score
100.0%
Overall Framework High Score
100.0%
Entire Group
50.0%
Incorporating sanitation technology with water supply technology leads to more
sustainable interventions than either one independently. Coupling the two seems to
strengthen the beneficiary’s investment into the intervention in my experience, especially
in rural Nicaragua where water supply, sanitation, and the health of the watershed are
tightly intertwined. Most households that are without latrines get their drinking water and
do their washing (personal, dishes, clothing) in the same place while defecating in the
open – creating many vectors for transmitting water borne diseases. The low (50%) rate
of including both sanitation and potable water technologies in the entire study group of
interventions shows that this approach is still novel – and the tendency to focus on one
aspect of WASH may be a symptom of the common “quick-fix” approach.
TABLE 9. Results – Water Use Committees (WUCs)
Scoring Group
Achieved Outcomes
Created or Supported Water Use Committees
(WUCs)
Most Effective Measured Outcome
50.0%
100.0%
WASHplus Framework High Score
100.0%
WaterAid Framework High Score
100.0%
Overall Framework High Score
100.0%
Entire Group
50.0%
27
Although not a specific category on either framework, “Creating or Supporting
Water Use Committees (WUCs)” emerges as a critical component of a sustainable
intervention. As seen in Table 9 only two of the highest scoring interventions did not
create or support WUCs, leaving the remaining four scores with 100% coverage of this
parameter. The low (50%) rate of including both sanitation and potable water
technologies in the entire study group of interventions shows that this approach is still
novel – acting outside of the direct service of the intervention may be considered beyond
scope for some organizations.
TABLE 10. Results – Capital Contribution
Scoring Group
Capital Contribution from Beneficiary (in kind or fee)
Achieved Outcomes
Most Effective Measured Outcome
75.0%
100.0%
WASHplus Framework High Score
100.0%
WaterAid Framework High Score
100.0%
Overall Framework High Score
100.0%
Entire Group
66.7%
Capital contribution from the beneficiary is an important component to a
sustainable intervention. WaterAid’s definition of capital contribution includes in-kind
(materials or labor) or fee-based contributions. Fee-based contributions can be a singular
payment for a technology or an ongoing payment for a service (Carter et al, 2011).
Research shows that beneficiaries are more invested and likely to care for the
technologies if they contribute, which leads to further longevity and sustainability of the
intervention (Carter, Casey, & Harvey, 2011). Before launching the WASH Days
program in the Dominican Republic, the organization Project Hearts received free water
28
filters that were donated by another organization and indiscriminately gave them out to
families in need. During the baseline WASH assessment for the community, we found
that a fraction of these filters were still in use, which was the reason for instituting a
finance system for the beneficiaries (Machado, 2015). There had been no system to keep
track of the filters or for training the beneficiary on maintenance and proper use. If the
system is set up correctly, all the money collected from beneficiaries goes directly back
into the program, and the amounts collected are usually less than the cost of the
technology itself (Carter et al., 2011).
TABLE 11. Results – Monitoring System
Scoring Group
Monitoring System in Place
Achieved Outcomes
Most Effective Measured Outcome
75.0%
75.0%
WASHplus Framework High Score
87.5%
WaterAid Framework High Score
83.0%
Overall Framework High Score
87.5%
Entire Group
54.0%
Monitoring systems prove to play a critical role in the sustainability of
interventions. The importance of monitoring and evaluation is increasingly recognized in
the WASH sector, but can only be part of interventions in which the organization plans to
be available for extended amounts of time after implementation (Sobsey, Stauber,
Casanova, Brown, & Elliott, 2008; Ogunyoku, Nover, McKenzie, Joshi, & Fleenor,
2011). Commitments to ongoing consultation and dialogue between intervening
organization and beneficiary are sparse in the interventions analyzed in this study which
is reflected in the low score for “Monitoring System in Place” for the entire group – 54%.
29
TABLE 12. Results – Support System for Local Management
Scoring Group
Support System for Local Management (postintervention)
Achieved Outcomes
Most Effective Measured Outcome
75.0%
75.0%
WASHplus Framework High Score
100.0%
WaterAid Framework High Score
100.0%
Overall Framework High Score
100.0%
Entire Group
62.5%
Creating “Support systems for local management post-intervention” is a key
strategy for ensuring the sustainability of interventions. According to the WaterAid
framework, support can be “light”, however there needs to be a resource in the event that
local management experiences challenges in “skills and knowledge, material resources,
relationships and trust, and power.” (Carter et al., 2009, pp. 19-20). In the entire study
group, only 62.5% of interventions have support systems for local management in place.
Like establishing “monitoring systems” and “creating or supporting WUCs”, the category
of “Support systems for local management post-intervention” requires an organization to
commit to an ongoing relationship with the community.
TABLE 12. Results – Cross-Sectoral Coordination
Scoring Group
Cross-Sectoral Coordination
Achieved Outcomes
Most Effective Measured Outcome
50.0%
75.0%
WASHplus Framework High Score
75.0%
WaterAid Framework High Score
66.7%
Overall Framework High Score
75.0%
Entire Group
33.3%
30
The implementation of “Cross-Sectoral Coordination,” meaning the organization
breaches the boundary of working solely in the WASH sector, is rare in this study as seen
in the 33.3% rate of incorporation. However, the highest scoring interventions
incorporate cross-sectoral coordination at an average rate of 68.3%. Although the ability
to involve multiple sectors could be partly indicative of a larger-scale organization with a
higher investment ability, the highest scoring interventions in this study are from highly
varying scales of investment and capacity is not an influential factor for success of
interventions in this analysis.
Involving schools is an efficient and effective way to build the community’s
capacity for WASH infrastructure and knowledge sharing. For the WASHplus category,
the highest scoring interventions all involve local schools in the program As mentioned in
the “Study Design” section, I altered the category from School-led Total Sanitation
(SLTS) to “School Involved”, as the SLTS category limited the scope of involvement to
an entire movement, which is not currently implemented in Central America and the
Caribbean widely enough to assess accurately (Adhikari & Shrestha, 2008). In rural
Nicaragua, El Porvenir uses schools as community water points due to their centralized
locations, schools are not owned by a single family in the community, schools can be
accessed by everyone in the community, schools are generally respected as a safe zone,
and signage with directions for use and hygiene education are more available and
protected by the school’s structures and mutual respect for the space amongst community
members.
31
The category, “Support to Supply Chains” is important as evident in the high
number of entries in the “WASHplus Framework High Scores” scoring group. Only 38%
of the entire group of interventions in this study provide support to supply chains, which
is repeatedly identified in WASH literature as crucial for sustainability of interventions
(Sobsey et al., 2008).
Associations
As explained in the “Study Design” section, for an association to exist between a
given framework-field and high scores in one of the five scoring groups, the association
must fit one of two criteria:
1) The four interventions with the most entries in the given field are represented by
at least one of the five scoring groups
OR
2) The four overall highest scoring interventions (USAID – Dominican Republic,
Water for People – Honduras, Water for People – Guatemala, El Porvenir Nicaragua) are represented with the highest number of entries in that field.
An association exists between high scores in the WASHplus framework and the
interventions with the highest number of entries in the “Promotions” field – meaning that
promotions is a key element to the sustainability of interventions. All the interventions
with the most entries under the “Promotions” field are represented in the WASHplus
framework high scores (the highest overall framework score represents 67% of the
highest “Promotions” scores and the remaining scoring categories represent 33%). In my
32
experience in Nicaragua working with El Porvenir, it was surprising to see how effective
promotions can be for WASH interventions. Every week El Porvenir hosts an hour-long
radio show that promotes not only El Porvenir’s current activities but also includes
WASH education and training delivered in an entertaining way. Upon performing the
program evaluation for El Porvenir, I found that radio is the primary form of media
entertainment in the rural communities and that the show is listened to regularly and is
highly esteemed in most communities (Burgess, 2015). Even more interesting, the data
shows a higher frequency of beneficiaries sanitizing latrines and washing stations
properly when the beneficiary listens to the show on a regular basis. (Burgess, 2015).
An association exists between high scores in the WASHplus framework and the
number of entries in the “Enabling Environment” field – meaning that creating a
supportive environment for the intervention to function is a key element to the
sustainability of interventions. All the interventions with the most entries under the
“Enabling Environment” field are represented in the WASHplus framework high scores.
The “Outcomes Achieved” score only represents 25% of “Enabling Environment” scores,
however the most “Effective Measurable Outcome” and the WaterAid framework high
score represent 50% while the highest overall framework score represents 75%.
“Enabling Environment” means many things, but the core function is an enduring
relationship and ongoing dialogue between intervening organization and community. In
my experience in both the Dominican Republic and Nicaragua, one crucial component of
creating an enduring relationship with the community is having a central office that is
open for consultation with community members. For crisis situations, supply chain
33
issues, or general guidance on WASH related inquiries, the central office plays a crucial
role in enabling the community to develop sustainably.
An association between establishing a “Community-based, externally supported
Operation & Maintenance (O&M) system” and all four highest scoring interventions
(USAID – Dominican Republic, Water for People - Honduras, Water for People Guatemala and El Porvenir – Nicaragua) – meaning O&M systems are key elements to
sustainable interventions. In addition, both the “Highest WIF Framework” and the
“Highest WSF Framework” as well as the “Highest Combined Framework” scores meet
the criteria for the category. The association indicates that the Community-based,
externally supported O&M system is important for the sustainability of interventions as
supported by WASH literature (Ogunyoku et al., 2011; Sobsey et al., 2008). As found
repeatedly throughout this analysis, incorporating a “Community-based, externally
supported O&M system” is another example of a strategy that requires an organization to
commit to post-intervention involvement.
Discussion & Recommendations
First I discuss the dominant themes that emerged throughout the analysis. Then, I
discuss the functionality and dynamics of using the two frameworks to evaluate WASH
interventions broken down into advantages and limitations of each. Expanding on the
limitations of the frameworks, I then explain the current limitations to collecting and
analyzing WASH intervention data. To address the limitations and to act on the results of
this study, I conclude the section with a recommended framework for sustainably
approaching WASH interventions in Central America & the Caribbean.
34
Dominant Themes
Two main themes emerge from the analysis. The first theme is the highest scoring
interventions tend to take a holistic approach – employing strategies that expand on the
direct WASH service to address things that may affect the sustainability of interventions.
The other main theme that emerges is external involvement – creating systems that
enable organizational support post-intervention. Both themes represent interventions that
move outside of direct service and cultivate aspects that support WASH in a wider sense.
Holistic Approach
The highest scoring interventions in each scoring group tended to implement
strategies that incorporate more than the intervention itself; these strategies expand on the
direct service of the intervention to enhance other related factors. For example, all highest
scoring interventions implemented a combination of technology, behavior, and
community development, as well as incorporated both water and sanitation technology.
This means that for the intervention to be high scoring, it must focus on more than simply
providing a technology or conducting behavior change education. It also means that each
independent technology is more effective in an intervention if it is provided alongside the
other technology. For an intervention to provide leverage and catalyze further community
development, it needs to transcend providing either a service or a technology and rather
provide a functioning system.
Interventions that use a holistic approach consistently appear in the categories of
“Creating or Supporting WUCs” and “Capacity Building.” Constructing institutions and
encouraging partnerships that support WASH activities leads to more sustainable
35
interventions in this study group, and this is reflected in my experience as well. The
WASH Days program in the Dominican Republic would not exist without the partnership
of at least four other organizations. Partnerships can expand to “Cross-Sectoral
Coordination” which is not prevalent in this study group, although most of the highest
scoring interventions coordinate with entities beyond the WASH field.
Other holistic approaches represented by the highest scoring interventions in the
analysis include “Addressing Environmental Aspects Properly” and “Involving Schools.”
The holistic approaches discussed in this section are like the next theme, external
involvement, which also emerges as a theme representing action beyond direct service
from the intervening organization.
External Involvement
Like the holistic approaches theme, the other dominant theme involves
interventions that incorporate more than direct service – they incorporate aspects that
keep the intervening organization involved after implementation. For example, the entire
field, “Enabling Environment” in the WASHplus framework proves to be associated with
high scores. An “Enabling Environment” consists of the following categories: Supportive
Policy, Tariffs, Regulations; Institutional Strengthening; Capacity Building; Coordinated
Planning/Budgeting; Financing/Cost Recovery; and Cross-Sectoral Coordination.
Aside from the WASHplus framework, categories that rely on external
involvement that emerge from the WaterAid framework include “Support to Supply
Chains” and “Support Systems for Local Management.” These aspects ensure that the
intervention’s effects will continue after implementation with some degree of
36
involvement from the intervening organization. The framework definition states that
external support can be “light” and still effective (WaterAid, 2017). It is also important to
have a “Monitoring System in Place” that the organization can refer to ensure correct,
continuous, and consistent use of the technology or behavior change after initial
implementation. The monitoring data can be used to secure future funding or to redirect
efforts that are not producing desired effects.
As seen in the WASHplus framework, one entire field in the WaterAid
framework was found to be associated to high scoring interventions – “CommunityBased, Externally Supported O&M System in Place.” Although this category may
encompass aspects like supply chains and support systems for local management, it
stands alone because O&M is crucial for transcending direct service. Without a system
for troubleshooting that is supported by the intervening organization, the beneficiary
community is left to themselves to handle any externality without a knowledge base.
The final result that highlights the External Involvement theme is counterintuitive. From the outside, it would make sense that an intervention would be more
effective if the “Technology was Chosen by User.” However, this study showed the
opposite effect. The highest scoring interventions did not mention allowing the
beneficiaries to choose the technologies. This result points to the notion that some level
of expertise is necessary to effectively guide WASH development – which further
emphasizes the demand for effective WASH sustainability frameworks.
37
Functionality & Dynamics of Frameworks – WASHplus Improvement Framework
Advantages
The uncomplicated design of the WASHplus framework makes it intuitive;
program initiation and implementation stages are clearly delineated as the fields “Access
to Hardware & Services” and “Promotions.” These stages are kept separate from the
program execution stage where an “Enabling Environment” is conceptually created by
the intervening organization. This workflow is widely used in Project Management and is
applicable to conceptualizing global WASH programs (Cooke & Tate, 2010). Although
simple in design, WASHplus is non-linear. This is advantageous because it does not
depict an end to the intervention; rather, it depicts an ongoing relationship between
organization and beneficiary.
The WASHplus framework is progressive because it incorporates Menstrual
Hygiene Management (MHM), which is relatively novel in the WASH field. Gender
issues are not often recognized in WASH interventions and since women in Central
America & the Caribbean are largely responsible for WASH activities, the concept of
“gender mainstreaming” is crucial for sustainable interventions (Water and Sanitation
Programme, 2010). Gender mainstreaming is defined by the World Bank’s Water and
Sanitation Program as, “the process of assessing the implications for women and men of
any planned action, including legislation, policies or programs, in all areas and at all
levels.” (Water and Sanitation Programme, 2010). Although MHM is not grouped
optimally within the framework (see below), its presence shows that the thinkers at
USAID incorporate progressive strategies.
38
Another progressive strategy within the framework (although also not presented
optimally) that is not often considered is school involvement in the intervention. In rural
communities, schools often serve doubly as community centers and can provide a neutral
access point for community water interventions (Burgess, 2015). Since schools are not
owned by any individual family, no power dynamics are created when using schools as
water access points. El Porvenir in Nicaragua uses this strategy when prospecting for
locations for rural community wells, and they are even able to post education materials
about water treatment at the well, as seen in Figure 4.
FIGURE 4: Space for educational material at well-site at a local school in Camoapa, Nicaragua
39
However, the way in which USAID presented school involvement in the framework is
limiting for evaluating WASH interventions.
Limitations
As mentioned in the “Study Design” section, there are redundant categories in the
WASHplus framework that were collapsed into other categories. The framework
represents interventions in Central America & the Caribbean more effectively with these
edits. The limiting categories and the changes are listed below in Table 14.
TABLE 14: Limiting Categories & Proposed Changes
Limiting Category
Change to Framework
1. Water Treatment Removed
"Soap, Containers, Water Treatment,
(collapsed to "Water Supply")
Consumables, Menstrual Hygiene
2. Menstrual hygiene management
Management, and Anal Cleansing"
becomes own category
"Fecal Sludge Management"
Collapsed to "Sanitation Systems"
"Social Marketing"
Collapsed to "Mass Media"
Collapsed to “Coordinated
"Financing/Cost Recovery"
Planning/Budgeting”
"School-Led Total Sanitation (SLTS)"
Changed to "School Involvement"
Reiterated above, MHM is so rare in interventions in Central America & the
Caribbean that I recommend that it should be its own category. Isolating and highlighting
40
MHM could catalyze more action in this area, which has been shown to strengthen
attendance in schools as it can be a culturally sensitive issue (Sommer & Sahin, 2013).
WASHplus includes the category “School-led Total Sanitation (SLTS).” SLTS is
a model with proven success in Nepal that focuses sanitation efforts at the school level
with the goal of proper WASH habits permeating into their communities (Adhikari &
Shrestha, 2008). The model has also been implemented in Sierra Leone & India (Institute
of Development Studies, 2011). However, SLTS has not been implemented in Central
America & the Caribbean, and the specificity of the category limits the framework by
only including activities in schools that are central to the intervention. Excluding
periphery activities like WASH curricula or school events from the framework does not
lead to an accurate portrayal of WASH in schools in Central America & the Caribbean.
Instead, I recommend the category title, “School Involvement” which encompasses a
holistic approach to interventions that still includes schools as a pivotal institution that
can lead to a more sustainable intervention.
Finally, the WASHplus framework does not have an accompanying definitiondocument. A supporting document that explicitly defines the parameters of each category
would have greatly enhanced the usability of the framework. This limitation was
particularly highlighted by the fact that the WaterAid framework has a definitiondocument as described.
41
Functionality & Dynamics of Frameworks – WaterAid Sustainability Framework
Advantages
The WaterAid framework is structured with more priority on certain categories
which gives it a highly dynamic nature. “Community-based, externally supported O&M
system in place” is the center of the framework, and is included as a category but also
given the weight of an entire field. This extra emphasis solidifies that O&M systems are
keystones for sustainable interventions. Like the WASHplus framework, the layout of the
WaterAid framework is non-linear, therefore an ongoing relationship between
intervening organization and beneficiary is displayed. Prioritizing the ongoing
relationship is prevalent in other parts of the framework as well – for example, in the
categories that call for creating systems.
WaterAid has a focus on creating systems; the framework includes a minimum of
three systems that make a sustainable intervention: 1) Monitoring system in place 2)
Community-based, externally supported O&M system in place 3) Management systems.
Since there is a current need for effective conceptual strategies for WASH, a focus on
systems is advantageous for the WaterAid framework. Creating systems also enables
intervening organizations to take a step back and let the community take more control by
operating the system, reaching the outcomes themselves. Donelle H. Meadows discusses
the connection between systems thinking and sustainability further in Thinking Systems:
A Primer.
One specific category that WaterAid includes in the framework that is
advantageous to sustainable interventions is, “Environmental aspects addressed
42
properly.” Environmental factors are intrinsically linked to sustainability, so it is vital for
sustainable development. This strengthens the framework as a model for Central America
& the Caribbean because of the drought periods that are expected to increase due to
climate change (Intergovernmental Panel on Climate Change, 2014). One of the
interventions in this study located in Hato Mayor in the Dominican Republic is an
example of ignoring environmental factors. Although the intervention was a large-scale
program implemented by USAID with a large budget, the interveners did not sufficiently
address drought when designing the community water systems and it was reported as a
“critical undersight.” (Miranda & Zelaya, 2006). The other specific category that is
advantageous for the framework is “Support to Supply Chains.” As mentioned many
times in this paper, supply chains are often a limiting factor to success of interventions
(Sobsey et al., 2008).
Finally, perhaps the greatest advantage of the WaterAid framework is the
supporting document that explains the criteria for each category exhaustively (Carter et
al., 2011). This document truly makes the framework a worthy tool.
Limitations
Although not based in redundancy like the WASHplus framework, the WaterAid
framework is also limited by the design of certain categories.
The category “Technology fit for purpose & chosen by users” should be
separated, as they reflect different things. A technology being fit for its purpose is a
scope-based concern, while the technology being chosen by the beneficiary is a concern
about the autonomy of the community. Although these aspects of the provision of
43
technologies are connected to one another and related to the sustainability of
interventions, the data can become skewed from one or the other not being part of the
intervention. Further, in this study the beneficiary choosing the technology was not
associated with high scores; rather, the effect was the opposite (see “Findings”). This is a
complicated and delicate aspect of interventions to navigate because an intervening
organization may have pre-existing interest in the provision of a certain technology due
to factors like funding sources or business opportunities. These interests are beyond the
intervention itself and they have the potential make decisions about technologies
complicated both politically and bureaucratically. In the following example that occurred
during my time at Project Hearts in the Dominican Republic, the complicated nature of
choosing technologies is shown: Catalyzed by a partnership, we were presented the
opportunity to get receive all the ceramic filters for the program subsidized on the
condition that we sourced them from a local factory. In this case, control over the choice
of technology was not based in outside profit, however, these conditions can still limit
maneuverability in an intervention. My recommendation is to eliminate the “technology
chosen by users” portion of the category altogether as it does not seem to be related to the
sustainability of an intervention. However, it is important for the beneficiary to be part of
the decision, and this is encompassed under the category “Full user participation.”
Another limiting aspect of the framework is the parameters of the field,
“Community-based, externally supported O&M system in place.” I recommend the field
be replaced with, “Creating or Supporting WUCs” because this would capture more
beneficial information than an ambiguously defined O&M system. WUCs are established
institutions that can efficiently liaison with outside organizations for guidance on all
44
aspects of the intervention, encompassing all aspects of O&M and eliminating the need
for its own category.
Finally, the “High Quality Implementation” category is too arbitrary. In this
study, I required a justification for an intervention to receive a score in this category (see
“Study Design”). I recommend discarding this category altogether to keep the framework
succinct and conceptually relevant.
Current Limitations to Collecting/Analyzing WASH Data
Throughout this study the analysis shed light on the limitations to collecting,
analyzing, and comparing WASH data. The following section explains two themes
regarding these limitations. The first section is, “Hard to Compare” followed by, “Hard to
Measure.” The section ends with an explanation of potential approaches to addressing
these limitations.
Hard to Compare
The WASH field needs a more standardized method for reporting outcomes;
currently the terminology and metrics used are not fluid and the ability to compare
outcomes is complicated. Many outcomes are ambiguous or worded in a way that makes
them impossible to compare to other organizations’ outcomes even when they are
essentially equivalent in effect. Table 15 highlights some examples from the interventions
included in this study.
45
TABLE 15: Problems with outcomes
Intervention
American Red Cross (ARC)
Post-Hurricane Mitch
USAID - Dominican Republic
FEMSA - Nicaragua
FEMSA - Mexico
Outcome
% of households with appropriate
handwashing behavior
6 promoted macrobehaviors observed
increased number of community
members trained in healthy living
increased number of trained
individuals on health & hygiene
Reason Incomparable
Terminology
Ambiguous
Examples of outcomes that are widely used in the WASH field currently include:
Increased access to improved water source
Increased access to improved sanitation
% reduction in childhood diarrhea under age 5
% reduction in monthly income spent on drinking water
Although these outcomes are reported frequently in WASH, they are often
reported with varying terminology that renders them incomparable. It is difficult to
identify trends in various regions around the world when a researcher is unable to make
assertions without validity.
Hard to Measure
Effects of interventions are difficult to measure for many reasons including
availability of rural health data, long durations needed to gather data regarding health
aspects like diarrhea (change is observed over years), and ensuring the correct, consistent
and continuous use of technology or behavior change provided. It can be difficult to
measure important attributes of WASH interventions other than in qualitative studies like
this one because of criteria like, “training”, “capacity building” or “level of support.”
46
Measuring these criteria takes considerable resources and time to ensure validity. The
inability to measure vital attributes of interventions is a steep barrier to overcome.
However, there is an approach that is used widely across many sectors that could address
the limitation as well as enhance other areas of WASH reporting.
Addressing Limitations
One way for the WASH sector to improve on both the incomparability and
difficulty of measuring program outcomes is to adopt “Shared Management Systems”
that are a main component of the “Collective Impact” approach to collaboration.
Collective impact is a “structured approach to making collaboration work across
government, business, philanthropy, non-profit organizations and citizens to achieve
significant and lasting social change” (Kania & Kramer, 2011). A key component of
collective impact is standardized metrics amongst organizations that work in the same
sector – known as “Shared Measurement Systems.” Organizations create and share
reports under the same protocols for increased availability of data, comparability, and
collaboration. In the WASH field, the Millennium Water Alliance (MWA) has
implemented collective impact by becoming a “partnership broker” for WASH
organizations in Ethiopia; they established a coalition and encouraged a standardized
approach for reporting and sharing data (Davis & Dundon, 2013). Although MWA is
active in Latin America, the collective impact model has not been implemented widely in
Central America & the Caribbean (Millenium Water Alliance, 2017).
47
To further address these limitations and to act on the results of this research, I
conclude the “Findings” section with a recommended framework for sustainably
approaching WASH interventions in Central America & the Caribbean.
Recommended Framework
The framework displayed in Figure 5 is an amalgam of the most important
categories that emerged from each framework and categories that I recommend based on
participatory experience and the current WASH literature. The categories chosen as most
important met the following criteria:
Category is incorporated by at least 83% of interventions
Category is represented by the highest scoring interventions in the five different
scoring groups (see “Findings”)
FIGURE 5: New Framework - The Evergreen WASH Sustainability Framework
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The title, “The Evergreen WASH Sustainability Framework” provides credit to the
institution where the author of this thesis performed the research. The framework follows
the stages of a modified Project Management plan, from “Design” to “Monitoring &
Support” (Cooke & Tate, 2010). Each component begins at a given stage and continues
through the following stages as the intervention progresses. The arrow for “Capital
Contribution by Beneficiary” is dotted because if the intervention is a service, there may
be an ongoing fee required. As depicted in both the WASHplus and WaterAid
frameworks, there is no endpoint shown due to the expectation of an ongoing relationship
between organization and beneficiary.
Conclusion
USAID’s WASHplus Improvement Framework and WaterAid’s WASH
Sustainability framework proved to be effective for designing and evaluating
interventions in Central America and the Caribbean but not without limitations. To shed
more light on these frameworks’ utilities, this study should be replicated for another
region with high demand for WASH improvement like Southeast Asia or Sub-Saharan
Africa (UNICEF & WHO, 2015). Further, this study could be altered to focus on
emerging sub-sectors of WASH like Community Led Total Sanitation or School Led
Total Sanitation.
The key strategies that lead to sustainable interventions in Central America and
the Caribbean are taking a holistic approach and implementing systems of strong external
support after the intervention takes place. Both strategies involve the intervening
49
organization investing more time into interventions whether the additional effort is
expanding on direct service or keeping systems functioning externally. Future research
should explore the specific systems that organizations can lightly support after
intervention that lead to the longest lasting and most effective efforts.
It is crucial to build a stronger theoretical base for the WASH sector to make the
$220 billion annual efforts justifiable and to eliminate the remaining gap between the
global north and south that leaves a huge portion of the world without basic human needs.
50
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