The Overseas Development Institute (ODI) has developed guidance on how the water and sanitation sector can analyse political economy in practice. A recent working paper applies this approach to Vietnam, working with DFID to answer the question: why is performance so poor in the rural sanitation sector in Vietnam, and why have apparently effective innovative pilot projects not been scaled up?

Firstly, the paper identifies general WASH sector incentives which constrain efforts in rural sanitation: greater demand for water services and greater opportunities for rent-seeking from water projects and associated benefits to the political and social networks of decision-makers. Responsibility for sanitation has also shifted between government agencies but with little incentive for ministries because of the lack of associated budgets or staffing.

Beyond overall resource allocation issues, there are further barriers to the adoption of innovative approaches. The approaches in question – typically based on Community-Led Total Sanitation (CLTS) or Total Sanitation and Sanitation Marketing (TSSM) – are demand-led, software-focused, low- or no-subsidy and require more involvement of the private sector and non-state actors than the government. So these may not be attractive policies for the government to adopt as national strategies given historical expectations of the government as service provider – if the state is not seen as the direct provider, is there any political benefit for the central government? This lack of support from above is not countered by sufficient demand from below (due to low public awareness of the importance of rural sanitation) to give local governments enough incentive to take risks and adopt innovative practices which differ from central government guidelines, even if official discourse supposedly ‘encourages local innovation’.

The report concludes that if the innovative approaches are to spread, certain institutional reforms are needed. To minimise the political risk for local sanitation planners, there should be a legal basis for them choosing different approaches, for example from a ‘menu of options’ of sanitation activities. They will also need the funding to do so, probably from increased budgets for recurrent expenditure on sanitation, because of the emphasis on software rather than hardware in these approaches and the difficulty of implementing innovative approaches under the project/tendering requirements of investment expenditure.

So how can donors actually influence this? The report suggests that donors need to be more rigorous at analysing the recurrent costs of the pilot projects they support in order to demonstrate how these approaches could be taken to scale with government backing, and not be prohibitively expensive. I agree with this – I am working with WaterAid in Mali on similar analyses of the rural water service approaches that they promote to other actors – but I think it raises another interesting question on recurrent costs given the earlier observation about rural sanitation being an unattractive mandate for ministries because of its low budget. Is there an increased level of recurrent staff and resource costs – for example, for supporting follow-up visits to supposedly open defecation-free communities – at which rural sanitation would actually become politically attractive to central ministries? This is similar to a point made by Nick Burn from Water for People at last week’s learning event for sustainability that perhaps at high levels of rural drinking water coverage, monitoring and support issues will become more politically important to water ministries in order to justify their ongoing role.

A final question is why donors have not fully engaged with these issues before – as I suggested in my last post, donors need to analyse themselves as well as the wider political economy. In this case, the report suggests that DFID in Vietnam had previously noted the importance of the government shifting funding allocations for rural watsan further towards recurrent financing, but that this element subsequently seemed to become “marginalised” in DFID programming. Understanding the influence of internal donor issues on their wider engagement seems an essential part of such political economy analysis.

This work on political economy analysis highlights the benefits of clearly specifying the assumptions and theories of change behind a development programme. Chris Blattman argues that the first thing many development programme evaluations do is point out that the original assumptions and theories underlying the intervention may not have been thought through as well as they should have been. The Vietnam example described here shows how critical analysis of why a hoped-for change has not in fact happened can help adjust subsequent theories of change and suggest different approaches for donors.

Analyse local and national politics

Analyse donor politics

Think about scale

Talk about subsidy

Analyse local and national politics – Girish Menon, International Operations Director of WaterAid, characterised the current lack of sustainable services in the sector as a failure of governance. This is not in itself new, but there seems to be a growing move in the WASH sector to more explicitly analyse political economy issues – I’ll write more on this soon. For the moment there were some interesting examples considering political incentives that came up in the discussions, such as Nick Burn from Water For People suggesting the hypothesis that as countries do increase their coverage statistics (towards the ‘danger zone’), water ministries may be more keen to start addressing longer-term support issues in addition to new investment in order to justify a continuing role for themselves.

Analyse donor politics – But as well as analysing the rest of the country context, donors and NGOs need to take a look at themselves. Commonly-known internal constraints to supporting sustainable services were repeatedly mentioned throughout the day: short-term project cycles, pressures to disburse money quickly, targets based on numbers of new users rather than sustainable outcomes. At least there is some openness about this which means we can discuss more productively which donors might be able to fill which gaps. For example, at another recent Triple-S presentation to the World Bank, Sharon Murry from USAID admitted their constraints on giving direct budget support (video here). So perhaps other donors can do that while USAID works out how it can contribute towards sustainable services in other ways. The Triple-S project itself is an example of a positive move by the Gates Foundation to fund programmes which focus on building ‘learning alliances’ at country level instead of any form of infrastructure implementation. But in the absence of equivalent lump-funding for similar initiatives in other countries, we need to be creative in piecing together coalitions with similar aims but from multiple funding sources.

Think about scale – Harold Lockwood from Aguaconsult opened with the observation that the model of community management has proved impossible to scale up successfully; rather we need to focus on the direct support to community management (usually decentralised local government) and work out how to scale this up across a country. However, I argued in presenting initial findings from WaterAid in Mali that we need to consider if decentralised local governments are actually the right scale to support rural water services. Each local government may have the legal mandate for its own area, but for reasons of economy of scale (for example, having a geographic area with enough waterpoints to make a full-time technician cost-effective) we may need to explore sharing resources and staff across administrative boundaries.

Some initiatives such as this already exist in countries such as Mali and Burkina Faso. However, the examples I have seen so far are for collectives of larger villages which have small piped systems or boreholes with electric pumps and tanks rather than boreholes fitted with handpumps that are typical in smaller villages. Willingness to pay by users for services from the former systems generally seems higher than for handpumps, meaning that pooling money and risk across systems becomes more practical.

Another opportunity for sharing resources to help economies of scale is across sectors. The discussions were focused more on water services than sanitation and hygiene but the point was made that where local support staff are in place, hopefully they can follow up on long-term sanitation and hygiene issues such as whether CLTS communities are still open-defecation free after a few years or not, as well as support to water services. Alternatively, where local field staff exist for other sectors such as health, perhaps they can form part of the monitoring and support for WASH services.

Talk about subsidy – Patrick Moriarty from IRC presented a simple form for doing a back-of-the-envelope calculation on the predicted life-cycle costs of a particular service. Data from WASHCost and Triple-S shows that for a typical borehole fitted with a handpump in a rural village, this cost is in the order of magnitude (the figure obviously varies according to context) of 5 USD per person per year. Doing this simple calculation (and splitting the cost up by the categories used by WASHCost) helps open up the debate about who pays for what – and if the total costs can be covered by the “3 Ts” of tariffs (from users), taxes (from local or national government) and transfers (from international donors). This was perhaps the crucial final question – if we agree that basic access to water, sanitation and hygiene are human rights, who pays if it turns out that sustainable services are more expensive than we once thought?

• Relationship-led (i.e. using champions to mobilise change)
• Value-led (i.e. leveraging peer pressure and creating coalitions for change)
• Evidence-led (i.e. providing proof that the current approaches don’t work and proof that other ones do)

However, Triple-S and the Impact and Learning team are now reviewing progress to see if these Theories of Change need to be revised, and should be reporting back next week.

How do these thoughts compare with the Theory of Change put forward by WASHCost, Triple-S’s sister project? On the surface, their theory suggests a strong belief in the evidence-led aspect of change – the idea that better information on costs of water, sanitation and hygiene will lead to better choices:

Why a theory of change? Presently, services are in general neither reliable nor sustained, and nor are costs a major factor in decision-making around service delivery. To alter this situation, and bring costs into the equation, something has to change: the behaviour of the different sector stakeholders.

… Why should having cost information that relates to different types of service, at different stages of the service delivery cycle, lead to better service? The only answer that supports WASHCost’s theory of change is that the sector actors involved in service delivery are motivated by the desire to use resources rationally, to provide the best service level possible for a given context and a given user group.

However, the WASHCost team know that it is not as simple as that (encapsulated elsewhere in Patrick Moriarty’s comments on the use of RCTs as evidence: “It’s the (political) economy, stupid”). They go on to explain that there must be some form of decision-making arena with enough transparency where the different actors (service users or their representatives, service providers, and service financiers) can discuss the cost information and its implications i.e. a context of “good enough governance” (following Merilee Grindle’s phrase). In this environment, WASHCost hopes that the initial project research into costs will trigger certain actors to start collecting and using costs data themselves – see the diagram below. This seems to be where the Triple-S ideas of relationship-led and value-led change fit in: WASHCost and its collaborators as a catalyst for a virtuous circle of improved cost data and decision-making.

WASHCost (2010). Working Paper 1 - WASHCost's theory of change

How long might any changes take to emerge? Patrick Moriarty suggests in the video below that if everything goes very well, the Triple-S and WASHCost approach of Learning Alliances can lead to changes in the way people see their role and how they act within three years if working directly with district level actors, and perhaps five years at national sector levels. These should be taken as the minimum periods needed, if everything goes very well – change is both hard and slow.

However, there are already some positive signs of the effect that small catalysts can have in certain areas. Arjen Naafs from the WASHCost Mozambique team presented a poster at the RWSN Forum on how the collection and publication of existing cost data in contracts for borehole drilling and rehabilitation quickly provoked a debate on the differing unit costs and the use of the data in subsequent budgeting and procurement: a combination of getting evidence in the open and letting peer pressure (between different regional offices) take effect.

So we are gaining some insights into how change towards more sustainable service delivery can happen through action research coalitions. How might change happen in and from other organisations in the sector which are not directly part of these types of alliances? WaterAid is currently addressing this question through efforts to mainstream its Sustainability Framework within both the programming and the policy and advocacy work done by its country programmes. Richard Carter, head of the Technical Support Unit at WaterAid, has phrased this shift as “internal change for external influence”. In another session at the RWSN Forum, Nick Bundle, Regional Technical Advisor for WaterAid and focal point for sustainability, presented the Sustainability Framework and a conceptualisation of how this shift can develop in the organisation. The diagram below shows this as a cycle of internal marketing within WaterAid; putting the theory of the Framework into practice in the country programmes; generating knowledge where there are gaps; and using these experiences to influence others.

WaterAid (2011)

I will be helping Richard present an update on this process at an event organised by Triple-S and others on learning for sustainability next week (Tuesday 31st January in London, some spaces may still be available if you follow the link), including progress made by WaterAid and its partners in Mali in using the Sustainability Framework to analyse and address the challenges to rural service delivery. The change process within WaterAid in Mali so far has highlighted two key questions.

The first is closely related to the Triple-S Theories of Change: who is best-placed to promote change? One of WaterAid’s partner staff in Mali, Moussa Sidibé, is an excellent champion for his work in developing more sustainable approaches in the municipality of Dandougou Fakala (more details on this are in the paper that he presented at the RWSN Forum, available here, in French) and demonstrating to his peers what is possible. However, I think there is a danger of relying too much on particular inspirational individuals; we need to find a balance with collectively mobilising change as well.

The second key question is how the internal planning and reporting structures need to change to ensure that sustainability is properly considered in any decision made. As I discussed in my last post, current programming and monitoring is based on increasing the numbers of people served rather than understanding and improving the level of service people are actually accessing over time. WaterAid will soon be introducing a system of post-implementation surveys to monitor services at intervals of 1, 3, 5 and 10 years after the initial intervention, which will be an important internal shift in addressing sustainability. One of the challenges for the team in Mali is to combine this requirement with what is also needed by local actors for their own monitoring and follow-up actions, and for both these elements to support the government’s national database for waterpoint monitoring.

Despite these challenges, WaterAid in Mali is making progress on addressing sustainability within their work on rural water services. In particular, programme staff and partners have agreed a set of key issues based on the analysis so far which must be allocated particular attention and resources for activities in the next financial year – planning and budgeting for this is going on at the moment. As these internal organisational changes make progress, WaterAid will be better placed to engage externally on changes towards sustainability in the Mali rural water sector as a whole.

… the MDGs are one of the biggest competitors to the approach of sustainable services at scale … [they] have been great in mobilizing public investments for WASH… However, the focus on increasing coverage makes it also difficult to fund all the other life-cycle costs of water supplies, such as replacement of assets or post-construction support. In that sense, there is a competition brought about by the MDGs on whether to invest in coverage or dedicate funds to the sustainability of services. We would argue that both are needed, but that there are trade-offs between them. Therefore, a careful balance is needed in investing in that, a balance that even shifts over time.

In Mali, WaterAid’s programmes since 2004 have been based on an approach called the Local Millennium Development Goal Initiative (LMDGI). This was developed as a means of supporting decentralised local governments to fulfil their legal responsibilities of ensuring water and sanitation access for their populations. The focus so far has been on developing transparent local planning processes which translate the MDG targets into local goals and identify the needs in each village in the local government area. Since local governments in Mali are under-resourced, WaterAid has also begun direct local budget support to increase their staff capacity, combined with assistance in using the WASH plans they have developed as a tool to lobby other actors (the central government and other donors) for more implementation funds.

Some aspects of the LMDGI approach do promote thinking of sustainability beyond 2015. The emphasis on local governments as the key long-term presence, and other initiatives promoting increased engagement between citizens and local government, are positive steps. However there are other areas where Stef Smits’ observations on the MDGs ‘competing’ with sustainability may also apply at this local level. Firstly, the local WASH plans developed focus more on infrastructure investments than recurrent management and support costs – although encouragingly, some of the plans are clear on the need for significant capital maintenance expenditure too, an element that Triple-S identified as lacking in many policies in their country case studies. Secondly, the process of ‘marketing’ the WASH plans to raise funding from other actors has so far focused mostly on basic coordination and harmonisation between NGOs and local government for where new infrastructure is built rather than developing longer-term financing streams for ongoing services. Both these examples show the trade-offs involved in the choices made by local governments and NGOs in Mali, and suggest the potential shifts in emphasis that could be made as these plans are revised to think explicitly beyond 2015.

This leads into a wider question for the sector – what comes after the MDGs? Duncan Green discusses Claire Melamed’s general advice: don’t dive straight into a debate on targets and indicators before thinking about what the point of a post-MDGs agreement would be. In the rural water sector, I think this means we need to consider what our long-term vision looks like, and reminds me of a comment from Lant Pritchett:

I was living in India and discussing arrangements for household water supply with some development colleagues of mine. After about half an hour of pretty fruitless discussion I said, “let’s step back. tell me your long-run vision of the household water sector in India.” They said “Our vision is that India meets the target that every household lives within half a kilometer of an improved water source capable of providing 40 liters of safe water per person per day.” I said, “I see the problem. My vision of success is that every Indian can take a hot shower inside their own home.” The difference is that one can imagine meeting the first goal “programmatically” or with a series of “interventions” while the latter clearly requires endogenously functional systems. No one I know wants to have to go to a group meeting to take a hot shower. They want to turn the tap and it works.

In contrast, the vision of the Rural Water Supply Network (published last year and presented at the RWSN Forum last month) proposes that “water should be available very close to (though not necessarily in) the home”. This vision is more pragmatic than Pritchett’s, citing the previous failures of international targets to achieve even basic access for all and acknowledging that community management will still play a significant role for the foreseeable future. I would like to side with Pritchett in terms of ambition, but he perhaps underestimates the scale of the challenge. As the sector is realising – and RWSN expands on this in its full vision document – even achieving a basic level of reliable access of sufficient quality and quantity requires a service delivery approach rather than a series of projects.

So how might the sector deal with these tensions over vision and coverage vs sustainability in a possible post-MDGs agreement? The World Health Organisation has started the debate on how progress on WASH might be monitored after 2015. The report on the first stage of the consultation process recognises the benefits of a vision which goes beyond the ‘basic’ access currently defined, but does not yet indicate how far towards Pritchett’s argument this might go. The report also seems to show agreement on other key areas: the importance of monitoring equity of access to water and sanitation, the possibility of emphasising hygiene behaviour as a target, and the challenge of developing a global agreement which is somehow both ‘nationally owned’ and positively influences national governments.

This last point is one of the key questions raised by Melamed and Green: if international aid money becomes a less important part of the funding mix, what post-MDGs agreement might influence national governments to invest more in sustainable WASH services? WaterAid’s recent Off-track, off-target report on why WASH investment is poorly targeted suggests that water and sanitation-related ministries tend to be less successful than their health and education counterparts in lobbying finance ministries for funds, and do not focus on sustainable services when they do get the money. The Triple-S submission to the post-MDGs WASH consultation stressed the need for any new goals or targets – at both international and national levels – to reshift the focus from tracking coverage to monitoring sustainable service delivery, but this shift is not yet evident in the language in the first report. These concerns demonstrate the importance of the links between national and international politics for rural water services, and must be addressed as the consultation continues.

Triple-S, 2011

The diagram illustrates how a country needs to redirect its financing for rural water services as coverage (the percentage of the population with access to services) increases. When a country has very low levels of coverage (say less than 30% of the population), capital investment is a priority in order to get infrastructure up and running in the first place. However, as coverage rises above 50%, recurrent expenditure (on operation, maintenance and management support) and capital maintenance (major rehabilitations or replacement of old infrastructure) begin to dominate the effort and finance needed by the sector.

In particular, the Triple-S work has identified a ‘danger zone’ – coverage levels which risk stagnating at 60-80% when there is insufficient attention to capital maintenance and/or other recurrent costs, meaning that old systems fail at about the same rate as new ones are built. Patrick Moriarty discusses here how Uganda has reached this danger zone. Looking at the national figures for rural water coverage, Mali might not be in the danger zone quite yet – but some districts within Mali which have higher coverage than the national average probably do fall in this zone. These areas therefore represent opportunities to understand what costs might be needed at local levels to get out of the danger zone and move towards sustainable services. I’m currently working with WaterAid’s partners in five local government areas to analyse coverage, functionality and costs data, and we hope to share initial findings soon.

Adapted from Triple-S, 2011

… this is the myth that there is an inherent demand for ‘clean’ drinking water in rural areas. In my experience there isn’t. There is a demand for water – of course. There is a demand for convenient water (that you don’t have to march for miles lugging a jerry can to collect). There is demand for (no adjective added) drinking water. And for livestock water. And for irrigation water. And for business water. And much of this demand is well captured in myth no. 4 – “what rural dwellers need is 20 litres per person per day of clean water”. Which makes the point that actually people need far less than 20 litres of clean water (probably only about 5 for actual drinking and cooking) and quite a bit more for other uses.

… But … the assumption is still there that there is demand for these 5 litres of clean water. And there isn’t – at least not always. Of course, from a public health perspective people need at least five litres of clean water. But without basic education and behaviour change interventions people do not demand it.

WaterAid’s Sustainability Framework is clear that demand – and subsequent willingness by the users to pay certain costs – is the first element of the whole framework, without which everything else fails. So any intervention has to test that assumption of demand, and/or promote behaviour change to create the demand.

The challenge is that testing demand is very difficult before the actual water service is up and running. Rural water infrastructure investments typically require an initial contribution to this cost from the users as a proxy for ‘demand’, but this is not necessarily a reliable indicator of their ability and willingness to pay over the lifetime of the service.

The quote from Patrick above, and a comment from Stef Smits on one of Patrick’s previous posts about demand, also emphasise that people actually want water for a variety of uses, and what they demand (in terms of accessibility, quality, reliability etc) varies according to the use. The ‘myths’ paper summarises the implications of this:

… there is urgent need for: (i) consideration of other water requirements, such as for livestock and crops and how these needs can be better linked to requirements for clean drinking water; (ii) full consideration of household values with respect to water (particularly distance to source and reliability alongside water quality) and (iii) presentation and demonstration of real and affordable choices for household water supplies.

This implies a significant effort on the part of service providers to understand what rural water users already do for themselves, and how ongoing external support can help them build on that – luckily these were key elements of the discussion sessions at the RWSN Forum on multiple-use services, post-construction support, and self-supply. I’ll follow-up on some of these later in the week, including getting started on one of the crucial questions: if better external support is needed to promote demand, support multiple-use services and improve sustainability, how much does this support actually cost?

… you may decide that some of these are not myths at all, but are glaringly obvious. Take the example of the myth that “building water supply systems is more important than keeping them working”. Your reaction may be that this is not a myth, and that you are well aware of the importance of operation and maintenance. But then ask yourself what you are actually doing in your programmes to address this major problem. Many of us are well aware that the issues set out in this paper are myths. Nevertheless, most of us carry on as before.

This is a good reminder that while it might be organisations that sign up to Sustainability Charters, we need significant self-reflection and commitment to long-term aims as individuals too.

The ultimate myth is that there is a quick fix for rural water supplies; a simple idea, such as a new pump or a clever way to organise a village committee. We argue in order to provide a basic level of reliable service to all rural dwellers, there is no quick fix to substitute for many years of political negotiation, institution building, education, long term investment and innovation.

I hope the debates at the RWSN Forum promote useful reflections from both personal and organisational perspectives on these issues. I’ll be blogging from here and hope to contribute via the WaterAid and RWSN event blogs as well.

This is part of recent moves in aid towards “admitting failure”, and I’m going to take it as a starting point for discussing what this idea means for the WASH sector, as part of the Second Aid Blog Forum organised by Tales from the Hood.

Sustainability – of water supplies, sanitation services, and hygienic habits – is now widely acknowledged as the key challenge in the sector. We know this because of previous failures: tens of thousands of water points, toilets or handwashing practices that were abandoned after the initial intervention.

So the WASH sector has already started admitting failure to itself, even if it is often implicitly, via a more positive framing of “sustainability”. But I think we are in the early stages of admitting this to Western donors. Breslin’s video above is still a rare example of communication meant for a general audience which directly refers to these problems.

Is this because of the fear of losing funding suggested by Tales from the Hood? In other posts in this Forum, Marc Bellemare and Terence at Waylaid Dialectic disagree on whether NGOs who start admitting failure before the rest are right to be afraid – there are plausible arguments for donors responding either positively (good, you’re honest and learning, here’s more money) or negatively (so you failed, why should we give you more money?).

Which is more likely for the WASH sector? For example, does it matter that a charity evaluator such as GiveWell already takes the position of not recommending giving money to water programs, based on the criticism that few organisations in the sector can currently demonstrate the sustainability of either the basic functioning of water services or the real impacts on health? Two points are important in response to this. Firstly, GiveWell is currently reviewing its research on this topic, so it will be interesting to see how their 2012 update reflects the recent initiatives on sustainability in the sector. Secondly, it is generally agreed that measuring the health impact of any particular WASH intervention is difficult and costly – but that we know that an acceptable basic level of water, sanitation and hygiene services is an essential part of good health. For these reasons it seems unlikely that there would be a large-scale withdrawal of funds from the sector as a whole – but money may come with more demands for better monitoring of long-term services, or be reduced in unstable countries where failure is seen as more likely. This is probably the “two steps forward; one step back” scenario that IRC suggested as one possible vision for the sector in 2020.

But perhaps before we talk directly about admitting failure, we should start by “admitting tension”. As part of the WASH sustainability debate, there is a growing recognition that we need to think about services rather than projects or programs. In the long-term this means some local combination of users, the private sector, and government working together with enough money, expertise (and incentive) to keep services running indefinitely – if any particular water or sanitation infrastructure breaks or reaches the end of its life, it is repaired or upgraded and the service continues. But in the short-term much of the sector still works via time-bound projects and programs, and understandably feels the pressure for quick construction to increase the official numbers of users covered in line with national or international targets. We need to more openly admit that there is a tension between allocating resources to new construction vs (less sexy) post-construction support, and that failures can and will still occur at either end.

Are we ready for this? Tim Harford makes the point in Adapt that Western politicians or policy-makers do not often admit they got things wrong (nor that they probably will in future too). Unwillingness to admit failure is hardly unique to aid. So I think there is a key question linking issues of WASH, sustainability and aid to a higher level – how much will our discussions of failure in the development sector lead or lag the issue in wider public policy debates? If openly admitting failure becomes an accepted and encouraged practice in the aid sector, could this contribute to more constructive debates in other areas? Or will the idea of admitting failure in aid and development only become common if other public debates reach this level of self-criticism first?

The whole speech is worth reading in full, but here are some highlights and comments:

The only form of sanitation that we are really interested in is on-site sanitation, i.e., sanitation that is not connected to sewers. It is a wonderful ambition to provide entire populations with gold-standard flush toilets connected to sewer systems and wastewater treatment plants. Indeed, this still appears to be official policy in many places. But it is not the form of sanitation that serves the people we aim to serve…

That does not mean, however, that we think that poor people, who can’t afford the flush toilets that you and I use, have to be satisfied with the outhouses that we happily left behind us sometime in the last century…. Wouldn’t you rather have a toilet in your house that directly recovers the energy, nutrients, and water that we currently throw away? Wouldn’t you like a toilet that helps you recycle waste in the same way that we now recycle paper, glass, and plastic? I bet you would. So, yes, we think that the toilet should be reinvented.

Well, maybe some people would. But we know already that cultural attitudes to shit (and what to do with it) differ widely according to time and place and have a big influence on what types of toilets people use (or don’t). The ambition here is to use the technology to change people’s desires – “toilets that everyone will aspire to have”. Rijsberman makes the now-common comparison between the number of mobile phones and toilets in Africa and extends the analogy to iPads and Kindles, things we didn’t know we wanted until we saw them. It’s certainly ambitious, and I’m fascinated to see how the different grantees for the toilet-reinvention challenge try to adapt and pitch the different ideas in different contexts.

Rijsberman himself acknowledges that being “technology zealots” is not a single answer. Science and technology – aka the reinvented toilet – is only the first of the Foundation’s three sanitation initiatives. The second is delivery of programs at scale, based on Community Led Total Sanitation – what Rijsberman refers to as CLTS++. I like the organisation’s key questions:

1. What is the effectiveness and cost of the initial program that supports ending open defecation for millions of people?
2. What is the sustainability of such programs? Are communities still ODF 12 or 24 months later?
3. What is the sustainability of such programs in terms of emptying the latrines when they are full – even in rural areas?
4. What is the most effective way of combining supply-side measures, such as sanimarts, with CLTS-style demand creation?
5. What is the degree to which subsidies are necessary to reach the poorest of the poor?
6. What is the most effective way to engage to engage with, or hand over, CLTS efforts to governments?

This final question – reaching the stage of government-enabled services rather than one-off programs – is key. As I have noted before, the question of where CLTS fits into wider public health policy is a tricky one. Going by this speech, the Gates Foundation’s idea seems to be to work out how to push down the cost of CLTS as much as possible, so that it becomes possible for governments in poor countries to support rural sanitation services via this approach. It will be interesting to see how this develops given some of the other obstacles identified by CLTS proponents such as vested interests in hardware-subsidy and construction projects, and to what extent cost is a driver compared to other influences. The third aspect of the Foundation’s strategy is the policy and advocacy necessary to promote the role of governments in providing or enabling sanitation services. There are a few examples of this work in the speech, but given the Foundation’s other initiatives, it will be worth watching how they further position themselves in this arena.