Health, WSS& The Poor

Health, Water Supply, Sanitation and the Poor
Hanoi, 2008
Copyright 2008 of Vietnam Ministry of Natural Resources and Environment (MONRE) and United Nations Development Programme (UNDP) Published in Vietnamese and English with the approval of MONRE and UNDP. Publishing contract Number .. date Responsible for publishing: Asso. Prof.Dr. Truong Manh Tien Edition: Dr. Nguyen Trung Thang Dr. Michael Parsons MSc. Kim Thi Thuy Ngoc MA. Nguyen Thi Phuong Ngan Ms. Phan Th H Ms. Nguyn Th Ngc nh Ms. Hong Hng Hnh Mr. Nguyn Hong Minh Printed in Hanoi, Vietnam
Preface
Strengthening capacity for sustainable natural resource use and environmental protection to reduce poverty presents a major challenge to Viet Nam and its development partners. Environmental conditions have a significant impact on the livelihoods, health and security of poor and vulnerable groups in particular women and children and better environmental management is vital to poverty reduction, sustainable growth and attainment of Viet Nams Development Goals. The Harmonizing Poverty Reduction and Environmental Goals in Policy and Planning for Sustainable Development (2005-2009) project, better known as the Poverty and Environment Project or PEP, seeks to strengthen Government capacity to integrate environment and poverty reduction goals into national and provincial policy and planning frameworks for sustainable development. The project has four focal areas; forestry, fisheries, renewable energy and natural resources and environment. It is funded by UNDP and DfID, and implemented by MONRE with the participation of the MPI, MARD, MOIT, and DONREs in four provinces. Ha Tay and Ha Tinh are the two pilot provinces and Ha Nam and Ninh Thuan are the two replication provinces where pilot activities will be extended. The goals of PEP are to achieve: Improved knowledge and awareness within government and civil society of barriers, capacities and opportunities for natural resource use and environmental protection to contribute to national goals, targets and strategies for poverty reduction and sustainable development; Strengthened institutional capacity to monitor and report on poverty-environment indicators and outcomes, and to use those data effectively; Strengthened institutional mechanisms and capacity to integrate poverty reduction and environmental concerns into development policy and planning frameworks; Strengthened capacity in MONRE to set strategic priorities and develop policy and legal instruments that encourage environmental protection and natural resource use and support poverty reduction and improved equality; Strengthened institutional capacity of MONRE to coordinate donor support within a programmatic framework, regarding natural resource use and environmental protection, and links to poverty reduction.
To fulfill these objectives PEP put out to Public Tender three separate sets of activities, as Tender Packages. The first set aims to identify and raise awareness on poverty-environment linkages and promote best practices in poverty reduction and environmental protection. It is being conducted by a consortium led by ICRAF. The second set, being carried out by IMHEN, aims to strengthen poverty-environment monitoring capacity and procedures. The final package, being undertaken by SDIN joint venture, seeks to mainstream environmental and poverty concerns into policy and planning at national and provincial level, to enhance MONREs capacity to develop policy and legal instruments and to build stronger partnerships to secure poverty reduction through environmental protection. The first Tender Package, named Support expansion of the knowledge base on poverty-environment linkages through conducting 10 case studies, reviews of national programmes and focussed projects and the development of policy and investment models, includes the following ten case studies: i. ii. iii. iv. v. vi. vii. viii. ix. x. Understanding the voice of the poor Impact of the environment on health Water supply and sanitation for poor communities Poverty in environmental policies and legislation EIAs and the poor / coping strategies Income sources for poor people from the environment Improvement of environmental conditions for the poor Renewable energy for poor communities Gender dimension of povertyenvironment issues Impact of migration on environment
and two policy-investment models, which are to be piloted in Ha Tay and Ha Tinh. These models will suggest the policy support required to ensure the long-term success and replication elsewhere in Viet Nam of practical poverty reduction measures for environmental protection. The research outputs of these ten case studies are presented in a series of six thematic study reports namely: 1. 2. 3. 4. 5. 6. Understanding the Voice of the Poor Environmental Polices, Legislation and the Poor, Health, Water Supply, Sanitation and the Poor, The Environment, Income Generation and the Poor The Environment, Renewable Energy and the Poor The Environment, Gender, Migration and the Poor
All edited reports will be available for download from the Poverty Environment Network (PEN) website www. povertyandenvironment.vn managed by PEP on behalf of the ISGE. PEN members are regularly invited to meetings and seminars held by PEP, and are able to participate in other events organized by the Network on poverty and environment issues. This research output would be interesting for all development stakeholders and useful for policy makers. The PEP also strongly encourage the readers to become members of the Poverty Environment Network, to participate in PEN activities and to provide feedback on issues raised by posting comments and contributing to discussions on the website forum It is our honour to present this report to readers
NATIONAL PROJECT DIRECTOR ASSOC. PROF. DR. TRUONG MANH TIEN
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Acknowledgements
We would like to express our gratitude to the kindly support and participation in field work, report writing activities as well as valuable comments from Mr. Nguyen Doan Sang, Mr. Pham Van Binh, Ms. Nguyen Thi Thanh Thuy (PEP Ha Tinh), Ms. Nguyen Thi Ha Tan (Chairwoman of Women Uniton, Loc Ha District, Ha Tinh Province, Mr. Nguyen Vinh Luyen (PMU for Da Lat sanitation project), Dr. Vo Thi Khuong (Deputy Director of Da Lat Health Care center), Mr. Dagoud Tri (Deputy Director of Lac Duong PC), Mr. Doan Van Ti (Director of Xa Lat commune PC, Head of Health Core Group), Mr. Le Huu Tuc (Deputy Director of Don Duong PC), Mr. Tran Tan Xi (Director of Da Ron commune PC), Mr. Tran Manh Thang (Vice Director, Phu Tho Cerwass), Ms. Nguyen Thi Lan (Medical Doctor, Phu Tho HIV/AIDS preventive and control cente), Ms. Tu Thi Thanh Giang (Vice Chairwoman of Viet Tri Women Union), Ms. Luu Thi Ban (Chairwoman of Tien Cat Ward, Viet Tri Women Union), Mr. Le Van Ton (Head of Health Care Station, Thach Son commune, Lam Thao, Phu Tho), Mr. Vu Xuan Sinh ( Head of Unit 5, Trung Vuong commune, Viet Tri, Phu Tho) and Ms. Bui Quynh Nga (Carl Bro Vietnam staff ) Last but no least, we desperately appreciate the great supports of local staff and people in studied sites: Ha Tinh, Lam Dong and Phu Tho for fulfilling our field trips.
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Abbreviations and Acronyms

ADB AusAID CBO CPC DANIDA DFID DONRE DOSTE DPI DVC Latrine GTZ HIA ICRAF IEC IMHEN ISGE KfW MARD MOIT MOH MOLISA MONRE MPI MRDP ODA PAPOLD PCERWASS PEP PHAST PPA PPC PRA PTWSC RWSS SCUK SDIN SEDS SIDA Asian Development Bank Australian Agency for International Development Community Based Organisation City Peoples Committee Danish International Development Assistance Department for International Development (UK) Provincial-level Department of Natural Resources and Environment Department of Science, Technology and Environment Provincial- level Department of Planning and Investment Double Vault Composting Latrine German Technical Cooperation Health Impact Assessment World Agroforestry Centre (International Centre for Research in Agroforestry) Information, Education and Communication Institute of Meteorology, Hydrology and the Environment International Support Group on Natural Resources and Environment Kreditanstalt fur Wiederaufbau (German Development Fund) Ministry of Agriculture and Rural Development Ministry of Industry and Trade Ministry of Health Ministry of Labour, War Invalids and Social Affairs Ministry of Natural Resources and Environment Ministry of Planning and Investment Rural Development Programme Official Development Assistance Participatory Analysis of Poverty and Livelihood Dynamics Provincial Centre of Rural Water Supply and Sanitation Poverty and Environment Project Participatory Hygiene and Sanitation Transformation Participatory Poverty Assessment Provincial Peoples Committee Participatory Rural Appraisal Phu Tho Water Supply Company Rural Water Supply and Sanitation Save the Children UK Sustainable Development Institute of the North The National Strategy for Socio Economic Development for 2001- 2010 Swedish International Development Agency
URENCO UNDP UNESCAP WB WPC WSC WSS
Urban Environmental Company United Nations Development Programme United Nations Economic and Social Commission for Asia and the Pacific World Bank Ward Peoples Committee Water Supply Company Water Supply and Sanitation
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Table of Contents
Preface ...........................................................................................................................................................................................................i Acknowledgements .............................................................................................................................................................................. iii Abbreviations and Acronyms.............................................................................................................................................................. v Table of Contents .................................................................................................................................................................................. vii CHAPTER 1. Introduction ...................................................................................................................................................................... 1 1.1. Introduction ............................................................................................................................................................................... 3 CHAPTER 2. Methodology and Site Selection ............................................................................................................................... 5 2.1. Methodology ............................................................................................................................................................................. 7 2.2. Sites and Programmes for Reviews, PRAs and Case Studies ..................................................................................... 8 2.3. Principles, techniques and materials ................................................................................................................................. 9 CHAPTER 3. Summary of Findings ..................................................................................................................................................11 3.1. Summary of Findings CHAPTER 4. Analysis of Findings......................................................................................................................................................29 4.1. Links between Health and Environment .......................................................................................................................31 4.2. Links between Health, Environment and Poverty ......................................................................................................32 4.3. WSS Technologies Directly Assisting the Poor .............................................................................................................33 4.4. Gender Issues ...........................................................................................................................................................................34 CHAPTER 5. Conclusions and Recommendation .......................................................................................................................37 5.1. Links between Health and Environment .......................................................................................................................39 5.2. Links between Health, Environment and Poverty ......................................................................................................39 5.3. WSS Technologies Directly Assisting the Poor .............................................................................................................40 5.4. The Importance of IEC Activities and Participation of both Women and Men.................................................40 5.5. The Importance of Strengthened Co-ordination ........................................................................................................41 APPENDIX 1. CASE STUDY 1: Impacts of Environment on Health. Community Awareness Campaign, Phu Tho Water Supply Company, Viet Tri City, Phu Tho Province..........................................................................................................43 APPENDIX 2. CASE STUDY 2: Water Supply and Sanitation for Poor Communities. The Rural Water Supply and Sanitation Project, Ha Tinh Province, Viet Nam (incorporating the Project/Programme Review) ...........................51 BIBLIOGRAPHY .......................................................................................................................................................................................61 LIST OF RESEACHERS/EXPERTS INVOLVED IN THIS STUDY .....................................................................................................63
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Chapter 1 Introduction
Photo: Pham Thi Thu
Chapter 1: Introduction
1.1. Introduction
The Poverty and Environment Project of MONRE funded by UNDP and DFID began its work in October 2005. One of its earliest activities was to initiate research into poverty-environment linkages; the first output of this research was an initial review of existing information on such linkages in Viet Nam; the report from that Study, hereafter called the Inception Report, was presented at a national workshop held in Hanoi on the 5th of February 20071. The Inception Report was to be followed by six thematic study reports, covering ten case studies. This Report is the second of the 06 thematic study reports, the thematic study dealing with health, water supply and sanitation and the poor. It is perhaps in this area, the area of water supply and sanitation, that the lessons in development practice, the concerns for sustainability and the need to address both poverty and gender have been around the longest. Early failures in development projects, and the lessons learned about citizen participation in particular, came from attempts to provide clean water in communities without proper consultation about location, technology and operation and management issues2 . Many of the toolkits currently in use have been developed out of the lessons learned from water, and more recently from water and sanitation programmes. In many locations, and especially so in Viet Nam, sanitation has been intended by donors to focus on latrines, but has developed a wider meaning in terms of environmental cleanliness which can include waste management and avoidance of pollutants. The link between water and sanitation and health has been very early documented, and forms the primary basis for water and sanitation projects. The link between health and poverty is also well established with the cycle of poor health, low productivity, low income, poor facilities and poor health care affordability being well accepted. The gender dimensions of the health/poverty/water and sanitation matrix have also been well documented, with women having most household responsibility for household sanitation and water supplies3 4 5 , and suffering most of the consequences of the lack of these including care of household members who are ill, long working hours fetching adequate supplies and in more remote areas chronic back pain related to carrying water for long distances. This thematic study seeks to elaborate the linkages described above. The Inception Report on Poverty-Environment Linkages pointed out that four main gaps in knowledge can be found in current policies, programmes and projects. Firstly, there is a significant level of inequity in access to safe water and sanitation throughout Viet Nam because of (i) low investment in safe water and sanitation, and; (ii) poor management. Significant numbers of lowland poor using dug wells or surface water are affected by lack of access to, or pollution of drinking water. However, the question of How much of this is due to (i) poor rural infrastructure? (ii) high price? (iii) low income? has not been answered or addressed in current studies. Secondly, the ethnic minorities are in higher incidence of diseases related to water and sanitation is visible but not fully explained. There is no information on diseases and sanitation measures, no knowledge about diseases and their causes and no effort to treat diseases and take sanitation measures. These are gaps that have not been well-addressed in published documentation and papers. Thirdly, safe water and sanitation programmes face a challenging issue of targeting. Competition for access to improved services arises between poor and non-poor households or communities in a context of limited budgets. Government Programme 135 allows targeting at the commune level. How can poorer villages within these communes be most effectively targeted? Finally, pro-poor solutions to the dug-well pollution issue will require affordable technical innovations. Pollution from local domestic and human sources can be addressed through improved waste management. It is not so, however, for diffuse pollution of agricultural and, increasingly, industrial origin. How can we ensure that the poor have access to affordable alternative solutions to dug wells?
1 2 3 4 5
Poverty and Environment Linkages in Viet Nam, Report 1, Hanoi, April 2007, p. 6. Kumar, S 2002, Methods for Community Participation: A complete guide for practitioners, Vistaar Publications, New Delhi. Berghof, C & Dinh, T 2002, Men and women in rural water supply and sanitation in Viet Nam, Ministry of Agriculture and Rural Development Centre of Rural Water Supply and Sanitation, Hanoi Viet Nam Womens Union, 10 July 2005 accessed at http://hoilhpn.org.vn Danida, 2006 Management Lessons Learned during the Implementation of the WaterSPS and NTP 1 and Recommendations for Next Phase Draft Document, Hanoi August, 2006
Among the lessons most recently learned in Viet Nam through the implementation of the National Rural Water and Sanitation Strategy, as well as through programmes of urban and peri-urban health promotion and water and sanitation provision, are the following: Health promotion needs to incorporate both traditional and modern approaches in order to be effective and to promote changes in health behaviour. The PHAST6 method (Participatory Hygiene and Sanitation Transformation) provides for participatory approaches to increasing awareness in communities, as well as for community approaches to planning health goals and activities. Added to this has been the experience of social marketing, mainly until now used in the fight against HIV/AIDS, which looks for both barriers and incentives for behaviour change and places emphasis on finding the cues to prompt more rapid behaviour change in the individuals, households and communities7 . Change happens slowly step-by-step is a common theme in planning meetings in Viet Nam, and this is true in terms of maintaining valued traditions and customs. However, environmental protection and poverty reduction are both issues which cannot wait a generation for change. Communities must have access to affordable and appropriate technologies for the provision of water supply and sanitation. Households even poor households - must also have access to affordable credit in order to make investments in household and community infrastructure. Micro credit programmes operated through the Viet Nam Womens Union and other sources, together with informal community credit mechanisms, have been shown to have had considerable success in making improvements to water supply and sanitation facilities. Participation must be focused to planning and implementation, including the participation of women. In Viet Nam we know that the participation of the Mass Organizations is one way to achieve this. Health, water and sanitation issues, along with environmental concerns do not exist in a vacuum and must be integrated into the broader aspects of development, including the promotion of inter-agency co-operation and collaboration and provision of local planning and consultation mechanisms. The objectives of this study are: To elaborate linkages between health, the environment and poverty among the rural and urban poor. To examine, in particular, issues surrounding the development of environmentally sound, clean and efficient water supply and sanitation technologies that directly assist the poor in urban and rural areas (including means of disseminating and replicating environmentally appropriate technologies). The outputs of this study are: 1. Adapted PRA methodology 2. Summarised results of PRAs in target districts (Fact Sheets) Six separate Fact Sheets have been prepared, one for each of the PRA sites 3. Project programme reviews, highlighting lessons learned (Fact Sheets) Three separate project review documents have been prepared 4. Detailed PRA analysis One PRA analysis document has been prepared, based on the six PRA studies and the fact sheets produced for each PRA 5. Case study reports Two case studies have been prepared. Each case study is based on one of the project reviews (output 3) and two PRAs, all from the same province. 6. Minutes of the national workshop held on 29 August 2007 7. An Analytical Paper summarising all the above outputs Comments received from during the national workshop held on 29 August 2007 and subsequent comments received from the Poverty and Environment Project (PEP) have been incorporated into the above-mentioned outputs.
6 7 WHO, 1998 PHAST step-by-step guide: A participatory approach for the control of diarrhoeal diseases McKenzie-Mohr, D. and Smith, W, 1999 Fostering Sustainable Behaviour: An Introduction to Community Based Social Marketing.
Chapter 2 Methodology and Site Selection
Photo: Bui Hoa Tien
Chapter 2: Methodology and Site Selection
2.1. Methodology
The methodology for the Health, Water Supply and Sanitation Studies included a combination of qualitative and participatory tools used for the PRAs in selected districts and communes, together with Project Reviews incorporating document reviews and in some cases key informant interviews with project staff, community leaders and health authorities. The combination of methods enabled the triangulation of qualitative and some quantitative data collected, which is a means of validation, particularly for qualitative studies.
Adapting the PRA Methodology

The methodology for the PRAs included a combination of qualitative and participatory tools representing both well established PRA methods and introducing an adaptation of the PAPOLD (Participatory Analysis of Poverty and Livelihood Dynamics) methodology, mainly involving the collection of some Stages of Progress8 data and ensuring that both poor and non-poor participants were selected. The PRA approach included four data collection methods; Secondary data review: books, files, reports etc.; this mainly took place at Project/ City/ Province level in connection with the three project reviews and at national level in relation to national policies, strategies, reviews and evaluations. In addition, water supply and sanitation data as well as health data were collected from relevant local authorities in connection with the six community-level PRAs. Observation: direct observation and wandering were done in connection with the six commune-level PRAs. Semi-structured interviews were carried out in connection with the six commune-level PRAs: An Interview Guide was prepared in which only some of the questions were pre-determined, allowing new questions to arise during the interview in response to the interviewees answers and from observations. The guide was pre-tested, discussed among the research team and revised before the data collection began. The interviews consisted of: (1) key informant interviews, (2) focus group discussion, and (3) individual in-depth interviews. Workshops: Mini workshops were conducted in each province and were attended by representatives from related organisations, local authorities and local people. Formal permission from local authorities was sought prior to the field study. Consent of the participants was obtained before conducting interviews and focus group discussions. Confidentiality and anonymity of the informants was maintained at all times. Local languages were used in the interviews and discussions, where necessary. The Interview Guide is included below. The focus group discussions were held with groups of 10-15 community members chosen from four groups of households (male-headed and female-headed, poor and non-poor) as well as choosing both older and younger participants. Field notes from the interviews and focus groups at community level were taken by hand and quotations and personal stories were recorded. The recorded information included the observation of the surroundings, informants attitudes and photographs. Data collected during the interviews and focus group discussions at community level was sorted and checked for completeness and internal consistency. This process started during the data collection period in order to achieve timely detection and supplement missing data, to re-check ambiguous information and address new questions that arose. The information was cross-checked against observation and independent sources. Manual compilation was used due to the limited number of the informants, as well as the qualitative nature of the information collected.
The Stages of Progress method, when implemented fully, involves choosing participants for the PRA who are older and are able to provide an historical perspective on changes in the community often up to 25 years of change. Whilst the team felt it important to get the views of older people about the changes, it was also considered important to have the views of younger people, and to look at the impact of more recent change. Hence in the sample selection both older and younger people were selected, and additional questions about change were asked of the older people.
2.2. Sites and Programmes for Reviews, PRAs and Case Studies
The team chose to conduct the studies in Lam Dong, Ha Tinh and Phu Tho Provinces, in order to achieve a mix of coastal and northern locations, highland, rural and peri-urban environments and to incorporate the views of ethnic minority as well as Kinh majority populations. We included Ha Tinh Province as representative of the coastal areas, and because we identified relevant projects in environmental management and rural water supply and sanitation in that province. Ha Tinh is one of the first pilot provinces for the implementation of the participatory and demand-responsive National RWSS Strategy. The Ha Tinh RWSS project has been included to explore the lessons learned from the pilot implementation of the Strategy. Ha Tinh Province was also chosen because there was a synergy in relation to the cross-cutting thematic studies and the final target pilot plans. Lam Dong Province was selected as representative of the highland areas, and because of the high degree of poverty experienced there, much of which has been linked to environmental conditions and to transmigration. Furthermore, Lam Dong Province is home to a large population of ethnic minority groups. There have been four major Danida-supported projects in Lam Dong province around urban and peri-urban water supply, urban and peri-urban sanitation, water resources management and rural water supply and sanitation. Within all of these, Danida has had a strong focus on poverty alleviation and reduction. We have included the Dalat Sanitation Project as an example of an urban environmental sanitation project. We selected Phu Tho Province, and in particular Viet Tri City, as representative of northern areas. The completed KfW Water Supply project incorporated a water treatment plant and construction of a new piped water system, as well as promoting alternate clean water and sanitation facilities for those in the poorer, peri-urban areas not covered by the grid. There was significant participation of the Viet Nam Womens Union and the Preventive Health Centre in the awareness campaign, which incorporated both Participatory Hygiene and Sanitation Transformation (PHAST) and social marketing approaches. The lessons learned from this project have been incorporated into international presentations as well as into further PHAST and social marketing training in Viet Nam. Looking at this project again provided an opportunity to look not only at the lessons learned, but at aspects of sustainability which can only be observed after completion of the intervention. In each province two districts/sites were selected. One of the PRA districts was part of an ODA-supported project with an innovative implementation approach, while the other PRA district had had support either through a National Government programme or from local authorities. One peri-urban and one rural district/ site were chosen in each province. All of the selected areas and their related projects were chosen because they could shed light on the main objectives of the study, both to elaborate the linkages between health, environment and poverty among both rural and urban poor and to look at issues related to water supply and sanitation technologies that assist the poor in improving their WSS situation, including the means of dissemination and replication. The table below gives an overview of the water and sanitation projects reviewed as well as the districts and sites selected for the community-level PRA studies. Table 1: Overview of Provinces, Projects Reviewed and PRA Districts and Site Region Province Project Review (urban/rural) Dalat Sanitation Project (urban) Rural WSS Project (rural) PRA district/ward 1: ODA-supported Lac Duong District, Lac Duong Town (peri-urban) Cam Xuyen District, Cam Quan Commune (rural) PRA district 2: Gov./local auth. supported Don Duong District, Da Ron Commune (rural) Loc Ha District, Ho Do Commune (peri-urban)
Highlands Coastal Northern
Lam Dong Ha Tinh Phu Tho
Phu Tho WSC: Commu- Viet Tri City, Tien Cat Ward Lam Thao District, Thach nity Awareness Project, (peri-urban) Son Commune (rural) Viet Tri (urban)
Note 1: All the PRA districts and sites selected had a high level of poverty, except for one of the sites, Tien Cat Ward, Viet Tri, Phu Tho Province Note 2: The ODA-supported PRA districts received support under the projects reviewed, e.g. Lac Duong district received support under the Dalat Sanitation Project
Chapter 2: Methodology and Site Selection
2.3. Principles, techniques and materials

The following key PRA principles were taken into account when the study team designed and conducted the community-level PRAs: Participation of the local people who served as partners in data collection and analyses. Flexibility: Semi-structured questionnaires were developed but room was left for facilitators to expand depending on the concrete situation. Team work: Both outsiders and insiders, men and women, mix of disciplines: public health, NGO social worker, teacher, women union, IEC staff were chosen to formulate the team. Optimal environment: Facilitators in cooperation with local community representatives chose the most appropriate times for group discussion ensuring that when participants participated in the group discussions they were concentrated on sharing opinions and not worried about their domestic work or field work. Systematic principle: For validity and reliability, partly stratified sampling and cross checking were applied
Concrete techniques and materials used for conducting PRAs in each site:
Focus group discussions and in-depth household interviews: In each commune four groups of households were chosen: male-headed and female-headed, poor and non-poor, and including some older household members. Key informant interviews: In addition to group discussions, in connection with community-level PRAs the following key informant interviews were carried out: Leader of Provincial Centre of Rural Water supply and Sanitation (PCERWASS); Leader of Phu Tho Provincial Urban Water supply company; representative of Commune health station, Commune Peoples Committee, two Project cooperators (one in commune and one in ward/district) Observation: direct observation at household and community levels to verify and get further information related to water supply and sanitation facilities and the environmental and hygiene situations Secondary information collection: Secondary information regarding social economic status, % of poor households, % of access of different socio-economic groups to water supply and sanitation, incidence or prevalence of water sanitation related diseases have been collected from health stations, from village and district data and from data collected in some cases by the Projects.
To assist in the conduct of PRAs a semi-structured questionnaire was developed, based on material in several main documents and reports: Report 1 Analytical Paper of PART 1 with conclusions and guidance for further detailed study emphasizing three main areas that need attention in the Health, Water Supply and Sanitation study Final report of project Viet Tri Community Awareness Campaign on Water Supply and Sanitation for Public Health National Rural Water Supply and Sanitation Strategy up to year 2020 Joint Government Donor Review of the Rural Water Supply, Sanitation and Health in Viet Nam - Summary Sector Status Report Nov. 2004 with conclusions and lessons drawn from reviewing different rural water supply and sanitation projects throughout Viet Nam Evaluation of water supply and sanitation projects in urban areas with community participation , and emphasis on the question Can poor households get better water supply and sanitation service? supported by World Bank -2003 In accordance with the Terms of Reference for the Study, two case studies were prepared. One case study was for Ha Tinh Province, while the second was for Phu Tho Province. Each case study was based on the project review and the two PRA studies in the respective province.
Chapter 3 Summary of Findings
Photo: Le Huu An
Chapter 3: Summary of Findings
3.1. Summary of Frindings

The findings outlined below are drawn from the six community-level PRAs and the three project reviews in the three Provinces of Lam Dong, Ha Tinh and Phu Tho, and are also presented separately in the case of Ha Tinh and Phu Tho in the two case studies. Some findings from the six PRA sites are summarized in Table 2 below. It includes information on the general socio-economic and health situation, the water supply and sanitation infrastructure used, WSS project support provided to the sites and some issues identified. Additional findings from the six PRA sites are included in the document Detailed PRA Analysis (output 4 of the Study). Table 3 includes an overview of the three water and sanitation projects reviewed, including objectives, poverty targeting, key elements and approach, and achievements and issues. Additional findings from the project reviews are included in the three project review documents (output 3 to this Study) and the two case studies (output 5 to this Study). The tables are intended to serve as background for the subsequent more overall analysis of findings from the Study.
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Table 2: Characteristics and Findings from Six PRA Sites Socio-economic and Health Situation of Town/ Commune/ Ward Type of WSS Infrastructure Project Support and Issues
Province/District/Site
Lam Dong Province In 1999, the Dalat Water Supply Rehabilitation Project supported the connection of 500 poor households; during the time of the PRA (2007), there were 60 poor households not connected to the piped water system. In 2005, nearly 600 septic tank latrines were constructed with support from the Dalat Sanitation Project; 80% of these were used at the time of the PRA. The household contribution consisted in the construction of the superstructure, but some poor households said they could not afford this. Health and hygiene education was a very important component of both the Water Supply Rehabilitation Project and the Sanitation Project. There is still a serious issue of inadequate wastewater disposal and solid waste collection in the town. Water supply in town: Socio-economic situation: 90% households have piped water Peri-urban, close to Dalat City supply from Dalat City. Population in town: 4,828 Cil and Lach ethnic minority groups: Traditional water sources: springs and dug wells. 45% Poverty 15%; of these 75% ethnic Sanitation in town: minority groups 70% of households have septic tanks. Health situation: No epidemics related to water- 30% of households have simple dug latrines. borne diseases in last 5 years Malarial cases insignificant In 2006, 57 cases of acute diarrhoea, but no fatalities Health station staff considered improved health situation to be due to most people using clean water and improved latrines; improved hygiene awareness; and a diarrhoea control programme
District: Lac Duong Site: Lac Duong town
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Province/District/Site The Government Programme 134 has supported the construction of 3 bore-wells and the establishment of a piped system with connection of 70 households. There seemed not to have been sufficient funds to connect more households, but people were unsure of the reasons.
Socio-economic and Health Situation of Town/ Commune/ Ward
Type of WSS Infrastructure
Project Support and Issues
District: Don Duong Site: Da Ron Commune
Socio-economic situation: Water supply in Da Ron Commune: Rural, mountainous 70 households connected to 3 bore-wells through Government. Population: 7,482 Programme 134; poor households Ethnic minority: 45% supplement with rain water and Poverty: 29%, of these 71% ethnic water from dug wells. minority Remaining households use dug Da Ron recognized as very poor wells and rain water only; dug wells commune since 2001 have to be very deep.
The National RWSS Target Programme supported the construction of 100 Health station information: Sanitation in Da Ron commune: It was not possible to collect any health 55% Kinh households use septic septic tanks for ethnic minority households. At the time of the study, data tank latrines. half of the facilities were not used as Great majority of ethnic minority the programme did not complete the households use simple dug pit construction. latrines. Many interviewees complained that they had not been provided with sufficient information before and during the implementation of the two programmes and they did not know the reasons why the constructions had stopped. Health and hygiene education had not been part of the support from the two programmes, but residents had received some information on health and hygiene through village meetings and the church.
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Province/District/Site
Socio-economic and Health Situation of Town/ Commune/ Ward Water supply: 65% of all households had piped water; with 90% of better-off households, 65% of average households and 60% of poor households having connection. The remaining households used dug wells and ponds. In the dry season, the wells usually dried up and only a few deep wells had water; people therefore had to carry water over long distances. Sanitation: One- and two-compartment latrines were very common in the commune. Water supply: No fresh ground or surface water is available in Ho Do, despite many investigations. Only water sources are rain water collected from asbestos and other types of roofs and water purchased in 20-litre cans at around 20 times the price of piped water in other areas. Wealthier households can afford to construct big rain water tanks, while poor households cannot afford such investments.
Ha Tinh Province in Cam Quan commune with support from Danida. In 2006, this was expanded to cover 13 additional hamlets in Cam Quan and Cam Thang communes. The expansion took place with support from the Ha Tinh RWSS project. It is not specifically mentioned in the PRA fact sheet, but the Ha Tinh RWSS project also provided grants and loans for the construction of latrines as well as for water supply. Furthermore, information, education and communication activities on health and hygiene issues, amongst other things, were an important component of the project. 2005, Ha Tinh Provincial Peoples Committee (PPC) provided Ho Do with 2.5 billion VND for installation of a piped water system from the water plant in Ha Tinh town. Treated water was/is stored in 7 reservoirs for 13 villages/ hamlets. Heads of village/hamlet were in charge of managing the reservoirs and selling the water in 20 litre cans.
District: Cam Xuyen Site: Cam Quan Commune
Socio-economic situation: Rural Population: 8,400 100% Kinh population Poverty: 39% of households
Health situation: The number of cases of diarrhoea is very low compared to the national average Over recent years trachoma has been reduced from 35% to 15% The rate of reported parasitic worm infestations was 45% at the time of the study
District: Loc Ha Site: Ho Do Commune
Socio-economic situation: Officially rural, but peri-urban characteristics as it is on the outskirts of Ha Tinh town Population: 8,400 100% Kinh population Poverty: 30% of households
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Province/District/Site Sanitation: No information was collected on the sanitation situation, as the PRA focused on the poor water supply situation. However, neither the commune authorities nor local people were consulted on how to use the money allocated by Ha Tinh PPC in an efficient way. People had thus had to queue for a long time to get a small amount of water and there was insufficient money for operation and maintenance of the reservoirs. After one year the reservoirs had broken down and the operation stopped.
Health situation: The number of diarrhoea cases is significantly higher than in other areas No serious epidemics have been recorded recently
Phu Tho Province Water supply: 95% households connected to the Viet Tri piped water supply; the remaining 5% have not been connected mainly because of topographical problems; 8% of the poor households (10/125 poor households) are not connected. The remaining households mainly use dug wells. In 2001-2002, the Community Awareness Project linked to the Viet Tri Water Supply Project assisted in promoting existing and new customers to connect to a new piped water system. The Viet Tri Water Supply Project did not specifically target the poor households in fact the original target group was people who could afford to connect to the piped water system. In Tien Cat ward the proportion of people connected to the piped water system increased from approx. 50% to 95%. Both existing and new customers had to pay a connection fee.
City: Viet Tri Site: Tien Cat Ward
Socio-economic situation: Peri-urban Population: 14,856 100% Kinh population Poverty: 3% of households
Health situation: Before project, diarrhoea 306 cases/100,000 population; worm infestation nearly 100%
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Province/District/Site Sanitation: The number of hygienic latrines and bathrooms has increased significantly as a result of the Community Awareness Project.
After the project, the registered cases of diarrhoea and worm infestation decreased and also malnutrition in children fell No epidemics caused by water and sanitation related diseases have been reported since the project
No special finance mechanism was established for poor households to connect to the piped system. For very poor households who could not afford the connection even with a reduced fee (because of many households connecting to the same pipe), the whole group of households often paid for them and poor households would repay the group monthly without any interest. The Community Awareness Project also assisted with local community initiatives to construct latrines and bathrooms. In a peri-urban commune of Tien Cat ward 73 new bathrooms and 310 new latrines were constructed and repairs and maintenance was done to 63% of the dug wells. Information, education and communication (IEC) activities was very important in connection with the local community initiatives, where no financial support was provided for construction and improvements of WSS facilities.
District: Lam Thao Commune: Thach Son
Socio - Economic Situation : Peri-urban Rural, though close to Viet Tri City Population: 7,346 100% Kinh population
Water supply: Most households use water from shallow dug wells. 50% of households are able to get a very small quantity of water from a piped water system established in 2001; according to provincial tests, the quality of the piped water is not good.
The number of cases of respiratory diseases and cancer are very high in the commune, with increasing incidences of cancer since 2005. The Commune Health Station does not know the reasons for all the incidences of cancer, but considers it very likely that pollution from the fertilizer factory through both air and waste water disposal is the reason.
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Province/District/Site Poverty: 13% of households A superphosphate fertilizer factory is located near the commune and causes much pollution of the air and water canals Sanitation: No information was collected about latrines as the PRA focused on the environmental pollution caused by the fertilizer factory.
Socio-economic and Health Situation of Town/ Commune/ Ward NoThese diseases force people to spend a lot of money for treatment, which has resulted in some families becoming poor. Recently, in order to support these people, the Cancer Hospital in Hanoi agreed to provide free treatment for people coming from Thach Son Commune. Also recently, the district Peoples Committee has provided funds so the commune can be connected to the Viet Tri piped water system. At the time of the PRA, the bidding for the construction work had been completed.
Health Situation: In recent years no serious outbreaks of intestinal diseases; 120 cases/10,000 population of diarrhoea (only slightly higher than national average) Number of cases of respiratory diseases very high Cases of cancer very high (see also last column of table)
Note: The poverty figures mentioned above are according to the criteria from the Ministry of Labour, Invalids and Social Affairs (MOLISA)
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Table 3: Characteristics and Findings from Review of Three WSS Projects Objectives and Target Groups Key Elements and Approach Achievements and Issues
Province/ Name of Project/ Period
Lam Dong Province
Dalat Sanitation Project
Period: 2001 - 2007
Development Objective: To improve the living conditions for the people in the urban areas of Dalat by an increased service level within provision of sanitation, in an environmentally, socially and financially sustainable manner, affordable to the poor.
Establishment of centralized waste water treatment plant with connection of households free of charge. A Willingness-to-Pay (WTP) and Affordability-to-Pay (ATP) survey was carried out before calculation of a wastewater tariff, which incorporates poverty aspects. Rehabilitation of the Citys two main water courses, with improved drainage of the two streams that cut through the Citys central area. Construction of 4.300 septic tanks and 1.900 double vault composting (DVC) latrines for poor households located beyond the coverage of the city sewer system. 3.830 were constructed for the poor in the peri-urban areas and in Xa Lat/Lac Duong on the outskirts of Dalat.
Connections to the sewer system were provided free of charge, which meant that low-income families within the sewer service area were also able to connect. Furthermore, the wastewater tariff includes subsidization between higher income groups and the poor.
Immediate Objectives: 1. Increased awareness leading to behavioural changes in relation to proper hygiene and environmental sanitation in Dalat City
2. Wastewater and major natural watercourses discharged in the most populated parts of Dalat City without constraints on health and local development
As a result of the improved drainage of the two streams, flooding in slum areas was substantially reduced, benefiting the poor living alongside the two streams. Furthermore, the garbage previously being stacked on the banks or blocking the stream flow and overflowing into the properties during floods has now disappeared together with pathogens previously posing great health hazard to the poor.
3. Creation of an efficient wastewater management body that operates as a public enterprise with consumer oriented performance criteria and operating on a financially sound basis
The poor was a specific target group, see also development objective.
A septic tank (the underground structure) was constructed free of charge by the project for the households selected, while the superstructure (walls and toilets) was to be constructed by the owner. DVC latrines, on the other hand, were provided fully operative.
The mentioned number of septic tanks and DVC latrines were constructed with project support. In addition, some 2000 households constructed own facilities, most likely influenced by the health and hygiene promotion activities. After the projects construction of DVC latrines in Xa Lat, many households were unwilling to use them because of concerns that the sludge when removed would cause environmental pollution. Furthermore,
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Province/ Name of Project/ Period Resettlement of 358 households affected by the land acquisition required for the project components. Also relocation of an abattoir situated in the central part of the City to a sparsely populated area to allow for the construction of a pumping station. Implementation of a comprehensive Environmental Management Plan to preserve and improve the City environment. it was against their tradition and culture to re-use the composted sludge as fertilizer. Following community consultations, a great number of DVC latrines were changed into septic tanks or modified to suit the inhabitants needs.
Objectives and Target Groups
Key Elements and Approach
Achievements and Issues
Generally, households found septic tank toilets very convenient and appropriate. However, some poor households faced difficulties in financing construction of latrine superstructures; many needed time for this, so the number of latrines in use only increased gradually. The problems with DVC latrines and construction of superstructures for the septic tanks may not have occurred if there had been proper consultation from the start. Poor households living close to the stream are now relocated to a better environment, i.e. in properly established resettlement areas, after proper consultation. The relocation of the abattoir has considerably improved the environment, as it is no longer polluting the stream with its wastewater and other pollutant matters. This is to the benefit of poor and non-poor households alike.
Health and hygiene promotion activities at community level, with use the Participatory Hygiene and Sanitation Transformation (PHAST) method, competitions in schools and other places, TV and radio programmes and other communication channels. Face-to-face communication through volunteer motivators was an essential part of the health and hygiene promotion activities.
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Achievements and Issues The health and hygiene education activities of the Dalat Sanitation Project were a continuation of the activities started under the Dalat Water Supply Project in 1999. The health and hygiene education activities started in two pilot wards with duplication to all 16 wards and communes within the project area. Steering committees consisting of representatives from relevant institutions, especially the Health Service and the Womens Union, were established both at city and ward/ commune levels. These committees were essential for the efficient and coordinated planning and implementation of activities. In the final stages of the project, the steering committees were gradually able to operate on their own without project support. No health impact assessment as such was carried out for the Dalat Sanitation Project, but Health Service data showed a decrease in diarrhoea, dysentery and typhoid from 4-5% in 1999 to 1.7% in 2006. This is assumed to be partly due to project activities.
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Ha Tinh Province
Ha Tinh Rural Water Supply Project (implemented in 5 districts)
Period: Dec. 2000 June 2006
Development Objectives: Improved living conditions for people in rural areas within the geographical focus area of Danish assistance by a demand-responsive support to improved domestic water supply and sanitation, provided in a socially and financially sustainable manner Immediate Objectives: 1. To establish sustainable institutional framework for provision of water supply and sanitation services including access to credit facilities and competent staff 2. To establish community managed water supply and sanitation facilities based on user demand and reflecting the needs of women and the poor
Sustainability was emphasized, including financial resources for construction, management, operation and maintenance of facilities; local ownership of facilities; technical/ operational sustainability and use of appropriate technologies and environmental sustainability.
In the five districts where the National RWSS Strategy was being piloted with support from the Ha Tinh RWSS project, both clean water supply and hygienic sanitation coverage increased from 30% in 2002 to 63% in 2006. The increased coverage was financed through grants provided to poor households, low-interest loans and self- financing. 7445 grants were given for latrines, 5540 grants for individual water supply facilities and grants for six piped water systems. The grants covered 80% of the construction costs and were for officially poor households. Grants were provided from 2003-2006.
General principle that users were to pay for construction and operation of WSS facilities. However, in line with the National RWSS Strategy grants were provided to the poor and low-cost loans were provided to women, through a rolling credit scheme managed by the Womens Union after extensive negotiations with the Viet Nam Bank for Agriculture and Rural Development had failed. A range of technical WSS options were developed, including household and piped water supply options and a number of latrine options. Communities were provided with information on WSS options technically suitable in their local areas and were able to make a choice between these options
1100 loans were given for latrines, 2678 loans for individual water supply facilities and loans for 5 piped water systems. Loans were given to women in all socio-economic groups, including the poor. It is uncertain how many of the loans went to officially poor households. The great majority of loans were provided in 2004-2005. According to the Project Completion Report and project staff, it had good results in providing grants to the poor, both because they were the main target group of the project
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Achievements and Issues and because the WSS facilities constructed by poor households acted as demonstration models for other households.
3. To increase awareness of the linkage between improved hygiene and sanitation and health and improved hygiene practices
Improved health and hygiene awareness and practices were other important topics of the IEC activities. A variety of communication methods were used, including face-to-face Ha Tinh was one of the first pilot communication through local RWSS provinces for implementation of motivators and commune staff, the National Rural Water Supply and distribution of materials, special events Sanitation Strategy and use of the mass media. IEC groups were established at provincial and The poor was a specific target group, see district levels consisting of relevant also immediate objective 2 departments and mass organisations Ha Tinh IEC staff played a key role in developing IEC materials for implementation of the National RWSS Strategy, including development of picture sets and a motivators manual for the PHAST method.
Throughout the project there was a degree of tension between the need to raise awareness and bring the communities on-board and the need to complete construction according to project timelines and targets. In some cases, construction had to wait while communities discussed and selected among different WSS options and raised their financial contributions, but this was considered important to ownership and sustainability.
A health impact assessment (HIA) was carried out in 2006 in the first two pilot districts based on available health service data on WSS related diseases, clean water supply and hygienic sanitation coverage, and interviews and observations in 8 villages and 7 schools. Data on diseases and WSS coverage are A gender focal point person was appointed at provincial level to provide not disaggregated according to poor/ non-poor people. It was therefore not support for the mainstreaming of possible in the HIA to include specific gender issues. Key activities in annual data on the projects health impact on gender action plans were gender training at various levels and promotion the poor. of a relative gender balance in various groups/units and among village motivators.
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Achievements and Issues The HIA concluded that the prevalence of WSS related diseases had generally decreased over the project period. In one district diarrhoea and malaria had been nearly halved, whereas trachoma had been stable. In the other district, the low prevalence of diarrhoea had been stable, whereas trachoma was very high but had decreased considerably to nearly 1/3. Malaria prevalence had been low, but increased slightly (reportedly imported from outside). The HIA also found that coverage with hygienic bathrooms was 74%, which is high, as was the percentage of people noted for always washing hands with water and soap. A high percentage though never washed hands with soap and water after helping children with defecation. The use of human and livestock excreta for fertilizer was very common in nearly all the surveyed villages and reported to be used safely by nearly all the households. Safe disposal of solid waste was practiced in the majority (83%) of the households. According to the HIA, the mentioned improvements were likely, to a large extent, to be the impact of the high WSS coverage and health & hygiene education activities.
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Phu Tho Province
Community Awareness Campaign on Water Supply and Sanitation for Public Health, Viet Tri
The project was linked to the Viet Tri Water Supply Project
Purpose: Sustainably improved water safety and personal hygiene practices and sanitary environment in the communes of Viet Tri City, thereby optimising the benefits of the KfW Water Project Capacity development for Phu Tho WSC staff to undertake public relations activities both through organisational strengthening and training.
Assisting Phu Tho WSC with the smooth transfer of customers from the old water supply network to the new one, and promotion of the new network among potential customers. Both existing and new customers had to pay to be connected to the new network.
Period: 2001 - 2002
Specific Objectives: 1. Safe, hygienic practices in relation to water and sanitation and other kinds of environmental pollution on a household level. 2. Improved and sustainably maintained living conditions in a healthier environment
The transfer of customers to the new water supply network was completed in mid 2002. The number of customers connected had increased from 7,513 to 16,799 households by end December 2002. In 2007 nearly 35,000 customers were connected and the rate of collection of water tariffs is close to 100%. Success was attributed in part to the Awareness Campaign.
3. Informed joint community effort towards improved water supply and sanitation
Initially, the poor were not a specific target group.
No special financial mechanism was provided for the poor. Nevertheless Health and hygiene promotion activities the percentage of poor gaining access to piped water was high 92% in the at community level, with use the urban area, and quite high in the poor Participatory Hygiene and Sanitation peri-urban areas as well. Poor families Transformation (PHAST) method, were able to connect to the network competitions in schools and market because of the community support they places and other communication received in the form of subsidies and/ or channels. Activities focused on loans with low or no interest. One of the community initiatives to improve their reasons for this community support was own sanitation situation and hygiene that the connection fee would reduce practices. for everyone if more households were The project did not include any finance connected. mechanisms such as loans and/or A Customer Relations Unit was subsidies. established with Phu Tho WSC and the capacity of its staff to under public relations and marketing activities were enhanced.
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Province/ Name of Project/ Period As a result of the health and hygiene promotion activities, there was construction of approx. 2000 latrines, repair of another 1300 -1400 latrines, construction/ improvement of approx. 2000 bathrooms and improvements to more than 2000 dug wells in areas not covered by piped water. There were also local initiatives and discussions with the Urban Waste Management Company regarding improved solid waste collection and management. The health and hygiene promotion activities of the project was so successful that a number of communes not initially involved in the project asked if they could be included in this part of the project. Interviews with Health Centre staff indicated a reduction in WSS related diseases since the implementation of the project. However, because the project did not set out to measure health improvements, no baseline was taken. Furthermore, the project was too short for any health impact to be measured at the end of it.
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Chapter 4 Analysis of Findings
Photo: Chu Duc Hoa
Chapter 4: Analysis of Findings
The first part of this section focuses on the links between health and environment seen in relation to both poor and non-poor households, while the second part looks specifically at the situation of the poor and how their poverty is linked to their environmental and health situations. The third part focuses on WSS technologies assisting the poor, while the last part looks at gender issues.
4.1. Links between Health and Environment

Out of the three WSS projects reviewed only the Ha Tinh RWSS project had conducted a health impact assessment (HIA) at the end of the project. This was carried out in the first two pilot districts, where activities had started 4-5 years before the assessment. The HIA found that the prevalence of WSS-related diseases had generally decreased over the project period. In one district diarrhoea and malaria had been nearly halved, whereas trachoma had been stable. In the other district, the low prevalence of diarrhoea had been stable, whereas trachoma was very high but had decreased considerably to nearly 1/3. Malaria prevalence had been low but increased slightly (reportedly imported from outside). The availability of hygienic bathrooms is considered an important indicator of good hygiene practices, which are known to influence health. The HIA found that the coverage with hygienic bathrooms was 74%, which is high, as was the percentage of people noted for always washing hands with water and soap (after defecation, before eating, before preparing food, and after helping children with defecation.), a high percentage though never washed hands with soap and water after helping children. As to the impact on environmental pollution, it was found that the use of human and livestock excreta for fertilizer was very common in nearly all the surveyed villages and reported to be used safely by nearly all the households. Safe disposal of solid waste was practiced in the majority (83%) of the households. The HIA concluded that the above improvements in health, personal hygiene and reduced environmental pollution were probably attributable to the impact of the increased coverage with clean water and hygienic sanitation (from 30% in 2002 to 63% in 2006) and to health and hygiene education activities. No health impact assessments had been carried out in the areas that had benefited from the WSS projects in Viet Tri and Dalat. However, data from the Health Service in Dalat showed a decrease in diarrhoea, dysentery and typhoid from 4-5% in 1999 to 1.7% in 2006 in Dalat City, although figures were not readily available for the poorer ethnic minority area of Xa Lat/Lac Duong. The decrease in the prevalence of the mentioned diseases is assumed to be at least partly due to activities under the Dalat Sanitation Project and the previous Dalat Water Supply Project. In connection with the latter, a number of additional poor and non-poor households had been connected to the rehabilitated water supply network, while many poor and non-poor households had experienced improvements in their living conditions as a result of the sewer network and the construction of on-site sanitation facilities. Improved hygiene practices had also been an important focus of both projects. Furthermore, the reduced flooding and improved garbage disposal/collection around the two major streams in Dalat City had resulted in improved living conditions and reduced environmental pollution. The relocation of an abattoir from the central area of the City had a similar effect. In Viet Tri, interviews with Health Centre staff indicated a reduction in WSS-related diseases since the implementation of the Viet Tri Water Supply Project and the attached Community Awareness Campaign Project. Furthermore, no epidemics caused by water and sanitation related diseases have been reported since the project. In Viet Tri many households experienced improvements in their living conditions after their transfer/ new connection to the new water supply network. The number of customers connected had thus increased from approximately 7,500 in 2001 to nearly 35,000 in 2007. Furthermore, as a result of the health and hygiene education activities many households had improved existing latrines and bathrooms or constructed new ones. Also solid waste disposal/ collection had improved through local initiatives. Both poor and non-poor households thus had their living conditions improved as a result of the project and many people considered these improvements as important for improving their own health situation, as for example illustrated in the PRA from Tien Cat Ward. One of the PRAs in Phu Tho (in Thach Son commune) noted that local community members and health staff linked the increasing number of cases of respiratory diseases and cancer with the air and waste water pollution from a nearby fertilizer factory. Both the PRAs and the project reviews thus indicate that the commonly accepted link between improved water supply, latrines, waste disposal and improved hygiene practices on one side and improved health on the other side can also be made for the locations included in this Study.
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4.2. Links between Health, Environment and Poverty

The links between health, environment and poverty were more difficult to establish through this Study, as the Health Services data on water- and sanitation-related diseases are not disaggregated according to poor/nonpoor people and neither are the WSS coverage data available at different administrative levels. However, the perceptions of participants in the PRA studies suggest that the links are strong. One example is that people in Thach Son commune in Phu Tho province, who were exposed to air and waste water pollution from a fertilizer factory, mentioned that the many cases of respiratory disease and cancer had forced people to spend much money on treatment, which had resulted in some families becoming poorer. The point was made in all three Provinces that poor households and communities suffer more greatly from geographical isolation than other households. This isolation makes it more difficult to provide poor households with sustainable and affordable water, sanitation and solid waste management options. The further away from the main road a community is, the greater the cost of, for example, connecting to a piped water supply or sewerage system, or of affordable household-level water supply and latrine facilities (the construction costs are often higher in more remote areas because some materials have to be transported over longer distances). In mountainous areas, this often becomes an even greater problem because of lack of water and/or dug wells having to be very deep. For many, this issue of accessibility was seen as a greater problem for poor communities than was affordability. It is, however, still important that the ability of the poor, including the poorest of the poor, to pay for the construction and operation and maintenance costs of improved water supply and sanitation facilities is considered. The situation in Da Ron commune in Lam Dong province gave one example of this. Here three borewells and a small piped water system had been constructed with support from the Government Programme 134. Interviewees considered the piped water safe and convenient, but many poor found the water tariff high and therefore reduced their consumption by supplementing with water from dug wells or rainwater. This again affected the financial sustainability of the piped system, so that the supply had to be restricted. Furthermore, during dry seasons water in dug wells was scarce, while in rainy seasons it turned very turbid. The lack of sufficient quantities of water during the dry season and use of potentially low-quality water during the rainy season may have resulted in a worse health situation for the poor than for other households. Another example was the situation in Ho Do commune in Ha Tinh where the only water sources were rain water and water purchased in 20-litre cans at around 20 times the price of piped water in other areas. The many poor households in the commune (30% of the population) were not able to afford construction of big rain water tanks as were the wealthier households. The poor households thus had purchase water at a high price and were, as mentioned by many interviewees, forced to severely restrict their use of fresh water and to re-use it wherever possible. The prevalence of diarrhoea was significantly higher in Ho Do commune than in other areas with more clean water was available at a more affordable price. The poor in Ho Do commune are likely to experience more and more severe - episodes of diarrhoea than other households because of their more limited access to fresh water. It was found that generally the poor attach higher importance to access to clean water than to hygienic latrines, proper disposal of garbage and other improved hygiene practices (as for example hygienic bathrooms). In many cases, clean water was one of first household spending priorities, whereas improved latrines, bathrooms and appropriate garbage disposal had a lower priority. It is thus the experience of IEC staff and grass-root WSS motivators that commitment to sanitation improvements is typically more difficult to achieve than commitments to improved water supply. However, the project reviews and PRAs of this Study suggest that simple PHAST, social marketing and other IEC methodologies targeting community members and households directly can be very effective in achieving sanitary improvements and improved hygiene practices among both poor and non-poor women and men. The Lessons Learned case study from the Danida-supported RWSS programme in Viet Nam, which was recently published on Danidas web-site, also demonstrates this9. The PRAs and project reviews clearly show the importance of using a demand-responsive approach in relation to both poor and non-poor households, enabling poor households to choose among several environmentally appropriate WSS options and to be properly consulted before construction starts. The problems experienced in connection with the construction of on-site sanitation facilities by the Dalat Sanitation Project could without doubt have been avoided, or minimised, if the poor ethnic minority households had been properly consulted
9 Nguyen, TA and Stoltz, HT, Good Practice Case story, Rural Water Supply and Sanitation Programme, Viet Nam Danida, 2007 located at http://www.danidadevforum.um.dk/NR/rdonlyres/255CE9CB-6C46-424B-8963-38B060E38EA2/0/Viet NamRWSS2007.pdf
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about different latrine options before the start of construction and had had sufficient information about their own contribution. As a consequence of inadequate initial consultations, a great number of double vault composting latrines had to be changed into septic tanks or modified to suit the inhabitants needs, while poor households needed time to invest in the construction of the superstructures for the septic tanks provided by the project. A survey in the last quarter of 2007 showed that 80% of the new septic tank latrines were in use. The Viet Tri Community Awareness Project is an example of a project where the demand-responsive approach resulted in considerable, low-cost sanitary and environmental improvements. Participation in the programme of environmental clean-up became so popular that even the more remote and poorer peri-urban communities of Viet Tri City asked if they could participate, even where there was no intention to extend the water network to those communities. The Study also showed that some communities have been willing to support the poor to invest in improved water supply and sanitation. The best example of this is the Viet Tri Community Awareness Project, where neighbours and communities helped their poorer members with loans or gifts, in the knowledge that the more customers that connected to the piped water system, the lower the cost would be for everyone. However, the availability of appropriate finance mechanisms for the poor, in the form of subsidies and/or loans for improvements to existing or construction of new water supply and sanitation facilities, are also important as illustrated by the Ha Tinh RWSS Project. Here grants were provided to households that were registered as poor according to the poverty criteria of the Ministry of Labour, Invalids and Social Affairs. A demandresponsive approach was used, allowing poor households to choose among a number of locally appropriate WSS technologies. Grants covered 80% of the construction costs, within an upper limit for each type of technology. Furthermore, low-interest loans were provided through the Womens Union to women from all socio-economic groups. Those that were officially poor, but not able to benefit from a grant, could apply for loans and a significant number of poor households did so. The loans also benefited many households who were just above the official poverty line.
4.3. WSS Technologies Directly Assisting the Poor

4.3.1. Informed Choice between WSS Options
As mentioned above, the availability of - and dissemination of information on - low-cost WSS technologies are important for the poor to be able to improve their own water and sanitation situation. This was done in the Ha Tinh RWSS Project by developing IEC materials on a range of locally appropriate water supply and latrine options, including several low-cost options. Both poor and non-poor households were then able to choose among these options after having obtained information on technical aspects, construction costs as well as operation and maintenance requirements and costs. The same approach was used by the Viet Tri Community Awareness Project as far as sanitation was concerned. The project developed, for example, a sanitation ladder, showing how improvements can be made gradually. Low-cost improvements to existing facilities were also promoted by the two projects, e.g. putting a cover on the dug well and improving the floor surface of an existing latrine so it was easier to keep clean and hygienic.
4.3.2. Low-Cost Water Supply Options

In many rural areas, people are able to improve their water supply situation by using fairly low-cost technologies like dug wells or through rainwater collection. In some areas, the use of low-cost water supply technologies is, however, restricted because of the water resource situation. An example is that in many coastal areas in Ha Tinh, and also in other provinces of Viet Nam, much of the groundwater especially in the upper aquifers is salty which means that dug wells and boreholes are often not appropriate options. Rainwater collection may still be an appropriate and low-cost option in many of these areas, but is dependent on people having a roof that is suitable for collection of rainwater. Furthermore, poor households are very unlikely to be able to store sufficient rainwater to last throughout the dry season (this is also a problem for many non-poor households). In fairly densely populated urban and peri-urban areas, like Viet Tri City, piped water supply is often the only appropriate water supply option, as water from lower-cost water supply options like dug wells have a considerable risk of being polluted by nearby latrines, waste water disposal from small- and larger-scale
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industrial production, households etc. In Viet Tri a substantial number of poor households were able to get a house connection to the new piped water system because of the assistance, in the form of loans and gifts, provided by other households in their local areas. The establishment of communal water taps or kiosks connected to a piped water system is another lower-cost option that can be considered by poor communities often found in peri-urban areas. Experience in Viet Nam and elsewhere, however, shows the importance of setting aside sufficient time for community consultations and discussions before such a communal option is selected and implemented.
4.3.3. Low-Cost Latrine Options

In many rural areas, people are able to improve their sanitation situation by constructing low-cost pit latrines, using local materials. The lowest-cost latrine option which the Ministry of Health (MOH) considers appropriate in rural areas is the ventilated improved pit (VIP) latrine, one of the requirements being that it has to be constructed at least 10 meters from any drinking water source (MOH Decision from March 2005). This type of latrine can be constructed quite cheaply in most areas, as materials are available locally, perhaps with exception of the vent pipe and in some cases concrete for the slab. However, the VIP latrine is not appropriate in all areas, e.g. not in areas prone to flooding or in densely populated areas. Furthermore, in many areas, particularly in the central part of Viet Nam, as for example Ha Tinh, people would like to use composted human excreta as fertilizer on their fields and therefore prefer to construct double vault composting (DVC) latrines although the cost is higher than that of the VIP latrine. If poor rural households cannot afford to construct a DVC latrine, they are likely to find a cheaper, less hygienic way of storing the human excreta until it is time to use it on their fields (without first composting it properly). In the case of urban areas, like Dalat, connection to a sewer system in areas where this exists is often compulsory as this is the most technically and environmentally appropriate technology. This would not be an affordable technology for poor households if they were to pay their full share of the construction costs, either through a high connection fee or a tariff that had built in the construction costs. In Dalat, all households were connected to the sewer system free of charge, so connection was not a problem for poor and other low-income households. Furthermore, cross-subsidization from better-off to poor households has been built into the wastewater tariff.
4.3.4. Affordability through Finance Mechanisms

Both the Dalat and Ha Tinh projects provided subsidies to poor households so they were able to improve their water supply and sanitation situation using technically and environmentally appropriate technologies. In Ha Tinh, low-interest loans were also provided to both poor and non-poor households, with a number of officially poor and households just above the official poverty line benefiting. Provision of subsidies to the construction of on-site latrines in Dalat gave rise to some problems because of the lack of proper consultation before the start of construction. However, in Ha Tinh there were generally positive results with the subsidies as they enabled many poor households to improve their own water supply and sanitation situation and surveys showed that the far majority of poor households used their subsidies for the agreed WSS improvements. In Viet Tri, some poor households got loans from their neighbours and community members which enabled them to connect to the new piped water system. Another way that connections to a piped water system or a sewer network could be made more affordable for poor households is to allow them to pay the connection fee in instalments.
4.4. Gender Issues

Interviewees during the six PRA studies and the three project reviews all agreed that women bear the brunt of inadequate water and sanitation facilities. They are responsible for the management of water in the home and most of its use washing, cooking, cleaning, bathing children, as well as, in rural settings, being at least half of the farmers. Carrying water is time consuming and causes chronic back-ache, as well as, in many cases keeping young girls away from school. Girls school attendance has therefore often improved because of improved water and sanitation facilities and because of their improved health. In Lam Dong, one participant commented that many women have seen the arrival of piped water as emancipation from hard labour.
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Improvements in household health have also reduced the burden for women, both in labour and cost for medicines. Participation in awareness campaigns and community consultations has increased some womens decision-making position within the household and/or their standing in their communities, thereby providing them with new leadership opportunities. This was found to especially be the case for women who have been actively involved with the Womens Union. Generally, the water and sanitation situation of poor women is worse than the situation of women from other socio-economic groups. Consequently, their health is also often more adversely affected than is the health of other women.
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Chapter 5 Conclusions and Recommendations
Photo: Do Thuy Mai
Chapter 5: Conclusions and Recommendations
5.1. Links between Health and Environment

The health impact assessment carried out at the end of the Ha Tinh RWSS project concluded that the improvements in health, in the form of a reduced prevalence of water and sanitation related diseases, personal hygiene and reduced environmental pollution were likely to the impact of the increased coverage with clean water and hygienic sanitation (from 30% in 2002 to 63% in 2006) and the health & hygiene education activities support by the project. No health impact assessments have been carried out in areas included in the Dalat Sanitation Project and the Community Awareness Project in Viet Tri, but there are similar indications that the improved water supply and sanitation combined with health and hygiene education also in these locations have lead to improved health and reduced environmental pollution. This Thematic Study is not an epidemiological study, so it has had to rely on available studies and data. These do, however, indicate that the commonly accepted link between improved water supply, latrines, waste disposal and improved hygiene practices on one side and improved health on the other can also be made for the locations included in this Study.
5.2. Links between Health, Environment and Poverty

It is more difficult to reach a relatively firm conclusion concerning the links between health, environment and poverty, as the Health Services data on water and sanitation related diseases are not disaggregated according to poor/non-poor people and neither are the WSS coverage data available at different administrative levels. However, the perceptions of participants in the PRA studies suggest that the links are strong. The evidence from the Study suggests that remoteness (or geographical inaccessibility) has more to do with the decisions about allocation of water supply systems than has poverty, although of course these are often linked. Ethnic minority communities, for example, are often the most remote, and are also among the poorest people in Viet Nam. Peri-urban areas, such as some areas around Viet Tri city and Dalat city, can also be considered to be geographically remote for the purposes of infrastructure development where the terrain has made it difficult for communes to be linked to the piped systems being developed close by. It is often the poorer households that live in these locations, and hence the poor suffer further from lesser access to environmental and health facilities. By speaking directly with poor and non-poor households in the communes affected by the projects which were studied, we were able to gain a sense of the overall value and commitment that communities and households place on water and sanitation as a path to improved health, and therefore also to improved productivity and economic development. While perhaps not being able to afford some technical options, poor and non-poor alike placed a high value on clean water, in some cases coming first in household spending priorities, or second after the education of children. Improved sanitation was also often considered to be important, but still had a lower priority than access to clean water. The PRAs and project reviews clearly show the importance of using a demand-responsive approach in relation to both poor and non-poor households, enabling poor households to choose among several environmentally appropriate WSS options and to be properly consulted before construction starts. More generally, it can be concluded that while most water and sanitation projects have stated objectives to target health and poverty, and many do provide measures to assist the poor to participate, in many cases projects are still constructionand investment-focused; where this is the case, the demand-responsive approach adopted is really about creating demand for technical options rather than responding to need. Hence, many poor people in difficult geographical areas are still struggling to have clean water supplies and appropriate sanitation solutions. The Study showed that some communities have been willing to support the poor with no- or low-interest loans and gifts to improve their water supply and sanitation situation. This may of course not apply in the same way in every community, but does highlight the need to consult community members and to point out the benefits for every one of community participation and co-operation. It is, however, still critical to consider appropriate finance mechanisms for the poor and also for those just above the official poverty line. The Study indicated that both subsidies and loans can be appropriate, as long as a demand-responsive approach is used. Direct loans, as well as group-based micro-finance projects have been
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successful, particularly when targeted at women. The Viet Nam Womens Union has thus managed such loan schemes in connection with, among other programmes, the Ha Tinh RWSS Project and a number of other WSS projects and has developed considerable experience in loan management something which should not be lost but which should be harnessed for use in other development activities. In addition, Government support for appropriate financial mechanisms, particularly through the Viet Nam Bank for Social Policy, is playing a positive role in progressing clean water supply and sanitation in rural areas in Viet Nam. It should though be emphasized that clean water and hygienic sanitation is still not available in many rural communities in Viet Nam, and particularly not to the poor, and therefore needs further attention from Government agencies and donors. Finally, it should be mentioned that while the three projects reviewed demonstrated participation of the poor, and in some cases specific measures to ensure subsidies or low cost loans are in place, there has been little measurement of the impact on poor people, and of the level of their participation in the programmes designed to benefit them. We are still struggling with the questions of the impact of environment on poverty and vice versa, with suggestions from the project reviews and PRA studies that the impacts work both ways. It may be more difficult to measure the impact on poverty in the short term following a WSS project, but it might be possible now that there are a number of WSS projects have been completed over a decade or more. Further, it is also recommended that projects include specific poverty impact evaluation measures.
5.3. WSS Technologies Directly Assisting the Poor

Technical WSS options need to be locally appropriate, affordable and acceptable, and should not be more complex than is necessary. Keeping it simple is the key to community perceptions of appropriateness and therefore community engagement. The Study showed that the availability of and dissemination of information on low-cost WSS technologies is important for the poor to be able to improve their own water and sanitation situation. Low-cost improvements to existing facilities can often be the first step in this connection. In many rural areas, people are able to improve their water supply situation by using fairly low-cost technologies like dug wells or through rainwater collection. However, in some rural areas the use of low-cost water supply technologies is not possible because of the water resource situation. Likewise in densely populated urban and peri-urban areas, there may only be one appropriate water supply option, namely piped water, which is normally not a low-cost option. However, also lower-cost options can be presented to and discussed with poor communities in connection with piped water systems, namely in the form of communal water taps or kiosks. In many rural areas, people are able to improve their sanitation situation by constructing low-cost pit latrines. Local materials can often be used for the construction of a hygienic pit latrine and is therefore often relatively affordable, even to poor households, but perhaps not to the poorest of the poor. Pit latrines are, however, not appropriate in all areas, e.g. not in areas prone to flooding or in densely populated areas. It can therefore be concluded that although priority should always be given to presenting poor households with low-cost water and sanitation options, such options are not technically and environmentally suitable in all areas. This points to the importance of making appropriate finance mechanisms available to the poor for them to finance the initial investment costs. Cross-subsidization in piped water and wastewater tariffs will also make the consumption of adequate amounts of water and disposal of the same water - more affordable to poor households.
5.4. The Importance of IEC Activities and Participation of both Women and Men
Participation of the mass organizations, local government (Peoples Committees) and other existing local structures is critical to the success of water and sanitation projects, not least in order to ensure that the poor also benefit. Furthermore, the existing motivator networks have been vital to the achievement of improved
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Chapter 5: Conclusions and Recommendations
public awareness and public commitment in these and many other projects in Vietnamese communities. In relation to water supply and sanitation, the Viet Nam Womens Union has been a very active partner and should continue to be involved in such projects. The use of a range of participatory methodologies, as well as both traditional and modern means, is critical. While it is commonly heard in public meetings that change happens slowly, there is evidence of quite rapid change in some public behaviours, such as with the adoption of mobile phones and internet technology. So, traditional approaches of face-to-face communication through motivators, participation in local events, use of loudspeaker systems and so on can be supplemented by more modern social marketing approaches (which, for example have been successful in other health promotion areas, such as HIV/AIDS awareness) which include market analysis and use of the modern media, such as television and radio. Furthermore, both traditional and modern methodologies are most successful when they target local issues and use locally relevant materials. Hence, the PHAST materials were designed for each location and have subsequently been re-adapted for other locations in Viet Nam. TV programmes, as another example, need to address local concerns and situations, and target local audiences at times that are locally convenient. People are much more likely to take notice of something that is about their local area than a generic programme located somewhere else even if the health, water and sanitation messages are the same. Similarly, local awareness of environmental health conditions can be enhanced by showing what those conditions are for example by using a microscope in community awareness campaigns, or providing local water quality data, or by taking before and after photographs and conducting community walks. Engagement and participation are also critical to success. True participation also means allowing local participation in project formulation and design as well as in implementation and administration. Employment generated from projects should benefit local community members as far as possible and training and capacity building needs to be built into any project. Current knowledge of participation theory and practice suggests that too much participation discourse is still focused on community engagement to do the work of the project, and too little on real participation which allows communities to be the owners of their own work and development destiny. Effective participation will also depend on the capacity and skill of project staff. True participation also requires attention to gender issues. While it is recognized that women play a significant role in the health of their families, and in the management and use of water and sanitation resources, it is still evident that they are less involved in the decisions about investment in infrastructure. There is also a common community misperception that women are the main beneficiaries of improvements in water and sanitation especially in relation to the impact on household work, and in the programmes which have targeted poor women with microfinance options. However, both men and women benefit from improved environmental health conditions, and both men and women should therefore participate. As mentioned above, employment generated in projects should benefit both men and women, and opportunities for further training and career development should be offered to both. There are examples from the projects studied of women participating through the Womens Union who have had opportunities for further career development or further training and development. This also needs further consideration in the planning of projects and action by those responsible for their implementation, including contractors and consultants.
5.5. The Importance of Strengthened Co-ordination

Cooperation with local and national partners is critical to the success of water and sanitation projects. Technical experts need to work with Health Authorities and the mass organizations, together with local government (Peoples Committees). Furthermore, at present many Government and donor projects are working in isolation without effective coordination in both planning and implementation. Co-ordination needs to be strengthened in order to bring about effective and integrated outcomes and to ensure that water and sanitation projects focus on and measure outcomes for poverty alleviation, health and environmental management.
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Appendix 1. Case Study 1 Impacts of Environment on Health. Community Awareness Campaign, Phu Tho Water Supply Company, Viet Tri City, Phu Tho Province
Appendix 1. Case Study 1
Viet Tri City

Viet Tri is the capital city of Phu Tho Province, 85kms northwest of Hanoi. The city is made up of twelve communes and wards, some of which are peri-urban, with approximately 45,000 households; it is the political and economic centre of the Province.
Background
We selected Phu Tho Province, and in particular Viet Tri City, as being representative of northern areas. The activities in Phu Tho under this study included a review of the Community Awareness Project for the Viet Tri City Water Supply Company (funded by KfW a German development fund) with a desk study of documents and discussions with leaders and staff on progress since the completion of the project in 2002/03. As well, two PRAs were conducted in Tien Cat Ward in Viet Tri City and in Thach Son Commune in Lam Thao District. Tien Cat Ward, which was included in the Community Awareness Project, is a peri-urban ward, while Thach Son is more rural and is experiencing serious environmental pollution from a nearby fertilizer factory. KfW had funded the replacement of an old piped water scheme with a new one, which required existing customers to connect to the new network, at an additional connection cost, and which needed to have new customers in order to make the new network cost effective and viable. The primary purpose of the awareness campaign was therefore to promote the changeover and connection to the new system and to build the capacity of the Phu Tho Water Supply Company to deliver positive customer relations. In order to achieve this, it was decided that the focus of the campaign should be on the health and hygiene benefits of clean water. The sanitation focus was subsequently built into the project as a result of including the health promotion partners into the project team - and because most health awareness programmes related to water also include a sanitation component. The project did not have a specific focus on poverty, and did not target the poor. Neither did the project have an initial focus on environmental aspects of health. However, as aspects of the project grew, more communes, and poor households, asked to be part of the sanitation part of the project, even when they were not in the plan for connection to the new piped water supply. Further, the sanitation component expanded from being about toilets to include other aspects of environmental sanitation, including solid waste, wastewater and water source pollution. The case of the Viet Tri Awareness Campaign is therefore a case of a project which not only successfully completed its objectives, but went beyond those to get communities involved in cleaning up their environments and becoming more aware of the impact of the environment on their health.
Project Outcomes
The project succeeded in meeting its water supply connection targets ahead of schedule. Starting with just over 8,000 customers connected, within eighteen months that number had doubled to more than 16,000. The number has continued to grow, and in 2007 the number was almost 35,000, and the rate of collection of water tariffs is close to 100%. Success was attributed in part to the Awareness Campaign, which included aspects of health and hygiene awareness training, social marketing and public relations training, including the establishment of a public relations unit within the water supply company. However, the successes went well beyond the connection to the water supply. Other measures of success within the project period alone included the construction of approximately 2,000 latrines, repair of another 1,300 1,400 latrines, construction or improvement of approximately 2,000 bathrooms and improvements to more than 2,000 dug wells in areas not covered by the piped water supply. The true success of this project was in the engagement of the community in an environmental clean-up programme which was participatory, challenging, competitive, informative and fun.
Poverty
Poverty was not specifically targeted in this project in fact the target group was those who could afford to connect.
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No special financial mechanism was provided for the poor. Nevertheless the percentage of poor gaining access to water connection was high 92% in the urban area, and quite high in the poor peri-urban areas as well.
PRA Studies
The results of the PRAs in Tien Cat Ward demonstrate the positive experience of community members in the project, and their new-found awareness of and commitment to a cleaner and healthier environment. Their responses include such comments as: Clean water is the most important condition of our life We are still poor, but we must protect our health Shallow well water is clean but who knows if this is safe or not? Poor families and poor areas in Viet Tri have access to piped water, because in addition to very high level of awareness of the value of clean water in relation to health, local people were informed by the Phu Tho Water Supply Company that, the more customers connected to one pipe, the less money they would need to pay for connection, so community groups tried to motivate each other to join together. For very poor families who could not afford to connect even with a reduced connection fee, the whole group of households supported them to connect to the water supply, with the agreement that the poor households will refund the connection cost as they are able. In addition, the Bank of Social Policy has established loans of up to 3 million VND for water connection and sanitation improvement. This financial mechanism stimulates demand for piped water connection. The other PRA site, Thach Son Commune, was not included in the Viet Tri Awareness Campaign and had not benefited from the new connections to the Viet Tri piped water supply. Instead the PRA discussions focused on the serious environmental pollution coming from a nearby superphosphate fertilizer factory. People complained thus about a high number of respiratory diseases (about one-third of Health Station patients) and increasing incidences of cancer since 2005. One third of the deaths in the commune were reported to have been from cancer. Both people in the PRA discussions and the health authorities believed that polluted canal water and the air pollution from the factory might be the reason for the increasing number of cases of cancer and respiratory diseases. The situation in Thach Son commune had been reported on national television and various agencies had committed themselves to provide support to the inhabitants. The Provincial Peoples Committee had thus recently provided Thach Son commune with a grant of 15 billion VND, so that the commune can be connected to the Viet Tri piped water system. Furthermore, cancer patients from Thach Son were able to get free treatment in Hanoi Cancer Hospital. There is, however, still an urgent need for further investigations and actions to take place to ensure that people in Thach Son can live in a healthy environment.
Links between Health, Clean water and Hygienic sanitation

The link between health and clean water and sanitation were emphasized in the project through the focus on community participation and community planning to clean up their environment. Aside from the smooth transition from the old to the new water supply network, the Community Awareness Campaign also had significant health and hygiene initiatives. Local communities even those not directly connecting to the new network, also constructed latrines and bathrooms, as well as cleaning up and covering wells and addressing other environmental issues such as solid waste disposal. The table below shows significant progress in health and hygiene facilities:
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By December 2002 Planned Latrine Construction or Improvement New Repaired Well Improvements Covers Floors Drainage Bathrooms Constructed or Improved New Repaired 891 1,726 2,593 654 788 2,362 1,508 Completed (85% of planned) 1,964 1,314 (85% of planned) 2,225 547 666 (77% of planned) 616 1,405
While there is limited data available on the impact of these changes on the health of the population of Viet Tri, the PRA and review interviews with the Health Centre staff indicated a reduction in water-borne and intestinal disease. However, because this project did not set out to measure health improvements, no baseline was taken, and the project was concluded before improved health data could be collected. It was not a responsibility allocated to anyone in the project, as health improvements are generally seen as a longer term goal, not measurable in the project period.
Ownership and Consultation

The Project to reconstruct the Viet Tri water supply system was implemented without surveys or consultation with the community. Before construction, customers were not informed about why they needed to shift from the old system to the new one; what service level would be provided for them or what they would need to pay. This made customers very angry. But what was good was clear ownership of the water system facilities. The Phu Tho Water Supply Company took action very quickly and resolved this situation through the use of a Community Awareness Campaign. One reason for their fast response is that the project funding was a loan from KfW, so that the success of the project in terms of repayment of loans was dependent on having as many paying customers as possible. The establishment of the new public relations function helped considerably, and led to further actions: The establishment of customer service teams at the ward level. The organisation of an annual customer service conference, in order both to maintain a high level of awareness of the need for PR within the PTWSC, as well as to provide an annual forum for customer comment. The further development of administrative procedures for resolving customerscomplaints (procedures for recording and processing customer complaints were established earlier in the year, prior to the formal establishment of the customer unit). The further development of Information, Education and Communication and marketing materials to promote clean water supply and good public relations. Continued co-operation with local authorities and mass organisations in Viet Tri to provide for the needs of customers.
The Use of PHAST (Participatory Hygiene and Sanitation Transformation) in Health and Hygiene Promotion
The PHAST (Participatory Hygiene and Sanitation Transformation) method was one of the key methods used. The method was developed by the UNDP/World Bank Water and Sanitation Programme in partnership with the World Health Organization. It is an innovative approach designed to promote hygiene behaviours, sanitation improvement and community management of water and sanitation facilities using specifically developed
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techniques. The underlying basis for the approach is that no lasting change in the peoples behaviour will occur without understanding and believing. Specific participatory activities were developed for community groups to discover for themselves the faecal-oral contamination routes of diseases. They then analyze their own hygiene behaviours in the light of this information and plan how to block the contamination routes. Using this approach in Viet Tri has achieved considerable improvement in construction of new sanitation facilities, repairing old ones to meet certain hygiene standards, in achieving many new piped water connections as well as improving hygiene behaviours. Key informant interviews with project staff indicated that PHAST and social marketing methods helped to gain significant improvement in community participation in their own environmental management. This included construction of latrines, bathrooms, well covers and local initiatives and/or discussions with URENCO (Urban Environment Company) regarding solid waste management and disposal. Community participation methods are also now being used successfully in HIV/AIDS activities. Project beneficiaries also said that the communal competitions helped them to achieve a clean environment. A number of communes not yet connected to the piped scheme also asked to participate in the project. The Project was also so successful that it was completed ahead of schedule.
Lessons Learned
Communication methods and materials are critical: Face-to-face communication through village WSS motivators, including village health workers, and also through commune staff is critical. Distribution of materials, often in connection with face-to-face communication is important. Special events like music performances, competitions and theatre plays are popular and attract public attention. The focus should be on improved practices and not only improved knowledge or raising peoples awareness. The use of participatory methods has been very important in achieving improved WSS and hygiene practices. With the PHAST method, the community was equipped with basic knowledge related to the routes of transmission of faecal-oral diseases. They can identify what were the pollution problems related to their water supply, latrines and surrounding areas. They must prepare a plan to address pollution problems and organize monitoring to check progress and to identify measures to overcome difficulties. Because all was done by community members, they very strictly assessed the status of latrines, shallow wells, kitchens, animal sheds and prepared plans for improvement. About 86% of households had unhygienic latrines, but after less than one year of implementation, actual achievement was very high: 90% of latrines were hygienic; shallow wells, drainages, bathrooms, solid waste situation all were significantly improved. During field visits recently and through discussion with people we found that latrines were not only kept hygienic, but some families had invested more to reconstruct their kitchens and latrines. This shows that with real community participation, facilities can be sustained and kept in good order. At the start of the programme, it was agreed to use the PHAST method as the main participatory method. The PHAST method with pictures as tools is very effective to stimulate community discussions if the trainers are experienced and the approach is adapted to suit the community. The most important rules in using the PHAST method are: The method must be adjusted or adapted in term of length of the course, time to organize and use of appropriate tools, to suit local conditions. The course should not be divided up into sub-courses. Participants will forget the content of previous meetings and may not link all things together. Let people think in logical ways. Do not provide information in unrelated pieces. All the contents of the course must be logically linked, should lead participants step by step to the actions needed for improvement of the surrounding environment. A survey must be organized so that people have the chance to analyse their living conditions, identify problems and decide to take actions themselves. Encourage people but never push them.
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Trainers and motivators must be frank and sincere with people. If the local people know that they are the owners of the project it will be successful. If the project belongs to the trainers then it will fail. Trainers must be experienced and confident. Trainers without confidence should not lead the PHAST course, because they will make it ineffective.
Participatory IEC (Information, Education and Communication) activities based on motivators are the most important and effective communication methods at commune and village levels. The State does not have a policy to pay allowances to WSS motivators at the village level (the health sector pays their motivators, i.e. the village health workers). The lack of allowances means that the WSS motivators are less effective. In addition to allowances, training and regular refresher training is also important. The involvement of local authorities and the mass organisations is essential for success in connection with IEC activities. The recent PRA in Thach Son also highlighted that community members are able to identify further environmental challenges, and to make the link between increasing health problems (such as cancer) and environmental pollution. People should be informed about the technical choices available to them and the appropriateness of these to their circumstances. The project developed the sanitation ladder, where different technical options were presented to households and they could choose the most appropriate and affordable option for them. Many families put their first priority for household expenditure as education for their children, so water and sanitation must be affordable. Because of this, the percentage of actual achievement in renovation or new construction of latrines or other facilities was very high (70%-92%) and also poor families could afford hygienic latrines with very low price. Above all, the project has demonstrated that community members should not be underestimated, and that it is possible for communities to make the connection between the environment and their health and for them to take action to improve their situations, even when they are poor or where there are no external funds available.
Recommendations
1. IEC staff must be in place and supported To achieve greater effectiveness in IEC, permanent IEC staff and facilitators need to be allocated. The Government should issue a policy on subsidies/allowances for WSS motivators at grass-roots levels. Much attention should be paid to a gender-balanced composition of IEC groups and the grass-roots motivator network and generally to the mainstreaming of gender issues into IEC and other activities.
2. Community participation and the poor must be given priority It should be compulsory for water supply and sanitation programmes to use participatory methods, as for example the PHAST method, and to ensure that special priority is given to involvement of the poor, both women and men, in decisions and implementation. 3. People should be given a choice between different technical options Locally suitable options should be presented to local communities, including the construction, operation and maintenance costs. This will enable people to make an informed choice about how to improve their own situation, based on what they are able and willing to pay.
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Appendix 2. Case Study 2 Water Supply and Sanitation for Poor Communities. The Rural Water Supply and Sanitation Project, Ha Tinh Province, Viet Nam (incorporating the Project/ Programme Review)
Background
Ha Tinh Province is bordered by Nghe An Province in the north and Quang Binh Province in the south, by Laos in the west and by the South China Sea to the east. Much of the economy of the area depends on the mining of iron, together with rural subsistence farming, mainly rice. The coastal area suffers frequent damage in the storm seasons and is often subject to flooding. Water sources are often contaminated, and close to the coast are also quite salty. During the dry season, fresh water is also scarce, with shallow wells drying up, and households must then buy water. In some communes, there is no fresh water available at all and all water must be bought. Due in part to the small size of landholdings, poverty levels in Ha Tinh Province are high approximately 40%. Ha Tinh Province was chosen for Case Study, as being representative of coastal areas, and because there were relevant projects in Ha Tinh in environmental management and rural water supply and sanitation. Ha Tinh is one of the first pilot provinces for the implementation of the participatory and demand-responsive National RWSS Strategy; the Ha Tinh Rural Water Supply and Sanitation (RWSS) project, has been included to explore the lessons learned from the pilot implementation of the Strategy. Ha Tinh Province was also chosen because there was a synergy in relation to the cross-cutting thematic studies and the final target pilot plans. The activities in Ha Tinh under this study included a review of the Ha Tinh RWSS Project including a desk study of documents, particularly the completion report, a lessons-learned report, thematic reports related to Information, Education and Communication (IEC) activities and a Health Impact Assessment carried out in 2006. There were also discussions with key informants and project beneficiaries, including project staff, community leaders and poor people. As well, two PRAs were conducted, in Cam Quan Commune in Cam Xuyen District, which received support under the Ha Tinh RWSS Project, and Ho Do Commune in Loc Ha District. Cam Quan is a rural, rice-growing area, while Ho Do is a poor suburban area of Ha Tinh town. Both Districts have high rates of poverty 39% and 30% respectively.
The Ha Tinh Rural Water Supply and Sanitation Project

The National RWSS Strategy was promulgated by Decision No.104/2000/QD-TTg of August 25, 2000 of the Prime Minister. Its development objectives were to achieve: 1. Improved Health of the Rural Population 2. Improved Living Conditions for the Rural Population 3. Reduced Environmental Pollution from Human and Livestock Excreta The RWSS set as targets: By the Year 2020 All rural people will use clean water of national quality standards with at least 60 litres/capita/day and will use improved hygienic latrines, through the active promotion of community participation and a demandresponsive approach. By the Year 2010 85% of rural population shall have access to national-standard clean water with a volume of 60 litres/person/day, and 70% of rural households and population shall use hygienic latrines and will practise personal hygiene. By the year 2005 All schools and other educational establishments, hospitals, clinics, offices and markets in rural areas shall be sufficiently supplied with clean water and furnished with adequate hygienic latrines. In 1999, Danida and the Government of Viet Nam had agreed on the establishment of a Sector Programme Support (SPS) for the Water Sector in Viet Nam. The first phase of the SPS was implemented from 2000 2006 and included a RWSS component under which support was provided to four provinces. The Ha Tinh Rural Water Supply and Sanitation (RWSS) Project was one of the sub-components under the RWSS component of the SPS, and was thus one of the first pilot provinces for the implementation of the National Rural Water Supply and Sanitation Strategy, using participatory and demand-responsive approaches. Activities started in Huong Khe district in 2001 and were extended to include Cam Xuyen district in August 2002. In April 2004, three additional districts were included in the project, namely Duc Tho, Vu Quang and Nghi Xuan districts.
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The Ha Tinh RWSS Project, had as its development objective improved living conditions for people in rural areas within the geographical focus area of Danish assistance by a demand-responsive support to improved domestic water supply and sanitation provided in a socially and financially sustainable manner. The immediate objectives of the Ha Tinh RWSS Project were: 1. To establish sustainable institutional framework for provision of water supply and sanitation services including access to credit facilities and competent staff 2. To establish community managed water supply and sanitation facilities based on user demand and reflecting the needs of women and the poor 3. To increase awareness of the linkage between improved hygiene and sanitation and health and improved hygiene practices Approach and Principles The project emphasized sustainability, including financial resources for construction, management, operation and maintenance of facilities; local ownership of facilities; technical/operational sustainability and use of appropriate technologies and environmental sustainability. The general principle was that users were to pay for construction and operation of water supply and sanitation (WSS) facilities. However, in line with the National RWSS Strategy, grants were provided to the poor who were officially registered as such according to the criteria of the Ministry of Labour, Invalids and Social Affairs (MOLISA). Furthermore, low-cost loans were provided to women, through a rolling credit scheme for groups of women, organized and managed by the Viet Nam Womens Union (after extensive negotiations with the Viet Nam Bank for Agriculture and Rural Development had failed). A number of households also self-financed improvements to existing and construction of new, WSS facilities. A range of technical options were developed which included both individual household and piped water supply options and a number of latrine options. The technology options were focused on low-cost solutions. Communities were provided with information on the water supply and latrine options that were technically suitable in their local areas, and were able to make a choice between these options. Improved health and hygiene awareness and practices were other important fields for Information, Education and Communication (IEC) activities. Building awareness and behaviour change typically takes longer than building facilities, but is essential for achieving improvements. Throughout the project there was a degree of tension between the need to raise awareness and bring the communities on-board and the need to complete construction according to project timelines and targets. In some cases, construction had to wait while communities raised their financial contributions, but this was considered important to ownership and sustainability. A variety of communication methods were used, including face-to-face communication through local RWSS motivators and commune staff, distribution of materials, special events like launching days, music and theatre performances, competitions etc. and use of the mass media like TV and radio programmes. The IEC staff involved in the Ha Tinh RWSS project played a key role in adjusting existing and developing new IEC materials for use in connection with the implementation of the National RWSS Strategy. This included the development of picture sets and a motivators manual to use in connection with the implementation of the Participatory Hygiene and Sanitation Transformation (PHAST) method10. IEC groups were established at provincial and district levels consisting of departments and mass organisations already involved in IEC activities on water supply, sanitation and related hygiene issues. To support gender mainstreaming, a gender focal point person was appointed at provincial level to provide support to and monitor the mainstreaming of gender issues into all relevant activities. The project organized gender training courses together with the provincial Womens Union at provincial, district and commune levels. Annual gender action plans were also developed and implemented by the project. The action plans included promotion of a relative gender balance in various groups/units and among village motivators.
10 The PHAST method focuses on community decision-making, planning and implementation and is described in further detail in the Viet Tri Case Study/Project Review
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Poverty Targeting and Financing Poverty-orientation was a cross-cutting issue. Besides using a demand-responsive approach to RWSS investment, grants were also provided to the poor so they were able to improve their WSS facilities. The grants covered 80% of the construction cost for a latrine, an individual water supply facility, or the household cost of construction and connection to a piped water scheme. The poor households receiving grants were selected from the communes poor household list. Special meetings were organized for poor households where they were informed about the different technical water supply and sanitation options, the possibilities for grants, how they could apply, how much their own contribution would be etc. In addition the village motivators also visited both poor and non-poor households to discuss different issues related to water supply and sanitation and integrated these issues in different meetings. According to the Project Completion Report and project staff, there were good results from the provision of grants to the poor, both because they were a main target group of the project and because the WSS facilities constructed by poor households acted as demonstration models for other households. Non-poor households looked at the facilities constructed by their poor neighbours and constructed the same or better facilities. The loans provided through the Womens Union were targeted at women from all socio-economic groups. Those that were officially poor, but not able to benefit from a grant, could apply for loans and a significant number of poor households did so. The loans also benefited many households who were just above the official poverty line. Rebates were offered to the poor, but there was still a cost, and households which might never have otherwise been eligible for loans were able to take out a low-interest loan to construct their own water supply and sanitation facilities. At the end of the project, it was expected that the revolving fund, at the current rate of loan repayment, would last for approximately ten years without additional replenishment11. The following table shows the number of grants and loans provided under the project. Grants and Loans Provided by the Ha Tinh RWSS Project Type of WSS facility Household latrines Individual household water supply facilities Number of grants to poor hhs 7.445 5.440 Number of loans 1.110 2.678 Remarks All grants were for officially poor households; it is uncertain how many of the loans went to officially poor households. Grants were provided from 2003-2006, while the far majority of loans were provided in 20042005. A total of 28,990 persons benefited from the 6 piped water systems; the project completion report does not mention how many of these got a grant or a loan. According to information from the WU, more than 5,750 households benefited from the WSS loans. This seems to indicate that a substantial number of households obtained loans for connections to piped water systems.
Source: Rural Water Supply and Sanitation (MARD-DANIDA Water SPS), Sub-component 2.2, Rural Water Supply and Sanitation in Ha Tinh, Completion Report, June 2006
Piped water systems
Loans are repayable over 36 months, and were provided for both piped and individual water supplies and latrines. Loans of VND1-3 million were provided to members of credit groups, which were made up of women from 10-15 households who supported each other to guarantee repayments.
11 Source: Womens Union: DANIDA End of Project Report, 2006
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Project staff indicated that monitoring was initially weak, and some loans were used for other productive purposes. Considerable training and support was needed at the local level to support the Womens Unions capacity to manage and monitor the processes. Nevertheless, as the story is with many microfinance schemes, the rate of repayment was and is high, and poor households have benefited. In some cases, households have repaid loans and then requested further loans for additional facilities, such as first water and then a latrine or bathroom. Lessons Learned and Recommendations The Completion Report for the Ha Tinh RWSS Project and a Lessons Learned Report prepared by the four RWSS projects under the Danida-supported Water Sector Support Programme, as analysed and re-evaluated by the review team, included the following important lessons learned and recommendations: The demand-responsive approach, as outlined in the National RWSS Strategy, proved to be very appropriate and should be adhered to. Such an approach aims at ensuring that both poor and nonpoor households in a given area are provided with information on water and sanitation issues, health and hygiene and on locally appropriate technical WSS options, including construction, operation and maintenance costs. Households should always express their demand and willingness to pay for water and sanitation facilities before construction starts. IEC activities play a very important role in RWSS activities; they should pay special attention to poor women and men. The project found that IEC activities were most effective when a variety of communication methods was used. However, IEC activities based on participatory methods and using the local motivator network were considered the most important communication method in reaching both poor and non-poor women and men. There were serious delays in getting a finance mechanism in place and functioning for the Ha Tinh RWSS project, which caused much frustration. To avoid a similar situation again, it is very important that appropriate finance mechanism(s) targeting the poor is in place at the start - or very soon after the start - of a project, so sufficient and correct information can be provided. Information on the finance mechanism(s) should be provided at the same time as presenting WSS technology options. A variety of WSS technology options should be presented to local communities to choose from. However, it is important that water resources and other technical investigations have been made first to ensure that the WSS options are environmentally and technically appropriate in the local area. The WSS technology options should include low-cost technology options to make them more affordable to the poor and those just above the official poverty line. Much efforts was needed to mainstream gender into IEC and other relevant activities, so that both women and men (poor and non-poor) benefited from the project and were involved in decision-making and implementation. One of lessons learned was that much attention should be paid to selecting a relatively equal number of women and men as RWSS motivators as women often communicate better with other women than men do and vice-versa.
The PRA Findings

The people in the poor communities of Ho Do and Cam Quan communes told stories about the need for clean water and the priority they were prepared to give to clean water in particular, and to a lesser extent, to sanitation for the sake of the health of their families. One woman in Ho Do said: I am 74 years old. If I were asked what Ho Do people need most when I am lying in my coffin, I would still say fresh water. Investment in water and sanitation is investment in our health. Similarly, in Cam Xuyen District in Ha Tinh Province, where high priority had been given to IEC activities and community participation, a community official reported: Fresh water is a dream of villagers. In every voter meeting, the villagers always raise their demand for fresh water and in all the meetings of the Peoples Council and the Peoples Committee, fresh water is always the main topic. During the PRA discussions stories were told of the high cost of buying fresh water from vendors much higher than the cost of investment in facilities and therefore of the need to restrict the use of fresh water, leaving families still vulnerable to disease and parasite infestations.
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The people of Ho Do, where there is no fresh water, explained that they had either to catch rainwater (some of which falls on asbestos roofs) or buy water. They noted that funds had previously been allocated to extend the piped water system from Ha Tinh town, but according to the PRA participants the planning for this project had not been consultative, the funds had not been used efficiently and they must therefore continue to suffer the cost, inconvenience and health risks of buying water and of therefore restricting their use of clean water. They also raised the issue of sustainability, saying that pricing mechanisms needed to include the cost of operation and maintenance and not just the construction cost. It was interesting to see the community supporting this view even when it meant a higher cost. Many commented that good health is a very valuable commodity, and even the poorest could make this a priority. However, despite this general commitment to clean water and health, the same community members also reported that although there had been some improvement in access to clean water and hygienic latrines, some of the health benefits had not been realized because the message had not yet been accepted that hand washing is an important health behaviour especially for those farmers handling compost and animal manure. In Cam Quan commune in Ha Tinh Province, poor households received project subsidies when connecting to the piped water system, so that they only had to pay around a third of the connection fee paid by non-poor households. Furthermore, households not having sufficient cash to pay their connection fee were given loans with a low interest rate. This meant that at the time of the PRA 60% of the poor households in the commune had connected to the piped water system, while 90% of the better-off households and 65% of the averageincome households had connected. Although the proportion of poor households not connected to the piped water system was still higher than the proportion of non-poor households, this case illustrates that appropriate finance mechanisms are important for poor households to improve their own water and sanitation situation.
Linkage between water supply, sanitation and health

A health impact assessment12 was carried out in March 2006 in the first two pilot districts, Huong Khe and Cam Xuyen, in order to evaluate the impact of the projects activities regarding improved health of the rural population. The data collection was focused on two communes within each district, i.e. in total four communes. The assessment was based on available health service data on water and sanitation related diseases, and on coverage of safe water supply and hygienic sanitation. In addition to the health service data, interviews and observations were carried out in eight villages (totally 401 households), and observations and pocket chart exercises with groups of pupils were carried out in seven schools. The health services data on diseases are not disaggregated according to poor/non-poor people and neither is the WSS coverage recorded at different administrative levels. Consequently, it was not possible in the health impact assessment to include specific data on the projects health impact on the poor. For the assessment one disease was chosen from each of the three categories into which water and sanitationrelated diseases are commonly divided: 1. Faecal-oral transmitted diseases: The main measures of control are: improved personal hygiene, improved excreta disposal and improved water supply in quality and quantity. The chosen indicator was diarrhoea. 2. Water-washed diseases: Main measures of control are to increase water quantity, hand washing and improved hygiene practices. The chosen indicator was trachoma 3. Mosquito-borne diseases: Main measures of control are to eliminate stagnant water and maintain water supply. The chosen indicator was malaria. The following were the conclusions on the impact on health: The recorded prevalence of the WSS-related diseases, except trachoma in Cam Xuyen, was low in both districts. In Huong Khe diarrhoea and malaria had been nearly halved over the project period, whereas trachoma had been stable. In Cam Xuyen the low prevalence of diarrhoea had been stable; trachoma was very high but had decreased considerably to nearly one-third. Malaria prevalence had been low, but increased slightly. In the four communes considered in the health impact assessment, the recorded prevalence of diarrhoea was likewise low and declining. The prevalence of trachoma, which had been very high in the two communes
12 The Health Impact Assessment Report is included as an annex to the following report: Rural Water Supply and Sanitation (MARD-DANIDA Water SP) Sub-component 2.2. Rural Water Supply and Sanitation in Ha Tinh, Completion Report, June 2006.
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in Cam Xuyen, had declined significantly in one commune and seemed to be declining in the other as well. Prevalence of malaria was low in two communes and it had decreased significantly in one commune, but had increased in the last commune. Villagers were recorded to as commenting that WSS-related diseases were decreasing in the communities. Hygiene practices are known to influence health; the availability of hygienic bathrooms is important in this regard. The health impact study found that the coverage with hygienic bathrooms was 74%, which is high, as was the percentage of people noted for always washing hands with water and soap (after defecation, before eating, before preparing food, and after helping children with defecation.), a high percentage, though, never washed hands with soap and water after helping children. The following were the conclusions on the impact on living conditions: In the surveyed villages the coverage of water supply and latrines was 97% and 78% respectively, and thus well above the national target set for 2010. Likewise three of the surveyed communes had high rates of coverage for water supply and latrines, above the 2010 target, and the fourth commune was close to target. Approximately 50% of all households were recorded to have improved their WSS facilities recently. One district had, regarding water supply, reached the 2010 target, but had only reached half the target rate for latrines. In the other district coverage was above target for latrines, whereas water supply was on 67% of the target rate. The health impact study thus showed that in the communes and villages with project activities the WSS coverage was higher than average. The high percentage of bathrooms was likewise important for improved living conditions. This achievement is remarkable and most probably is also to be credited to project activities. The following were the conclusions on the impact on environmental pollution: The use of human and livestock excreta for fertilizer was very common in nearly all the surveyed villages and reported to be used safely by nearly all the households. Safe disposal of solid waste was practiced in the majority (83%) of the households. Stagnant water was found near 18% of the surveyed households, especially in two villages in Cam Xuyen district. It was checked with the Health Services whether this might be the cause in the (slight) rise of malaria cases. This was reported not to be the case; the malaria cases were reported to be imported. It was not recorded whether practices had improved during recent years, but the percentage of safe practices was very high. The health impact study concluded that the following health impacts were likely to be attributable to the Ha Tinh RWSS project: The prevalence of the WSS-related diseases had generally decreased. This was likely to be the impact of the high coverage of water supply and sanitation and the health and hygiene education activities. The recording of whether practices and facilities in households had improved was weak in some of the surveyed villages. However, the present health situation, living conditions, hygiene practices and reduced environmental pollution seemed to be very good, and some of this achievement is likely to be attributable to the projects support. The WSS coverage was significantly higher in villages and communes which had project support than in the districts as a whole. Health Staff from Ha Tinh Province, the two surveyed districts and the four surveyed communes agreed that the findings reflected the actual situation very well, and emphasized that not only the improved facilities, but very much also the IEC activities of the project had been of major importance for improved practices and consequently improved health. As mentioned, the health impact assessment was carried out in the two districts where project activities first started. However, significant improvements were also achieved in the three other project districts. The table below shows improvements in both water supply and latrine coverage over the project period, moving from 30% to 63% of the population in the five districts covered by the project. The coverage compares favourably with the national average.
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District Huong Khe Cam Xuyen Duc Tho Vu Quang Nghi Xuan Total
Population 100.188 144.333 107.148 30.858 87.954 470.481
2002 22.764 23% 38.096 26% 38.432 36% 7.142 23% 34.215 39% 140.649 30%
Water Supply Coverage 2003 30.193 30% 45.676 32% 42.037 39% 7.798 25% 35.209 40% 160.913 34% 2004 38.884 39% 63.721 44% 50.730 47% 9.406 30% 36.104 41% 198.845 42% 2005 48.925 49% 76.831 53% 60.539 57% 12.716 41% 45.844 52% 244.855 52% 2006 63.264 63% 87.905 61% 75.319 70% 17.628 57% 53.889 61% 298.005 63%
District Huong Khe Cam Xuyen Duc Tho Vu Quang Nghi Xuan Total
Population 100.188 144.333 107.148 30.858 87.954 470.481
2002 27.378 27% 41.213 29% 38.432 36% 6.070 20% 2.779 32% 140.872 30%
Latrines coverage 2003 33.746 34% 47.309 33% 39.994 37% 6.308 20% 28.773 33% 156.130 33% 2004 40.781 41% 63.396 44% 46.071 43% 7.636 25% 32.248 37% 190.132 40% 2005 5.490 56% 74.030 51% 59.455 55% 12.001 39% 41.113 47% 243.089 52% 2006 67.131 67% 88.810 62% 73.870 69% 17.158 56% 49.158 56% 296.127 63%
Source: Rural Water Supply and Sanitation (MARD-Danida WaterSPS), Sub-component 2.2, Rural Water Supply and Sanitation in Ha Tinh, Completion Report, June 2006
There is no doubt that many poor people have benefited from the improved water supply and sanitation situation in the five districts covered by the Ha Tinh RWSS project. This is supported by conclusions in a poverty targeting study carried out in 2005 in 18 communes in five provinces, including two communes receiving support under the DANIDA-supported Ha Tinh RWSS project. The study concluded that13 : The poor households have made improvements concerning WSS. The data from the household survey show that in general, 81.1% of poor HHs have made some improvements of water supply during the last 5 years. The more grants/loans were given in an area, the more improvements of WSS were made by poor HHs. The improvements in the WSS were made in several ways. Grants and loans were obviously significant factors contributing to that, yet the major part of improvements still remained with self-financers . (Self-financer in the study is defined as a household that has improved its WSS facilities without receiving any grant and/or subsidized loans).
13 Water Sector Programme Support: water supply and sanitation for the poor, Poverty Targeting Study, July 2005, Final Draft.
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Conclusions
The Rural Water Supply and Sanitation Project in Ha Tinh Province targeted poor communities in which to improve health through the establishment of clean water supplies and hygienic latrines. The health impact assessment in the first two pilot districts of the project showed that people had experienced health improvements, improved living conditions through improved water supply and latrines and their hygiene practices had also improved. Some of this achievement is very likely to be attributable to the activities and support of project. However, the health services data on diseases are not disaggregated according to poor/non-poor people and neither is the WSS coverage recorded at different administrative levels. Consequently, it was not possible in the health impact assessment to include specific data on the projects health impact on the poor. The project did, however, specifically target the poor, but was not able to show so well the link between improved water and sanitation and poverty alleviation, although again the people commented that there is a link. Better health in families, many commented, has provided women especially with more time for productive activity, which is critical in subsistence economies. In addition, better health means better focus on education, and reduced costs for households on medication and transport costs for treatment. What has been established is that it is possible to develop appropriate water and sanitation options and finance and other mechanisms to ensure that the majority of the poor can benefit. In the Ha Tinh RWSS Project both grants and very low-interest loans proved to be very important for poor households to be able to improve their own living conditions and health situation. In addition, the timely and persistent application of awareness campaigns is critical to gaining community buyin for investment in new facilities. Once committed to the priority of health, the project has demonstrated that even the poorest households will do whatever they can to find the necessary resources.
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Bibliography
General Berghof, C & Dinh, T 2002, Men and women in rural water supply and sanitation in Vietnam, Ministry of Agriculture and Rural Development, Centre of Rural Water Supply and Sanitation, Hanoi DANIDA, 2006, Management Lessons Learned during the Implementation of the WaterSPS and NTP 1 and Recommendations for Next Phase Draft Document, Hanoi August, 2006 Kumar, S 2002, Methods for Community Participation: A complete guide for practitioners, Vistaar Publications, New Delhi. McKenzie-Mohr, D. and Smith, W, 1999, Fostering Sustainable Behaviour: An Introduction to Community Based Social Marketing. Ministry of Agriculture and Rural Development, 2000 National Rural Water Supply and Sanitation Strategy up to year 2020 Minister of Health, 2005, Decision 08/2005/Q-BYT dated 11/3/2005, regarding issuing the Sector Standards: Hygiene Standards for Various Types of Latrines. Nguyen, TA and Stoltz, HT, 2007, Good Practice Case story, Rural Water Supply and Sanitation Programme, Vietnam, DANIDA located at http://www.danidadevforum.um.dk/NR/rdonlyres/255CE9CB-6C46-424B-896338B060E38EA2/0/VietnamRWSS2007.pdf Soussan J et all, 2005, Joint GovernmentDonor Review of the Rural Water Supply, Sanitation and Health in Vietnam - Sector Status Report Viet Nam Womens Union, 10 July 2005 accessed at http://hoilhpn.org.vn WHO, 1998 PHAST step-by-step guide: A participatory approach for the control of diarrhoeal diseases World Bank, 2003: Participatory assessment of water supply and sanitation projects in urban areas. How can the poor get better service? Lam Dong Province Carl Bro International a/s (2001): Inception Report Dalat City Sanitation Subcomponent Carl Bro International a/s (2001): Environmental Impact Assessment Dalat City Sanitation Subcomponent Carl Bro International a/s (2004): Household Survey Report on Ability and Willingness to Pay Dalat City Sanitation Subcomponent Carl Bro International a/s (2006): Project Document - Dalat Sanitation Phasing Out Carl Bro International a/s (2006): Project Completion Report Dalat City Sanitation Subcomponent Figures provided by District/ Commune Peoples Committees and District Health Centres and Commune Health Stations.
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Ha Tinh Province Ministry of Agriculture and Rural Development, CERWASS and Danida, 2005, Lessons Learnt from the Rural Water Supply and Sanitation Sub-components, the Water Sector Programme Support Rural Water Supply and Sanitation (MARD-Danida WaterSPS), Sub-component 2.2, 2006, Rural Water Supply and Sanitation in Ha Tinh, Completion Report (the Health Impact Assessment Report is an Annex to this report) Water Sector Programme Support, 2005: Water supply and sanitation for the rural poor, Poverty Targeting Study, July 2005, Final Draft Ha Tinh Sub-component, Internal Information, Education and Communication (IEC) Review Reports and other IEC Reports Womens Union, 2006, DANIDA End of Project Report Pho Tho Province Carl Bro International a/s, 2002: Final Report on community awareness campaign project on water supply and sanitation, Viet Tri Reports from Case Studies of Poverty-Environment Inception Report on Poverty-Environment Linkages, Part 1 of Studies Summarised results of PRAs in target districts (Six Fact Sheets), Part 3 of Studies Project programme reviews, highlighting lessons learned (Three Fact Sheets from projects in the three Provinces of Lam Dong, Ha Tinh and Phu Tho), Part 3 of Studies Detailed PRA analysis (based on the six PRA studies and the fact sheets produced for each PRA), Part 3 of Studies Case study reports for Ha Tinh and Pho Tho Provinces, Part 3 of Studies Minutes of the national workshop held on 29 August 2007, Part 3 of Studies
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LIST OF RESEARCHERS/EXPERTS INVOLVED IN THIS STUDY

Full name PhD candidate Ann Elizabeth Killen Dr. Do Van Dung Msc. Doan Y Uyen Mr. Pham Thi Giang Organization Carl Bro Vietnam University of Medicine and Pharmacy Carl Bro Vietnam Carl Bro Vietnam
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Health, WSS& The Poor

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Health, Water Supply, Sanitation and the Poor

Health, Water Supply, Sanitation and the Poor

NATIONAL PROJECT DIRECTOR ASSOC. PROF. DR. TRUONG MANH TIEN

Abbreviations and Acronyms

Health, Water Supply, Sanitation and the Poor

URENCO UNDP UNESCAP WB WPC WSC WSS

Photo: Pham Thi Thu

Health, Water Supply, Sanitation and the Poor

Chapter 2 Methodology and Site Selection

Photo: Bui Hoa Tien

Chapter 2: Methodology and Site Selection

Adapting the PRA Methodology

Health, Water Supply, Sanitation and the Poor

Highlands Coastal Northern

Lam Dong Ha Tinh Phu Tho

Chapter 2: Methodology and Site Selection

2.3. Principles, techniques and materials

Chapter 3 Summary of Findings

Chapter 3: Summary of Findings

3.1. Summary of Frindings

Health, Water Supply, Sanitation and the Poor

District: Lac Duong Site: Lac Duong town

Chapter 3: Summary of Findings

Socio-economic and Health Situation of Town/ Commune/ Ward

Type of WSS Infrastructure

Project Support and Issues

District: Don Duong Site: Da Ron Commune

Health, Water Supply, Sanitation and the Poor

Type of WSS Infrastructure

Project Support and Issues

District: Cam Xuyen Site: Cam Quan Commune

District: Loc Ha Site: Ho Do Commune

Chapter 3: Summary of Findings

Socio-economic and Health Situation of Town/ Commune/ Ward

Type of WSS Infrastructure

Project Support and Issues

City: Viet Tri Site: Tien Cat Ward

Health, Water Supply, Sanitation and the Poor

Socio-economic and Health Situation of Town/ Commune/ Ward

Type of WSS Infrastructure

Project Support and Issues

District: Lam Thao Commune: Thach Son

Chapter 3: Summary of Findings

Type of WSS Infrastructure

Project Support and Issues

Health, Water Supply, Sanitation and the Poor

Province/ Name of Project/ Period

Lam Dong Province

Dalat Sanitation Project

Period: 2001 - 2007

Chapter 3: Summary of Findings

Objectives and Target Groups

Key Elements and Approach

Achievements and Issues

Health, Water Supply, Sanitation and the Poor

Province/ Name of Project/ Period

Objectives and Target Groups

Key Elements and Approach

Chapter 3: Summary of Findings

Province/ Name of Project/ Period

Objectives and Target Groups

Key Elements and Approach