Rural sanitation and hygiene: beyond the finish line (The SSH4A approach)

Rural sanitation and hygiene: beyond the finish line (The SSH4A approach)

Informed programme learning is essential to better target and reach the estimated 2.4 billion people globally who lack access to toilets. An estimated 946 million people still practise open defecation; there is therefore a need to increase sanitation coverage worldwide, while paying special attention to not leave vulnerable groups behind, which is at the centre of the SDGs.

The Sustainable Sanitation and Hygiene for All (SSH4A) approach was implemented to address the need to improve access and usage of sanitation and hygiene services for all globally. The approach has been implemented by SNV over the past decade in at least 75 districts across 18 countries in Asia and Africa. SSH4A aims to increase area-wide sanitation coverage using an integrated model focusing on: 1) demand creation, 2) sanitation supply chain strengthening, 3) hygiene behavioural change communication, and 4) governance. Researchers at Emory University (Matthew Freeman) and at the University of Nevada-Reno (Joshua Garn and Paschal Apanga) have been collaborating with SNV on a four-year evaluation of the SSH4A approach, as it was being implemented in 11 countries.

Evaluation findings

In this four-year evaluation, we found that the SSH4A approach led to significant increases in sanitation coverage across many of its programme areas, as shown below.


Early SSH4A results suggest the average coverage of improved sanitation (as defined by the JMP) across all study sites increased by 47 percentage points across the four-year study period. In comparison, our recent systematic review of the literature observed an average 14 percentage-point increase in sanitation coverage due to sanitation interventions across 27 studies.

Our evaluation results also suggest that the SSH4A approach was reaching vulnerable groups, and was often able to close the sanitation gap between vulnerable and non-vulnerable groups across 11 countries as shown.

Picture of an avocado farmer

SSH4A uses several approaches to target all community members, specifically vulnerable groups. First, it is a rural sanitation programme that targets districts, which are hard to reach or that require higher sanitation and hygiene needs. The approach also uses inclusive and pro-poor sanitation business models appropriate to the context of communities, supports community members on making an informed choice on inclusive toilet designs, and trains masons on the production of inclusive designs. It also creates an avenue for the development of local leadership for collective community action, tailoring social mobilisation as well as demand creation and the promotion of behavior change communications. Moreover, SNV ensures that its SSH4A approach is integrated in local government planning and budgeting so that the approach can be sustained. Our approach evaluation findings are relevant in a global context, and provide a deeper understanding of how to equitably increase sanitation coverage among vulnerable groups.

Dissemination of findings

As the four-year evaluation of the SSH4A programme in 11 countries ends, the final results are beginning to be disseminated at international conferences. The first presentation will be in August, during the World Water Week in Stockholm Sweden, as a part of the panel discussion entitled “Beyond the Finish Line, from coverage to sustainable sanitation services.” The panel consists of experts from SNV, from several different international development agencies, and from research institutions across the globe. Dr. Garn will present on the final SSH4A evaluation results, with a focus on equity and patterns of progress across the four-year evaluation, and will share recent findings from our systematic review of latrine coverage and latrine use.

A second presentation will take place in October, in a symposium event at the American Society of Tropical Medicine & Hygiene annual meeting, held in New Orleans, USA. The panel consists of several researchers who have been involved in large-scale sanitation programmes, and the general topic of the panel is “Sanitation at scale: implementation, outcomes, and equity.” Drawing an audience of approximately 4,600 attendees, Dr. Garn will again be discussing the final results of the SSH4A evaluation, emphasising sanitation uptake across countries and programme equity.

**Note: ***Due to civil unrest in South Sudan, SSH4A implementation had to be halted. While all other countries reflect figures across the four-year programme, Sudan’s endline marks year 2 results.

About the Author: Dr. Joshua Garn is an Assistant Professor of Epidemiology in the School of Community Health Sciences at the University of Nevada, Reno. He has research interests related to understanding and quantifying the impacts of water, sanitation, and hygiene interventions on health and educational outcomes. He has been involved in household and school-based observational and experimental WASH studies taking place in various low- and middle-income countries throughout the world.

Photo credit: Simon Migaj/pexels