1.  C.L.E.A.N. The Key to Sustainable Total Sanitation Team 19 Kristy Hackett Samantha Kearney Theresa Lee Nicole Lipana Julia Roy Anjum Sultana

2. Can Global Sanitation 2020 Contribute to China’s Prosperity? ?

3. Sanitation Improve health Human capital Opportunity cost ProductivityLaborEducationEnvironment Catalyst for economic prosperity

4. Where to invest? ?

6. Why South East Asia?  Soft Power  International reputation  Political interest  Regional Stability  Need for sanitation improvement  Economic Gains  Growing population  Increasing purchasing power  Geographical proximity  Economic interdependence  Access to natural resources  Established infrastructure  Similar rural urban divide to China  Relative cultural similarity

7. Cambodia, Indonesia, Timor Leste  Rural/Urban Divide  Disproportionate access to improved sanitation  Cambodia – 20% vs. 73%  Indonesia – 39% vs. 73%  Timor Leste – 37% vs. 73%  93 Million people in rural areas

8. Economic Cost :: Sanitation Cambodia, Indonesia Timor Leste  US $6.2 Billion loss due to lack of sanitation [1]  Health  Productivity (Labor, education)  Environment (water, land)  Tourism China  China’s bilateral trade with these countries will increase by US $240 million per year if universal sanitation coverage is attained [1] Water and Sanitation Program (2008)

9. What and how to invest?  What?  How?

10. Feasibility EconomicTechnicalCulturalScientific

11. Step 1: Community Engagement (Create Demand)  Community-Led Total Sanitation (CLTS)  Originated in Rajshahi, Bangladesh by Kamal Karr  Benefits:  Community Ownership  Behavioral Change  Community Empowerment  Evidence-Based  Decrease rates of open defecation:  CLTS: 92%  Non-CLTS: 28% [2] [2] Rashid et al (2009)

12. Process of CLTS Pre Triggering Selection Building Rapport Triggering Participatory Sanitation Profile Analysis Ignition Moment Post Triggering Action Planning Follow Up

13. Demand Supply

14. Step 2: Ecological Sanitation (Provide Supply) Conventional Approach EcoSan Approach

15. EcoSan Options Urine diversion dehydration (UDD) toilets Composting toilets Vacuum sewers Semi- centralised biogas plants

16. CLTS (Demand) EcoSan (Supply) C.L.E.A.N.

17. Lessons Learned Project Rollout FundBuildAdoptReport Introduction of EcoSan and Solution building Develop planFunding request Triggering Participatory Sanitation Profile AnalysisIgnition Moment Pre-triggering Engage communityBuilding rapportIdentify sanitation problems C.L.E.A.N. Evaluation

18. Acceptability Community-led Participatory Feedback loops Equity-focused Cost Effectiveness DALYs avoided/ 1$ spent Health Impacts Change in % ODF Diarrheal disease <5 mortality Environmental Impacts Local water quality C.L.E.A.N. :: Monitoring & Evaluation Template

19. Recommended Evaluation Design  Randomized Controlled Trial (Gold Standard)  Carried out by University partners Region CLTS EcoSan C.L.E.A.N.

20. C.L.E.A.N. :: A Multi-faceted Approach  Stakeholder Integration  Policy: Governments & Institutions  Implementation: Civil Society & NGOs  Research: Universities  Benefits  Knowledge transfer  Evidence building in the scientific community  Capacity building of community  Soft power gains for China

21. Project Budget  US $5 Billion per year for 3 years of full-scale implementation

22. Additional Recommendation :: China in parallel  Vast inequities between rural and urban populations within China  Curb criticisms of not dealing with sanitation problems at home  Lessons learned in neighboring countries are transferrable  Strengthen research partnerships  Become a world leader in environmentally sustainable sanitation initiatives

23. Key Messages 1. C.L.E.A.N ignites the demand for and provides the supply of improved sanitation 2. Benefits of C.L.E.A.N. go beyond sanitation, addressing issues of equity and global responsibility 3. Improved sanitation in South East Asia leads to returns on investment and improves international relations and furthers economic gain

24.  Thank You. Questions?

25. References  Avvannavar, S. M., & Mani, M. (2008). A conceptual model of people’s approach to sanitation. Science of the Total Environment, 390, 1-12.  Cheng, J. Y. S. (2013). China-ASEAN Economic Co-operation and the Role of Provinces. Journal of Contemporary Asia, 1–24. doi:10.1080/00472336.2012.757430  Ferguson, R. J. (2012). China’s Long-Term Relations With Southeast Asia: Beyond The Pivot. Culture Mandala: The Bulletin of the Centre for East-West Cultural and Economic Studies, 10(1), 3–20.  Florini, A., Nachiappan, K., Pang, T., & Pilcavage, C. (2012). Global Health Governance: Analysing China, India and Japan as Global Health Aid Donors. Global Policy, 3(3), 336–347. doi:10.1111/j.1758- 5899.2012.00173.x  Hubbard, B., Sarisky. J., Gelting, R., Baffigo, V., Seminario, R. & Centurion, C. (2011). A community demand-driven approach toward sustainable water and sanitation infrastructure development. International Journal of Hygience and Environmental Health, 214, 326-334.

26. References  Langergraber, G., & Muellegger, E. (2005). Ecological sanitation – a way to solve global sanitation problems? Environmental International, 31, 433-444.  Montgomery, M. A. A. (2007). Water and Sanitation in Developing Countries: Including Health in the Equation (pp. 16–24).  Mosler, H-J. (2012). A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. International Journal of Environmental Health Research, 22(5), 431-449.  Murphy, H.M., McBean, E.A., & Farahbakhsh, K. (2009). Appropriate technology – a comprehensive approach for water and sanitation in the developing world. Technology in Society, 31, 158-167.  Nelson, K. L., & Murray, A. (2008). Sanitation for unserved popualtions: Technologies, implementation challenges, and opportunities. Annual review of Environment and Resources, 33 199-151.

27. References  Rud, S. & Munch, E. V. (2008). Ecological sanitation: Selected example projects from Sub-Saharan Africa, Asia and Europe. International Conference: Pahtways towards Sustainable Sanitation in Africa. Ouagadougou, Burkina Faso.  SOIL (February 2011). Introduction to EcoSan toilets.  UNICEF, & World Health Organization. (2012). Progress on Drinking Water and Sanitation (pp. 1–66).  Water and Sanitation Program. (2007). Economic Impacts of Sanitatn in Southeast Asia Summary (pp. 1–14).  Water and Sanitation Program. (2012). Introductory Guide to Sanitation Marketing Implementation (pp. 1–14).  Water & Sanitation Rotarian Action Group (2012). Guidelines for planning sustainable sanitation projects and selecting appropriate technologies. Wasrag Technology Series.

28. References  WaterAid. (2011). Construction Of Ecological Sanitation Latrine (pp. 1– 68).  Werner, C., Panesar, A., Rud, S.B. & Olt, C.U. (2009). Ecological sanitation: Principles, technolgoies and project examples for sustainable wastewater and excreta management. Desalination, 248, 392-401.  Whittington, D., Jeuland, M., Barker, K., & Yuen, Y. (2012). Setting Priorities, Targeting Subsidies Among Water, Sanitation, and Preventive Health Interventions in Developing Countries. World Development, 40(music), 1546–1568.  World Health Organization. (2012). Global Costs And Benefits of Drinking-Water Supply And Sanitation Interventions To Reach The MDG Target And Universal Coverage (pp. 1–67).

29. Appendix A Additional Recommendation :: China in parallel  Yunnan province  Rural population: 31.375 million  46.3% in need of improved sanitation  Total cost: US $745 million  Including cost of technology, facilitators, evaluation, and overhead cost

30. Appendix B: Cambodia, Indonesia, Timor Leste

31. Appendix C: Stakeholder Engagement Government – Ministry of Health, Water & Environment, Education (multi-sectional) NGOsUniversities and ResearchersLeading Sanitation Experts within MinistryRegional District - Health & EnvironmentDistrictCommunity/Village LevelElders, Leaders, Village Governing Council

32. Appendix D: Why Not Africa?  Maintaining Current Investment Proportion  Harder to Achieve Universal Sanitation  Risky Investment  No Established Infrastructure

33. Appendix E: SWOT Analysis for Investment in Africa Strength - Natural resources - Large population (900M, to double) - Emerging market - Rising middle class Many ODF initiatives Weakness - Low level of infrastructure - Political uncertainty (Human Rights and conflict) - Sanitation infrastructure can’t support population growth - Low level of ODF in both urban and rural area - Distance from China is high, meaning increased cost - Most need Opportunity - Generate trade and extraction - Increased purchasing power - Room to improve ODF% - Global stability and recognition - High reward Threat - Uncertainty about whether resources exist - Urbanization - Environment - Sanitation low in urban areas - Unfeasible sanitation target due to many confounding issues - Increased cost due to distance - Soft power decreases - High risk Total Cost to achieve universal sanitation coverage SSA: US $52 Billion SEA: US $10 Billion Benefit:Cost Ratio SSA: 2.8 SEA: 5

34. Appendix F: Biogas

35. Appendix G: Composting Toilets

36. Appendix H: Urine Diversion Dehydration

37. Appendix I: Evidence of CLTS  Not Effective

38. Appendix J: Budget for China C.L.E.A.N. Program

39. Appendix K: Global Budget Calculations

40. Appendix L: Philanthropy  Lots of money with comparatively little economic ROI  Foreign aid can simply be aid and doesn’t have to come with strings attached  This further improves international relations, friendliness and soft power

41. Appendix M: Evaluation Methodology  Qualitative:  In-depth interviews with key stakeholders at community level (women, children, youth, facilitators, village government members)  Focus on equity of uptake/participation/decision making

42. Appendix N: Evaluation Methodology  Quantitative:  Household Surveys (pre/post) in each village  Measures of water contamination  RCT: compare changes in indicators between arms  Surveys to capture:  Health indicators  Cost effectiveness data  HH hygiene/sanitation knowledge  Attitudes towards C.L.E.A.N. approach

43. Appendix O: Five Year Plan :: GANTT Chart

44. Appendix P: Evidence for CLTS

45. Appendix Q: EcoSan Selection(s)