"You can lead a horse to water but you cannot make him drink"

Water, Sanitation and Hygiene (WASH) programs have been influential in addressing the issue of poor sanitation facilities across the continent. In 2015, however, UNDP/UNICEF reported that worldwide, 30%-50% of WASH interventions failed after 2-5 years of implementation (UNDP/UNICEF, 2015). Why have WASH programs been so unsustainable? Let's look at the factors upon which WASH services are set up. In a project to implement WASH facilities in Lukaya, Central Uganda, Naybare et al. assessed the following: water supply sources, water quality, pollution threats and existing sanitation facilities. Focus was placed on assessing the technical and socio-economic factors of WASH in order to implement the most appropriate sanitation infrastructure (See Figure 1).  Though not all intervention programs follow the same criteria, many still follow this 'broad brush' approach whereby solutions are largely based on biological-epidemiological evidence (Akpabio & Takara. 2014), leaving out one crucial dimension to understanding the unsustainability of WASH programs. 

Figure 1 showing: Five sanitation practices observed in low-income settlements (Global Report, 2019)

WASH solutions have paid great attention to scientific evidence but has not taken into account the social, economic and particularly cultural behaviours that play an influential role in the success and failure of WASH programs. This is because hygienic norms are strongly influenced by cultural beliefs and taboos. In Madagascar for example, open defecation is encouraged because there is a belief that storing sewage underground could contaminate the dead who are worshipped in the country. There is also taboo against placing one person's excreta in top of another's, which has consequently hindered the development of effective waste disposal facilities (Black and Fawcett, 2008). Cultural behaviours therefore strongly determine sanitation strategies. In some cultures, there is also a cultural tolerance for human excreta. In Ghana for example, 'night soil' activities take place whereby workers handle and dispose of human excreta themselves because it is believed to be part of the process of traditional healing and treatment. Similarly, there is a proverb among the Efik ethnic group (a coastal group in Nigeria) which says 'ifio Efik iwuteke Efik', that translates to 'the excreta of an Efik can never kill an Efik' (Akpabio & Takara, 2014). In faecophilic cultures (cultures that handle the tolerance of faeces), human excreta is therefore not perceived as a health risk, but as something that 'heals' rather than 'kills' (Ibid). Practicing common hygiene practices like that of the global North may not be common because of cultural differences that determine individual choices. It is therefore worth considering what undermines the sustainability of WASH programs may not be due to their lack of awareness and knowledge about safe sanitation practices, but due to our lack of understanding of different cultural hygiene behaviours and practices. Interventions from the North that implement inappropriate water and sanitation systems in Africa - sounds familiar? So far, top-down approaches to WASH programs have prioritised 'hardware' dimensions such as the Western flush and discharge 'wet toilet system', and have neglected 'software' dimensions, which would be more effective if more individual local contexts were better understood (Jewitt, 2011). 

Though, I should note that this does not mean hygiene practices across the whole continent are dominated by cultural norms. And it is certainly not an excuse to overlook the other causes for the unsustainability or even lack of WASH interventions. These differing norms are more common in more rural than urban areas. In the urban landscape the gravity of WASH interventions is a cause for concern but this is due to other reasons. Over a billion people lack access to sanitation facilities and 100 million practice open defecation. This may be due more to poor monitoring, weak national planning and poor urban governance that struggle to accommodate to the over a billion people living in slums and squatters in informal settlements (IDS Policy Briefing, 2019)

Still, if WASH programs are to be effective in the future, there must therefore first be a shift from hard-based scientific and technical approaches to understanding the local cultural and geographic context upon which services are built. Secondly, interventions should also aim to communicate knowledge spreading appropriate practices. And finally, relevant and affordable infrastructure should be implemented in order to encourage desirable practices. So just as the title of this blog suggests, WASH programs can be implemented within communities, but if the programs don't contend with appropriate local sanitation practices, then it won't work.