The seminar will examine the widely neglected and underestimated adverse nutritional impact of lack of safe water, sanitation and hygiene (WASH). It makes apparent how governments struggling to feed their citizens can make a substantial contribution to food and nutrition security by making WASH investments. Reducing faecal infections through sanitation and hygienic behaviour is a major means for reducing the undernutrition of children, enhancing the wellbeing of children, women and men, and achieving the MDGs. Approaches for scaling-up WASH like Conditional Cash Transfers (CCT) as well as approaches to improve food and nutrition security through productive sanitation will be presented using regional case studies. Together with the participants the potentials and challenges of these approaches will be discussed in rotating discussion groups facilitated by distinguished sector experts. The goal is to get an in-depth understanding of this neglected link and to provide constructive impulses for promising ways forward to strengthen this nexus at scale and push towards fulfilment of the human right to water and sanitation. This seminar was part of World Water Week, 2012.

2. Integrating Hygiene and Basic Sanitation into
Conditional Cash Transfer Programs
Juan Costain and Almud Weitz
WSP
Stockholm World Water Week, August 29 2012

3. Conditional Cash Transfers – Concept
• Cash incentives for the poor
• To remove demand-side constraints
• Education: transport, uniforms
• Health and Nutrition: transport, food
• Supply available, or can be induced through
demand side
• Long-term interventions
• Dual objective:
• Alleviate current poverty
• Induce behavior change

4. CCT Design: Key Questions
• What are key constraints for
desired results by target group?
• What are private costs for
complying?
• What subsidy amount would
‘make a difference’?
• How can conditions be monitored
and at what cost?
Two basic CCT systems:
• Targeting households/families
(most common)
• Targeting communities

5. Why Do We Care About CCT Programs?
• Traditional financing not sufficient in advancing
sanitation
• Help align incentives in sanitation markets and foster
more efficient and equitable service delivery
• Can foster better poverty targeting
• Potential to reinforce impact on malnutrition/stunting:
• impact evaluations: overall level of consumption
and composition of consumption positively
affected
• evidence that hygiene and sanitation good
practice could increase nutritional impact/reduce
stunting further

6. CCTs Spread Rapidly Over Past Decade

7. CCTs Spread Rapidly over Past Decade
Over 30 countries with CCT programs

8. Country Example 1: Peru
• Rural chronic malnutrition has not improved in line
with poverty rates and access to sanitation (10%
versus 15-17%)
• Suggesting that either the infrastructure investment
in sanitation is not the right one (latrine) nor it is
used by the people served
Population: 30 million
Urbanization: 76%
Economic growth: 6.9%
Poverty rate: 31%, rural: 56%
GDP/capita: $5,463

9. Household CCT Program: JUNTOS in Peru
• Annual budget: USD 400 million
(0.23% of Peru's GDP)
• Coverage: 700 district in 14
regions (out of 25)
• 500,000 beneficiaries
• 1.7% of total population
• 27% of extremely poor
• Impact evaluation
• chronic malnutrition reduced from
28.5% in 2007 to 23.2% in 2010

10. Entry Points for Sanitation in JUNTOS Program
CCT Target
Households
Ministry of
Development and
Social Inclusion
Sanitation providers
Ministry of
Housing and
Sanitation
Regional
Multi-
stakeholder
Platforms
Resources for co-
financing sanitation
facilities
Local
Government
Compliance
verification
of households
behaviors and
providers
performance
JUNTOS
CCT Program
Resources for households
incentives
Delivery of non-
transferable coupon
to purchase certified
sanitation facility
according to demand
expression
Post installation
cash incentive
conditional to good
practices (hygiene,
use and maintenance
of services)
Strengthening demand creation and
post installation behaviors
Private sanitation supply through
existing public programs
Agreement collaborative
work on key issues

11. Demand
Sanitation promotion
Community mobilization
Information & counseling
Non-transferable coupon
to purchase certified
sanitation facility
Post installation cash
incentive conditional to
good practices
Individual
Sanitation and hygiene
awareness
Household
Willingness to demand /
purchase
Community
Local leader trained
Individual
Use of sanitation
facility
Hand washing with
soap
Household
Clean sanitation
facility
House defecation
free (clean floor)
Community
Open defecation
free
Chronic
Malnutrition
Height-for-age
in 0-24 months
children
Where Are We? Strategic Approach
Intervention strategy Intermediate results Behavior results Health impact
Supply
Training and certification
by Ministry of Sanitation
Business model for
sanitation (package of
goods and services)
Sanitation provider
Offers catalogue of certified
sanitation facilities
Local Government
Capacity for compliance
verification
Demandedsanitation
Installed
sanitation
Bottlenecks at local level
Assure articulated intervention in a locality
Local priorities
Assure complemented interventions (solid waste)

12. Population: 240 million
Urbanization: 54%
Economic growth: 6.1%
Poverty rate: 13.3%
GDP/capita: $2,945
Access to Sanitation: 130 million
Urban: 73% Rural: 39%
Open Defecation: 63 million
Urban: 18% Rural: 40%
Stunting under five: 35.6%
Country Example 2: Indonesia

13. • Annual budget: USD 55.5 million
• Coverage: 3, 755 villages in 370 sub-districts
of 8 provinces
• 12 education (4) and health (8) indicators
• Impact evaluation:
• Main long-term impact decrease in child
malnutrition (10% from baseline)
• More pronounced in areas with low
baseline indicators
• Making grants conditional upon
performance improves program
effectiveness in health
• e.g. , 19.2% decline in severe stunting in NTT
province in Eastern Indonesia
Community CCT Program:
“Healthy and Smart Generation” in Indonesia

14. Improve growth and reduce stunting
Interventions
What can be done to prevent stunting ?
Poor Maternal
Nutrition & LBW
0-6 mos: Poor
Breastfeeding
7-24 mos: Poor
Weaning, Morbidity,
Micronut. Deficiency
Hygiene &
Sanitation
SERVICE PROVISION:
complete pre-natal
care
– 4 visits
– nutrition counseling
– Fetal & maternal
growth monitoring
– Micronutrient
supplements
–Full immunization
COMMUNITY ACTIVITIES
– Awareness raising
– Increased participation
and use of MCH
services
– Removal of barriers to
service use
– Parental education
– Supplementary feeding
for insecure regions
SERVICE PROVISION
– Growth promotion
(height and weight)
– Immunizations
– Counseling for
mothers; hygiene
– Training for service
providers on-site
– Standardized protocol
to manage growth
COMMUNITY ACTIVITIES
– Awareness raising
– Increased use of MCH
services
– Removal of barriers to
service use
– Parental education
(family planning, early
childhood education
practices)
SERVICE PROVISION
Growth promotion
(height and weight)
– Immunizations
– Provision of micronut.
– Counseling for mothers
– Training for service
providers on-site
– Standardized protocol
to manage growth
– Treatment protocol
– Deworming
COMMUNITY ACTIVITIES
– Awareness raising
– Increased use of MCH
services
– Removal of barriers to
service use
– Parental education
– Supp. feeding (insec.)
SERVICE PROVISION :
Sanitation marketing –
approach
- Formative market
research
- Behavioral change
communications menu
- Training of sanitation
entrepreneurs
- Training of village
masons
COMMUNITY ACTIVITIES
(STBM)
- Training of STBM
facilitators
- STBM intervention at
hamlet
- Piloting reward and
recognition system
- ODF monitoring system
Joining Forces: “Generasi Plus”

15. Challenges for Merging Interventions
• At political level
– Multi-sector collaboration: common approach,
common language
• At strategic level
– conditionality or incentives?
– centralized and decentralized interventions
– targeted grants or whole communities?
• At intervention level
– Bottlenecks at local level: weak supply side, overloaded
facilitators
– Sequencing of interventions