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Sanitation coverage radically increased across the country

The nation leads the world in reducing the rate of open defecation with household sanitation coverage as high as 88 percent in target provinces

Khem Deourn uses a shovel to mix up a small pile of concrete. In a shaded spot beside his traditional house, the Cambodian, 50, dumps the damp concoction into a brick press and compacts it with a pull of a handle. Deourn then carefully removes a perfectly formed interlocking brick and places it at the end of a row of identical products on a table to dry. The process is repeated dozens of times throughout the day, as Deourn, who lives near the Vietnamese border in Svay Rieng Province, is busy meeting demand from community members who use the bricks to build fences around their homes.

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Khem Deourn (second from left) and his family at their home -- paid for with funds made from selling SMSU latrines. 

Making bricks and other construction materials provides Deourn and his family with a healthy income. However, things have changed. Until a few years ago, Deourn mostly made bricks to construct outhouses. At the time, he was also producing concrete rings, lids and other parts for pit latrines as part of an iDE sanitation improvement effort. Here in Svay Rieng, the Sanitation Marketing Scale-Up (SMSU) program has been so successful, demand for newly constructed latrines has greatly diminished, and Deourn now only sells and installs about one pit toilet a week. When he first started the business in 2016, he was selling four a week. “It’s not a problem for me,” says the father of six. “I can sustain my business. I have a plan to expand to sell more construction materials.

Deourn (right) allows his interlocking bricks -- used to build outhouses -- to dry.

Studies say improved sanitation can reduce incidence of disease

While his business model has changed, Deourn’s journey highlights a major achievement for communities across rural Cambodia. Following a concerted effort by national and subnational governments, iDE and other partner organizations joined forces to radically increase improved sanitation coverage and end the practice of defecating in the open. At least 88 percent of homes across all six iDE-targeted provinces now have improved toilets, greatly reducing the amount of untreated human waste ending up in the environment. A 2017 analysis of 171 studies on the possible link between improved sanitation coverage and reduction of disease found that sanitation is protective against diarrhea, active trachoma (an eye disease caused by infection), some soil transmitted helminth infections (hookworm, roundworm and whipworm), schistosomiasis (a parasitic disease caused by blood flukes), and stunting (low height-for-age), with no protective effect for other measurable human outcomes.

After beginning with a pilot in 2009, SMSU will come to an end in June 2023, providing durable, and aspirational sanitation for more than two million people. Under the program, more than 409,000 households across seven Cambodian provinces have invested in improved sanitation after being connected to iDE-promoted entrepreneurs. For a country that had particularly poor rates of sanitation coverage, this represents a remarkable achievement. Now one in five rural Cambodian households own a latrine from iDE-supported entrepreneurs – at a time when global efforts to improve sanitation and access to safe drinking water are falling behind international goals. iDE also supported 2,031 villages to claim “open defecation free” (ODF) status -- a phrase used to describe communities where use of “improved toilets” is universal -- in collaboration with Cambodian authorities. As a result of interventions from iDE and other partners, Cambodia made more progress in reducing open defecation than any other country between 2015 and 2020. 

Low-income family used subsidy to purchase toilet

When Chhouk Yal's husband passed away, life became hard for the 56 year old. Only one of the six people who lived in her old wooden house, in Svay Rieng province, had a job. While she owned a small plot of land, she didn't have the money to pay workers to help her with harvesting. Her situation also meant she couldn’t afford a latrine and the family members usually relieved themselves in a nearby rice paddy. “Using a field is not good,” says Yal. “If we go to a neighbor’s field they won’t like it and will talk badly about me.” Aware of Yal’s predicament, in 2019 village elders and an iDE latrine sales agent paid her a visit, offering a partial subsidy to install a latrine. While it costs US$57, the subsidy covered US$25. The village elders raised the remainder of the money and Yal is now the proud owner of a new, pour flush pit latrine, located beside her house. 

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Personal aspiration incentivizes low-income households

Unlike most international sanitation efforts a decade ago that ran behavior change campaigns, iDE took a market-based approach. We utilize the power of profit and personal aspiration to incentivize people living in low-income communities, who ordinarily couldn’t afford a desirable toilet, to produce, sell, buy, and install pour flush pit latrines. iDE started by working with existing family-owned construction businesses. They were shown how to cast latrine components, including concrete rings to line pits, that were lower-cost and more functional than those commonly found on the conventional market. These “latrine business owners” (LBOs) were also trained in business practices such as bookkeeping and marketing. Some 13 of 58 LBOs trained under SMSU3 were women. The program also employed hundreds of salespeople who went door-to-door in rural communities, educating people about the importance of sanitation, while offering to sell households the locally-made toilets, which were both affordable and desirable.

“iDE Cambodia’s sanitation efforts prove that low-income households should not be viewed as recipients of charity, but as legitimate participants in water, sanitation and hygiene markets,” said Kevin Robbins, iDE Cambodia country director. “By respecting and valuing people’s agency and aspirations, iDE worked with local entrepreneurs to ideate, test and deliver solutions people would be willing to pay for, use and maintain.” He said between 2018 and 2022, Cambodian households invested more than US$8 million in sanitation products sold by iDE-connected WASH business owners. The low slippage rates among toilet owners in the SMSU-targeted provinces – with only 0.1 percent toilet abandonment – support the hypothesis that when people invest their own money and are able to access durable sanitation solutions, they are more likely to maintain their behavior change.

Toch Polyva, provincial deputy governor of Svay Rieng, says the local sanitation effort was successful because his government and iDE shared responsibility for the program.

Three provinces including Svay Rieng declared “open defecation free”

In Svay Rieng province, in Cambodia’s south-east, just 19 percent of households were equipped with a latrine when iDE launched SMSU in 2009. With low coverage came a high demand for toilets, peaking in 2014 when 9,232 were installed in the province. In the same year 70,355 iDE latrines were installed by the program across seven target provinces. In Svay Rieng, efforts to increase sanitation coverage have been so successful, in April 2022 the province was the first to be declared ODF. Svay Rieng’s Department of Rural Development, which worked closely with iDE, was instrumental in achieving ODF status for its jurisdiction because of its deep understanding of sanitation sustainability, especially when it came to targeted subsidies and risks of market distortion. 

Toch Polyva, provincial deputy governor of Svay Rieng, added the sanitation effort was successful because his government and iDE shared responsibility, and were both committed to seeing the program through. “Our educational work emphasized the importance of improved sanitation, which helped change the mindset of the people,” said Polyva who proudly showed off a glass trophy recognizing his province was now ODF. He said the affordability of the latrines, compared to local income levels, and the fact Svay Rieng had low incidence of flooding, also helped the province achieve ODF status ahead of the rest of the country. Since Svay Rieng was declared ODF, Prey Veng and Kandal provinces, both supported with sanitation marketing by iDE, have been declared ODF.

Chhouk Yal (right) shows off her new latrine along with a village elder who raised funds to help pay for the toilet. 

Three sweeps model reaches laggard households

iDE’s sanitation marketing implementation strategy used three “sweeps” to achieve maximum efficiency of resource allocation:

  1. In the first sweep, sales agents targeted those who are willing and able to pay with cash and were willing to invest in a relatively new and unfamiliar product.

  2. The second sweep focused on poorer households, through targeted marketing, professionalized sales, product innovations, and the use of sanitation financing.

  3. The last sweep targeted “laggard” households with targeted subsidies and low-burden financing mechanisms such as interest-free installment plans.

Focus on the Most Systematically Marginalized Households

With the success of the first two programmatic phases, SMSU3 focused on the most systematically marginalized households which remained without latrines. SMSU3 reached 887,930 (as of April 30) households with behavior change messaging, and sold and delivered 143,469 sanitation products to rural households, supporting an increase in household latrine coverage in target areas from 67 percent to 88 percent. At the same time, iDE delivered more than 38,000 partial, targeted subsidies for low income households, while strategically avoiding market distortion, and also developed and tested subsidy-targeting methods for climate-vulnerable households. The program now leaves behind a resilient sanitation market that will help all Cambodia’s provinces reach ODF status and provide people with universal access to sanitation services. Moreover, some 91 percent of iDE-connected LBOs (53 LBOs) like Khem Deourn have a plan for adapting their business when SMSU3 is over. In the meantime, iDE will continue its sanitation marketing efforts under two separate programs in Siem Reap and Kampong Chhnang provinces with a strong focus on flood-prone environments beside the Tonle Sap lake, the largest body of freshwater in South East Asia, where sanitation coverage is particularly low.

Human-centered design delivers easy solution

Before iDE launched the award-winning “Easy Latrine”, existing sanitation options for rural Cambodians did little to drive increased sanitation coverage. For most households, options included open defecation, unstable dry pits, and expensive concrete bathrooms. Using a human-centered design approach, iDE identified the unique needs, desires and barriers of rural Cambodian users, and produced an affordable product that households wanted to buy and businesses wanted to sell, creating a sustainable solution that could be scaled across the country.

Lessons learned from SMSU3

  • Diversified product offerings and targeted subsidies help increase equitable access to sanitation services in some of the most systemically marginalized, hard-to-reach market communities. For example, LBOs sold 627 disability-friendly and accessible shelters catering to people with disabilities.

  • Business capacity building of LBOs and diversification of products create sustainable, long-term and independent sanitation markets that will help Cambodia reach universal access to sanitation services. Some 91 percent of all LBOs have a plan for adapting their business when SMSU3 is over.

  • A grassroots approach to public private partnerships (PPP) strengthens sanitation systems, creating a sustainable sector financing model that improves access to sanitation, and improves progress towards ODF status. In areas where the PPP team was active, local governments have allocated nearly $19,000 since 2020 toward subsidization of latrine purchases for 428 poor households.

  • Alternating dual pit (ADP) upgrades enable rural households to safely manage their sanitation but adoption of recommended practices is still a challenge in rural areas. During SMSU3, LBOs sold 22,661 ADP upgrades to enable households to treat and safely dispose of fecal sludge.

  • Integrating gender equality, disability and social inclusion helps ensure equitable access to and use of sanitation services. iDE partnered with SHE Investments, training 27 female and 38 male entrepreneurs on gender-focused and culturally tailored business practices, fostering a more inclusive sanitation market.

  • Promoting appropriate sanitation-challenging environment technologies, safely managed sanitation, and climate-targeted subsidies can increase resilience to climate change.  iDE conducted research that shows how climate vulnerability correlates with toilet dysfunction and abandonment and unsafe household fecal sludge management practices.

  • A cohesive effort and flexible funding mechanisms enabled the design and implementation of a cost-effective and resilient sanitation program.  For every dollar spent in grant funding on SMSU3, $3.30 was gained by a latrine purchasing household through income savings and improved productivity.

The program was made possible by donations

SMSU3 is winding down in the six provinces it was operating. Only Siem Reap, in the country’s north, still runs the program with funding from the Australian government under the Water for Women (WfW) fund. SMSU3 was funded by WfW and the Cambodia Rural Sanitation Development Impact Bond with up-front capital provided by the Stone Family Foundation, which was repaid by the United States Agency for International Development. SMSU3 also received support from UNICEF in specific operating areas.