We have pictures of the latrines we are helping to build.

And this is how it looks on the Thai language plans.

This is a study done by Servants in Cambodia re Latrines

The Impact of Latrine Provision on an Urban Poor Neighbourhood November 2001
K.R.Jack/Chea Linn

In 1999 Servants to Asia’s Urban Poor began a small scale Community Sanitation and Development (CSD) program, in recognition of the role sanitation and stool disposal plays in illness, health spending and ongoing poverty.

Previously latrines, wells and water filters had been built in cooperation with several local schools, but demand indicated it was time to expand this to the wider community. Therefore several more community based sanitation projects were investigated, including drainage and walkways. Initially much time was spent by Mr Chea Linn (in charge of the CSD program) surveying community needs and motivation amongst urban poor neighbourhoods within our health district (Khan Mein Chey, Phnom Penh). This involved discussions with local chiefs and residents to assess their sanitation needs and what they were willing to contribute to improving their own situation. In some cases the approach to the community was initiated by Mr Linn, in some cases by the community approaching Servants.

In September 2000, work began in cooperation with one urban poor neighbourhood in Prak Pra commune to provide latrines to a cluster of poor families who had expressed a willingness to contribute towards their construction and maintenance. It was agreed that the community residents would contribute 10% of the finances plus the labor required to dig the pits. Servants would raise the rest of the finances required (which was done with kind assistance from the U.N Community Health and Sanitation program) and arrange for a contractor to implement the more technical aspects of the latrine construction.

The cost of each toilet was approximately $134 US and $1.50 for each poster and cake of soap. Eventually 12 latrines were provided for 24 families (one toilet for two families), in total serving nearly 150 people.

A baseline survey was carried out by Mr Linn in September 2000 (at which stage residents had had toilets less than a month) looking at household health and health spending. At this time Mr Linn also provided basic health education (hand washing, toilet cleaning etc) to each family. A follow-up survey was the carried out six months later (February 2001) to assess the impact toilet provision had had on these families. This six-month follow up indicated a marked improvement in heath status and commensurate drop in health spending. A year (13 months) after the baseline survey we conducted a further follow-up survey (October 2001) with this community in order to see if health gains were sustained. In particular we wanted to check that the earlier improvement hadn’t simply been as a result of seasonal variation between wet (September-October) and dry (February) seasons. At this time each family was provided with a scrubbing brush, a cake of soap and a poster reinforcing the initial information.

The results are very encouraging, indicating that after one year, health gains were largely maintained (especially when measured either as gross spending on health care or as percentage of household income spent on health care). There probably was a seasonal health variation, but the positive impacts of the latrines appear to have been greater than that. Below the results are presented comparatively, in tabular form.

Table 1: Number of households, individuals and toilets. (Note – prior to Sept. 2000 there were no toilets in this area).
Sept. 2000 6 month f/up 1 year f/up
No. of households 20 23 24
No. of individuals 108 140 148
people per household 5.7 6 6.2
people per toilet 9 11.6 12

Comment: Over the year, an extra 40 individuals were added to the numbers living in this cluster of houses, either through birth or migration. One would have expected this to put increased pressure on the latrines, hygiene and health in general. However the following data indicates this was not the case.

Table 2: “would you describe your families health over these past 3 months as generally healthy or unhealthy?”
Sept 2000 6 month f/up 1 year f/up
Healthy 0 19 (83%) 21 (87%)
Unhealthy 20 (100%) 4 (17%) 3 (13%)

Comment: At the 6 month follow up there was a dramatic increase in those who described themselves as having been healthy. This increase was maintained (in fact increased slightly) over the year.

Table 3: “About how much would your family have spent on health treatment over the past 3 months?”
(Note $1.00 US = about 3900 riel). Expressed as % of respondents in each spending band.
Sept 2000 6 month f/up 1 year f/up
less than 10,000 riel 5.5% 78% 75%
10 – 20,000 riel 11% 17% 25%
20 – 30,000 riel 28% 5% 0
30 – 50,000 riel 44% 0 0
> than 50,000 riel 11% 0 0

Comment: There is a very sharp drop in spending on health treatment after 6 months. This drop is maintained after 1 year.

Table 4: “What have been your families main illnesses these past 3 months?
Illness Sept 2000 6 months f/up 1 year f/up
diarrhea 14 5 5
fever 19 7 12
sore stomach 5 2 4
headache 18 9 23
cold, flu 16 5 16
dengue fever 7 1 3
skin disease 0 0 0
TOTAL 79 29 63

Comment: The number of reported illnesses plummeted by more than 60% between Sept 2000 and the 6-month follow-up. By the 1-year mark, the figure had risen noticeably again (although still well short of the baseline figure of 79). It is quite likely there is a seasonal figure at work here, with people often experiencing increased viral infections (such as flu’s) during the wet season (June to October). Indeed most of the illnesses reported at the 1 year follow up consist of headaches, colds and flu’s (39 out of 63 cases). However, although the number of cases of illness had risen, it appears their severity had decreased given that 87% of people regarded themselves as “generally healthy” over the proceeding 3 months, & that overall health spending had continued to be very low.

Table 5: “Estimate how many people in your family have had diarrhea over these past 3 months”.
No. of individuals Sept 2000 6 month f/up 1 year f/up
0 0 9 (39%) 3 (13%)
1 – 2 8 (40%) 14 (61%) 20 (83%)
about 4 10 (50%) 0 1 (4%)
about 6 1 (5%) 0 0
about 8 0 0 0
about 10 0 0 0
more than 10 0 0

Comment: The reported cases of diarrhea plummeted substantially after 6 months, and this decrease was largely maintained at the 1-year mark. A decrease in incidents of diarrhea is a positive outcome one would hope to result from latrine provision and hygiene instruction - and this indeed is borne out by the data.

Table 6: “Estimate what your families income has been over these past 3 months.”
Income Sept 2000 6 months f/up 1 year f/up
less than 50,000 riel 0 2 (9%) 0
50 – 100,000 riel 4 (21%) 17 (74%) 0
100 – 150,000 riel 11 (58%) 2 (9%) 7
150 – 200,000 riel 2 (11%) 2 (9%) 13 (29%)
200 – 250,000 riel 1 (5%) 0 5 (54%)
more than 300,000 riel 1 (5%) 0 0 (21%)

Comment: Generally, family income dropped from baseline to 6 months, and further research would have been required to understand the macro and micro-economic reason behind this. Then, by the 1-year mark, overall incomes had risen substantially above either of the two previous figures. Undoubtedly there is a complex web of factors behind this, well beyond the scope of this simple questionnaire to ascertain. However, it is quite probable that improved family health and therefore productive energy was one of those economic factors at work here.

Table 7: Approximate spending on health treatment as a percentage of family income
Sept 2000 6 month f/up 1 year f/up
% income spent on health treatment 31% 23% 6%

Comment: As can be seen, the percentage of income spent on health care dropped noticeably between the baseline and 6 month survey. Although only a drop of 8%, this represents an important saving for an urban poor family – extra money than can be spent on schooling, clothes, food, housing and so on – investments that will further improve family health (and financial wellbeing) in the both the short and long-term. However, by the 1-year mark, family incomes have risen quite dramatically, and this combined with decreased health spending represents a really big boost to the household coffers for these families. Again, without undertaking in-depth research, it is impossible to comment on all the factors that may have lead to such an economic improvement in this community; but almost certainly improved health status has been one. This figure of only 6% health spending is far lower than that seen in other survey conducted amongst poor households in Cambodia (where percentages usually vary between a third and more than half of all disposable income). Furthermore, three families made a point of stating in their questionnaire that they had spent absolutely nothing on health care over the previous 3 months – another very unusual result in the Cambodian context.

Conclusion: Though very encouraging, these results need to be seen within the limitations of this small study. The numbers surveyed are not large (statistically significant); nor have we attempted to examine the myriad of other factors (in addition to latrines and health status) that may have changed over the year and effected this community’s economic well being.

With that said though, there are many indications here that confirm the strongly positive impact of latrine provision on a community - especially when that provision is accompanied by education, follow-up (reinforcement), and when carried out in a participatory way. Basic health infrastructure provision (like immunization and clean water supply) is demonstrably one of the highest impact and most cost-effective interventions that can be made, improving both the health status and economic well being of the families involved.

We are encouraged to continue our efforts at working together with urban poor communities to improve their health through the provision of latrines, hygiene and health education.