Water and Sanitation Sector Assessment Study
In spite of very large fund allocations for drinking water and sanitation in India, access of a vast majority of rural population to safe and sustainable drinking water remains incomplete. The challenges faced include the institutional ones of reducing financial leakage, setting and monitoring qualitative indicators of achievement and creating an environment where all agencies come together through a holistic approach at village level.

The issues of coverage being an ineffective indicator and access being denied to the poorer sections of rural society are largely ignored. The present approach does not adequately take care of the poor and the deprived. Resource constraints across many areas of India require source sustainability to be taken more seriously and ownership to become the wish of the people. Neither is happening, although both are key objectives stated in Government of India Guidelines.

Provision of drinking water to communities has long been a tool used by politicians to curry favour with electors, but sanitation has been missing in the political agenda. The change from supply driven to demand led approaches has done little to influence policy makers to accept the need for better health and sustainability. There have been no large-scale independent reviews of the status of water and sanitation in India in the last decade and coverage and slippage have become institutionalized.

Effective utilization of funds in the drinking water sector and the need for a massive increase in demand and use of sanitation facilities are major causes for concern. The danger that Swajaldhara and TSC remain top-down, target driven programmes with no monitoring of effectiveness, affordability and increased access for the poor is still real. The weakness of PRIs and the poor capacity of NGOs and civil society further exacerbate the outcome of sector interventions and capacity building still retains a very low ranking in importance in the minds of administrators, agencies and politicians alike. 

Government of India appears to recognize the reality of the situation but is weakly placed to influence the grassroot response. It is therefore attempting to influence states to attain higher levels of transparency, sustainability and effectiveness through the signing of an MOU with each state that will lay down clearer policies, set vision and goals and determine milestones of progress. As the first step in this process, Government of Orissa has commissioned this Sector Assessment that sets out to define the situation on the ground and will be milestone on the road towards an improved rural water and sanitation sector in the state

Communication Needs Assessment Study for total Sanitation Campaign in Orissa
Communication is the most crucial factor to change behaviour. This would bring about change in the ideas, attitude, knowledge and skills amongst target groups through transfer of information. Communication Needs Assessment (CNA) is needed to capture requirements for information, behaviour change and adoption of skills of stakeholders responsible for change in sanitation habits.

Before developing the communication strategy, the most pertinent issue will be to know the extent of current knowledge, attitude and practice of the different target groups regarding ideal behaviour. 

The study is divided into two phases; the first is to assess communication gaps to build awareness, motivation and behavioural changes amongst different target groups. In the second phase a communication strategy will be suggested with corrective measures under each component.

The communication needs assessment will be required to help in identifying the appropriate approaches, methods and means to reach the different groups. 

Finally the exercise will be able to identify messages/ issues that need to be addressed as part of communication.

Environmental Health Impacts of Water Supply, Sanitation and Hygiene Interventations in Rural Orissa, India
Water and sanitation service infrastructure and personal hygiene behaviors are potentially important determinants of health. In rural India, the infrastructure for providing safe water and effective management of human wastes is typically inadequate or completely missing. Consequently, people's options for managing household water and human waste are limited, and their coping strategies often include behaviors that are harmful to their health. The inadequate water and sanitation infrastructure and service delivery and unsafe behaviors are collectively responsible for high diarrhea incidence, especially in children (Hughes et al., 2001; Wang, 2002; WHO, 2002). In 1990, diarrhea alone was estimated to cause over 700,000 child deaths per year in India, second after acute respiratory infections (ARl), which may also be linked with poor hygieI1e practices such as hand washing (Murray and Lopez, 1996). In addition to contributing to high infant and child mortality, the resultant morbidity in young children negatively affects their growth and educational achievement and imposes considerable burden on their families.

The Government of India (GoI) has established ambitious goals for providing potable drinking water and reducing infant mortality across the country. Among the key development targets that India has set out in the 10th Five Year Plan are: (a) guaranteeing universal access to potable drinking water within the Plan period, and (b) reducing infant mortality rate from 72 per 1000 live births in 1999-2000 to 45 in 2007 and 28 in 2012 (GoI, 2002). These are very ambitious targets, exceeding those proposed under the Millennium Development Goals (MDG), and working toward their achievement requires effective cross-sectoral approaches to delivering water- and health-related services. In the state of Orissa, for example, the government has successfully piloted the demand-responsive, community-managed sector reform approaches for rural water supply and sanitation (RWSS) in Balasore, Ganjam, and Sundargarh districts (Government of Orissa, 2004). Moreover, the government of Orissa (GoO) is planning to scale up these approaches statewide under the two national programs, Swajaldhara and Total Sanitation Campaign (TSC), with support from UNICEF and several nongovernmental organizations (NGOs).

As efforts are scaled up in many Indian states to expand R WSS services, it is important to rigorously evaluate RWSS programs and policies for four reasons. First, demonstrating that a particular R WSS program yields health and hygiene benefits can be used to build support for program extension or modification. Second, even though specific RWSS programs show great promise, they might not work under all conditions. While there is considerable evidence that programs that provide sufficient quantity of good quality water to communities generate positive health impacts, there is also significant evidence that the health impacts are highly variable, with some interventions and programs showing little impact. Good evaluations can identify why this might happen and what adjustments can be made to correct it. Third, if small-scale RWSS projects are to make an important contribution to government policy, they need to be expanded or "scaled up". It is important to know what aspects of these projects lead to greater or less success. Fourth, under the sector reform approaches such as Swajaldhara and TSC initiatives, programs delivering RWSS services in India are demand-driven, whereby communities self-select services they want from a menu of options offered. At the local levels, the health impacts are less certain and sometime inconclusive. Local results can therefore help prioritize possible project interventions and adjust the menu of R WSS services.
Unfortunately, there have been little or no systematic evaluations of health impacts of water supply, sanitation, and hygiene (WSH) interventions in rural India, and certainly none in the proposed study sites of Maharastra and Orissa. Several recent studies that have used data from large scale national surveys could not find health impacts of public water supplies, which is the main mechanism of water delivery in rural India (Bonilla-Chacin and Hammer, 1999; Hughes et al., 2001; Wang, 2002; Jalan and Ravallion,2003). To some extent these results can be explained by inability to account for water contamination during handling and home storage (Jensen et al., 2002; Sobsey, 2002), or for insufficient flowing water and therefore hand washing (Curtis and Cairncross, 2003). It is also possible that the general purpose national surveys cannot reveal real health benefits of public water supply because their categorization of water supply types is too broad (ignoring issues related to water quality at the point of use, maintenance and proximity of stand posts) and their design does not allow for adequate modeling of all relevant co-factors (e.g., culture, diet, geography, socio-economic status, governance) that affect the linkages between R WSS and health. In general, the cross-sectional, non-experimental and non-specific nature of national survey data preclude their use in estimating the causal impact of WSH interventions. Nor can these data be used to empirically illustrate the causal chain from infrastructural investments and public health campaigns to sanitary practices, hygienic behaviors and ultimately positive health’ outcomes. Furthermore, a recent meta-analysis of WSH interventions studies conducted in the last two decades shows that despite impressive gains in our knowledge base, much remains unknown about the relationship between RWSS and health in the developing world (Fewtrell and Colford, 2004).

In this context, a study to measure and explore cost-effective ways of enhancing the health impacts of R WSS projects in a rigorous manner - by collecting primary data, using longitudinal research methods, controlling for a wide range of confounding factors, applying the most appropriate experimental estimators - is important and of direct operational relevance. A major contribution of this study will be to help measure and steer progress towards health-related MDG outcomes, as opposed to just project targets. This study is, therefore, able to focus on and fill some of these gaps of particular interest to the RWSS projects in India, thus contributing to both global knowledge and local programs.

The study will be conducted in two states with different geographic, public health and socioeconomic characteristics, together representing a good span of conditions in rural India: Orissa and Maharashtra. This study protocol is for evaluating the impacts of a randomized community trial of government sanitation initiatives under TSC. A study protocol for Maharashtra, where the World Bank funded Jalswarajya project is the focus of evaluation, has been prepared separately.

The main objective of this study is to determine whether sanitation and hygiene interventions due to government sanitation programs in Orissa cause differences in health outcomes for young children who live in villages that participate in the programs. Specifically, we will evaluate the extent to which construction and use of individual household latrines (IHL) contribute towards improvements in child health outcomes. A related objective is to identify individual and contextual factors that moderate the effectiveness of interventions, such as characteristics of individuals and communities.

The secondary objectives of the study are to develop proxy indicators for routine monitoring of the health impact of increased sanitation coverage. Here the goal is to identify the intermediate outcomes (e.g., use of latrines) that are causally linked to the intervention as well as the outcome. We will also evaluate the broader impacts of WSH interventions on rural livelihoods, such as savings in time, materials and money invested in coping activities; improvements in convenience and privacy; and indirect benefits to caregivers (e.g., gains in work efficiency and time and work reallocation within the household. Finally, subject to availability of cost data, we will evaluate fundamental economic evaluation questions by estimating averted burden of disease and cost-effectiveness and cost-benefit of various program interventions.

The remainder of the protocol is organized as follows. Section 2 briefly describes the study location and the TSC program. Section 3 presents a review of the conceptual framework, the empirical literature, the key primary and secondary research questions, and the evaluation design. Section 4 presents elements of the sampling strategy. Section 5 describes the measurement of the outcomes, interventions and covariates through collection of primary data (household, community, and institutional surveys and water quality sampling) and secondary data (government statistics). Section 6 summarizes the analysis plan with an emphasis on regression and difference-in-difference estimation. Finally, Section 7 presents a brief update of the completed activities and the proposed next steps.